ORTHODONTIC SPECIAL CASES BEST TREATED WITH SIMPLE ... · Orthodontics protocol) was done to reduce the chair side time at the bond up appointment. Such ... Orthodontic special cases

INTRODUCTION

ndirect bonding (IDB) even though has beenintroduced for over 3 decades is underutilized1. Ithas several benefits however the added cost and

time to deliver the transfer trays has deterred manyOrthodontists to establish it as a routine in practice.Commercial costs are generally excessive and costbenefit ratios low for the clinic. However, manyOrthodontists are devising simple clinic procedures thatwould allow easy application of indirect bonding2.Most important aspect of IDB is for those who benefitfrom less chair time such as medically compromisedcases like ADHD (Attention Deficient HyperactivityDisorder), Cerebral Palsy, CLP (Cleft Lip and Palate) and sailorrhoea cases to name just a few. Newtechniques for IDB are continuously evolving. Numerousmethodologies have been ci ted. His tor icalmethodologies cited in the literature are the Thomas3

and Hickham4 techniques, the flexible undertray byMoskowitz et al5 and the contemporary Sondhi techniqueusing 3M-Unitek APC brackets6 and adhesives whichneed to be chemically cured and have a relatively shortworking time.

In this paper a clinical case that was treated withIDB from the protocol adopted at the Brisbane school

of Dentistry is show cased for efficiency of treatmentand minimal finishing requirements due to precision ofbracket positioning by indirect bonding method.Secondly, IDB protocol is discussed in detail forinterested readers to apply in their own clinical set up.

DISUSSION

A young male patient aged 12 years was referredby a school dentist due to insufficient space for theeruption of 13, 23. He also had ADHD diagnosed sincethe age of four, and was on regular medications(Retalin® daily) and the mother reported low painthreshold. Habit of nail biting was evident too.

As he suffered from ADHD (Attention DeficitHyperactive Disorder) was anxious in the chair and did

JPDA Vol. 22 No. 04 Oct-Dec 2013 275

ORTHODONTIC SPECIAL CASES BEST TREATED WITHSIMPLE INDIRECT BONDING PROTOCOL

Shazia Naser-ud-Din PhD, MSc, BDS, DPHDent, FICCDE, DCPSP-HPE

Orthodontic treatment methodology has evolved considerably in the past few decades and much of technologicaladvances are definitely improving the efficiency and delivery of orthodontic treatment, but come at a higher cost.One such example is the commercial indirect bonding.In certain orthodontic cases with special needs indirect bonding (IDB) is not a luxury but a necessity and shouldbe considered . The additional cost can be eliminated by simple chairside technique that can be applied with success.The aim of this paper is to discuss an orthodontic case where IDB was used to successfully complete the case inshortest possible treatment time and secondly the methodology employed - The Brisbane Orthodontics IDB Protocol.KEYWORDS: Special cases orthodontic, Simple Indirect Bonding.HOW TO CITE: Naser.ud.Din S. Orthodontic Special Cases Best treated with Simple Indirect Bonding Protocol.J Pak Dent Assoc 2013; 22: 251-254.

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School of Dentistry | The University of Queensland 200 Turbot Street, Brisbane QLD4000 AUSTRALIAP: +61 7 3365 8084 F: +61 7 3365 8199Correspondence to:“Dr. Meena Kumari Rathi” <[email protected]>

Brisbane School of Dentistry

TECHNIQUE / CASE REPORT

Fig. No. 1

not like sitting still for too long. This affected the initialconsult (hence poor quality intra oral photographs).However, over a period of time he did acclimatize tous and was very friendly and open. Special precautionswere made such as first appointments in the sessionso that there was no waiting period that could aggravatethe anxiousness. Secondly indirect bonding (BrisbaneOrthodontics protocol) was done to reduce thechair side time at the bond up appointment. Suchmeasures not only enhanced patient cooperationbut ensure efficient treatment due to less wire bendingin finishing stages.

He had mild skeletal II base with average facialproportions. At the time of examination presented inlate mixed dentition with moderate maxillary andmandibular crowding and Class I molar relationshipbilaterally. On expressive smiling 1mm of gingivalshow with upper midline 1mm to the right and lower2mm to the left due to labially excluded 33 in the

mandibular arch. Radiographic examination revealedpotentially impacted 13 in sector 1 and 23 in sector 3placed within the line of the arch. 27 eruption wasobstructed by a developing tooth follicle - which couldbe odontome or the ectopic 28.

The aim was to keep the treatment time to theminimum with least number of visits. Hence, non-extraction treatment with 0.022x0.028” slot MBT(Victory Brackets) were placed by Indirect bondingprotocol to save chairside time and alleviate anxietyin the patient.

