concise yet complete presentation on banding procedure in orthodontics and general principles of bonding

1. BANDING PROCEDURE
AND GENERAL PRINCIPLES
OF BONDING
PRESENTED BY: DR SWETA SARAVANAN
PG 1ST YEAR
DEPARTMENT OF ORTHODONTICS

2. CONTENTS
• BANDING
• Introduction
• History
• Indications
• Requisites
• Technique
• BONDING
• General principles

3. BRIEF HISTORY
• MAGILL was the 1st to use plain bands cemented to the teeth.
• Steel replaced the gold as common orthodontic material, pinched
bands are welded rather than soldered.
• Preformed steel bands came into widespread use during the 1960s
and are now available in anatomically correct shapes for all the teeth.

4. INTRODUCTION
• The chief parts of modern fixed appliances are tooth
bands and arch wires
• Tooth bands are made up of metals and cemented to
the teeth and provides place for attachment of other
auxiliaries like brackets, buccal tubes, lingual buttons
etc.
• These auxiliaries can be either welded or soldered to
the bands.
• The tooth moving forces derived from the arch wires
are transmitted to the teeth through the bracket.

5. INDICATIONS
• Teeth that will receive heavy intermittent forces against the
attachments. E.g.: upper I molars
• Teeth that will need both labial and lingual attachments
• Teeth with short clinical crowns
• Tooth surfaces that are incompatible with successful bonding

6. REQUISITES
• Must fit the contours of the tooth as closely as possible
• Should not extend subgingivally any more than is necessary
• Resistant to deformation under stresses in the mouth
• Enough springiness that it can be forced over the height of contours
of the teeth and into undercut areas
• High polish to reduce the adhesion of food debris

7. TECHNIQUE
• MATERIALS REQUIRED
• SEPERATION
• SELECTION OF MATERIAL
• FABRICATION
• ADAPTATION OR FITTING OF BANDS
• CEMENTATION

8. MATERIALS REQUIRED
BAND THICKNESS(inches) BAND
WIDTH(inches)
INCISOR 0.003 0.125
CANINE 0.003 0.150
PRE-
MOLAR
0.004 0.150
MOLAR 0.005 OR 0.006 0.180
•
• How pliers
• Double beak anterior forming pliers
• Posterior band forming pliers
• Band cutting pliers

9. Other equipment
• Welding and heat treating equipment
Mostly the combined resistance and passivator
type used as an electric soldering unit as well
as a heat treating passivator.

10. Seperation
• In order to break tight interdental contacts
• Should be left for a week before banding procedure
• Various types of separators include:
i. Brass wire separators (0.5/0.6mm dia)
ii. Ring separators(stretched elastic rings)
iii. Dumbbell separators(stretched ring regains length
iv. and brings about separation)
v. Kesling’s spring separator(coil and 2 arms)
vi. C separation maintainers (TP Ortho).