On previous appointment, impressions with molarbands in situ were taken for fabrication of TPA (TransPalatal Arch). Total treatment time was 18 months,primarily due to the delayed eruption of bilateral upperpermanent canines. Number of visits and summary isprovided in the table.

The pretreatment weighted PAR was 28 and posttreatment 0, with 100% improvement. Both patient andmother were thoroughly satisfied with the treatment. Itwas indeed gratifying to see him settle well into ourclinic through the treatment duration.

Impacted canines need attention as when space isdeficient it retards the eruption or completely preventsit. In the latter case it may lead to cystic changes overa period of time. With growth potential on our side

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Orthodontic special cases best treated with simple indirect bonding protocolNaser-ud-Din S

Fig. No. 2

1 March 2011 Impression for IDB and TPA

2 April 2011 0.016’NiTi lower & 0.018” NiTi upper lace back all 4quadrants. OHI given.

3 July 2011 0.020” SS upper with activated compression coils andlig ties on 14,24. Lower 0.016x.022” CuNiTi. NV 0.017x0.025S/S lower and commence bite opening waitingforupper 13, 23 to erupt. Good progress OH improved.

4 Oct 2011 Increased curve of spee in lower 0.017x0.025”SS andundertied 3-3. Continued upper archwire with compression coils maintaining space for upper permanentcanines.

5 Dec 2011 Rebonded 35, and bonded 13. 0.018NiTi upper and 0.017x0.025”TMA lower.

6 Jan 2012 OH had gone down again OHI given. 0.017x0.025” CuNiTi upper and lower with compression coil for 23.

7 March 2012 OH improved placed 0.019x0.025”SS lower and 0.018x0.025”CuNiTi upper with soft sleeve.

8 April 2012 Bonded 23 and 0.016”NiTi upper and lower religatedthe 0.019x0.025”SS.

9 June 2012 Good progress placed 0.017x0.017” CuNiTi upper

10 Aug 2012 Removed the TPA and commenced finishing. Oralsurgeons opinion sought for the 27 possible impaction.To keep under observation.

11 Sep 2012 Placed 0.016”SS upper with finishing bends distal rootrotations for 22 &23 with extrusion for 23 and intrusionfor 14. Class II elastics 1/4” 4.5oz (ORANGE) all time.

12 Oct 2012 Debond, scale and clean with lower bonded retainercanine to canine and upper and lower Hawley retainers.


Orthodontic special cases best treated with simple indirect bonding protocol

resulting in shorter treatment time. Non-extractiontreatment was possible as the patient was in activepubertal growth spurt.

Although there was crowding, extractions of upperfirst premolars would provide the space for uppercanines. However, that would lead to excessive spacewith anchorage burning and Class II molar relationshipnot the ideal scenario. Not to mention it would prolongthe treatment time and every effort was made tokeep the treatment time shortest possible and leastcomplicated treatment methodology (medical history).

Generally assisting impacted canines into the archis anchorage demanding. Simple TPA would reinforcethe anteroposterior anchorage to maintain class I molarrelationship. TPA was removed after alignment of 13,23. TPA is more user friendly as compared to Nancebutton or the head gear in the experience of the author.

IDB Brisbane Orthodontics ProtocolIndirect Bonding (IDB) Brisbane Orthodontics

Protocol has fewer steps with cost effective materials.Low failure rate leads to predictable results. Steps tobe followed to ensure success are as follows:1. Use high quality recent alginate impressions ofupper and lower arches poured immediately in castplaster stone (colour contrast preferred for aestheticbrackets). The casts should befree of voids and bubbles. Usebrackets of choice onto theplaster model with UHU stick( G m b H & C o , B ü h l ,Germany).Apply sparingly onthe base and attach to thepredetermined long axis positionat the centre of the clinicalcrown (Fig 3). Let it dry forcouple of hours. The UHUadhesive is viscous and allowsfor placement of the bracket withno drift.2. Clear PVS (PolyVinylSilicate)-Memosil* is appliedevenly over the model (Fig 4). The PVS should extendfor a few millimetres all around the brackets andconformed into a transfer tray. Memosil* has a relativelyshort working time which can be extended byrefrigerating prior to use. Fingers dipped into soapywater allow the tacky material to be molded over thearch easily. Let the tray set for 5 minutes. Soak in

lukewarm water for 5 minutes to soften the adhesive.Peel it off like a banana peel from one end of the archto the other with gentle pressure. Follow the path ofleast resistance and ensure that all brackets havesuccessfully been transferred onto the tray. Immerse inwarm water (Fig 5) for couple of minutes and wash offthe UHU under running warm water or use a triplex to

clear away any remaining glue. The bracket bases shouldnow appear free of any residue.3. Dry the tray and bracket bases thoroughly prior tobonding. Application of the composite adhesiveis a “critical technique”. It is easy to apply excessiveamounts of composite and be faced with a lengthycleanup which is counter productive. Train yoursupporting staff for the protocol prior to theprocedure.Firstly, apply a flowable bonding agent ontothe bracket bases. Use Ortho Solo** as it has highestviscosity due to its increased filler content. Recentstudies indicate that it produces high bond strength.7Asmall amount of bonding adhesive ( Transbond ***) isapplied to the bracket base (Fig 6). Minimal adhesiveis required. The Transbond™ is then lightly pressedonto the bracket with a microbrush dipped into OrthoSolo™ to ensure the bracket base is well covered and

Fig. No. 3

Fig. No. 4

Fig. No. 5

Naser-ud-Din S

that the mesh base is engaged by the adhesive.4. Pumice, etch, wash and isolate the teeth. Place thetray avoiding excessive force as it may distort the trayand lead to inaccurate bracket placement. Immediatelylight cure ( Ortholux LED ****) for 12 seconds in theleft and right posterior sections and in the mid anteriorsection ( Fig 7 ). Three point curing assists in stabilizing

the tray after which the individual brackets can be curedfor 12 seconds each without supporting the tray toensure thorough curing. Peel off with similar maneuversas on model ( Fig 8 ) or use periodontal scaler to lift

it off. If severe undercuts or rotations present, the traycan be sectioned in-situ to remove it with ease.

5. Ensure no bonding has occurred interdentally byfloss check. Excess bond may occasionally appear thatcan be removed with tungsten bur at chairside.

*Memosil™, HeraeusKulzer GmbH, 300 ,Heraeus Way,South Bend, IN 46614; www.heraeus-dental.de.**Ortho Solo™ (Ormco,, Sybron Dental Specialties,Orange, CA).*** Transbond XT ™ 3M ESPE, St Paul, Minn USA.**** Ortholux™ Luminous curing light (3MUnitek, 2724 South Peck Road, Monrovia, CA 91016 USA).

CONCLUSIONS

The Brisbane Orthodontics IDB protocol has beenused successfully at the Postgraduate program at UQsince 2010. It allows a novice operator to be confidentespecially in the initial set ups. Hence, it is a vitalteaching methodology where the operator can get asupervisor to correct bracket positions prior to placementin-situ. Among other advantages such as efficiency oftime, cost effectiveness and reduced chairside time, theauthor has found its major utility with special needcases where bonding stage can be laborious andunpleasant experience for the patient. With Universityof Queensland tertiary care clinic special cases are seenmore often and hence IDB has been valuable in treatingsuch cases. The method is certainly technique sensitiveand proper coordination with staff is essential forpredictable successful results.

ACKNOWLEDGEMENTS

School of Dentistry, UQ is indebted to BrisbaneOrthodontics, Queens Street Mall Brisbane, to providethe opportunity to introduce this protocol to the post-graduate program and for publication.

REFERENCES

1. Keim RG, Gottlieb EL, Melson AH, et al. 2008JCO study of orthodontic diagnosis and treatmentprocedures. Part 1. Result and trends.J Clin Orthod2008;42:625-640.2. Qamruddin I, Ashraf B, Shahid F. Indirect bodingwith hot glue method.J Pak Dent Assoc 21 2012;21:252-254.3. Thomas RG. Indirect bonding: simplicity in action.

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Fig. No. 6

Fig. No. 7

Fig. No. 8

J Clin Orthod 1979;13:93-106.4. Hickham JH. Predictable indirect bonding. J ClinOrthod 1993;27:215-217.5. Moskowitz EM, Knight LD, Sheridan JJ, et al. Anew look at indirect bonding. J Clin Orthod 1996;30:277-281.6. Sondhi A. Efficient and effective indirect bonding.

Am J Orthod Dentofacial Orthop 1999;115:352-359.7. Wenger NA, Deacon S, Harradine NW. Arandomized control clinical trial investigatingorthodontic bond failure rates when using Orthosolouniversal bond enhancer compared to a conventionalbonding primer. J Orthod 2008;35:27-32.



ORTHODONTIC SPECIAL CASES BEST TREATED WITH SIMPLE ... · Orthodontics protocol) was done to reduce the chair side time at the bond up appointment. Such ... Orthodontic special cases

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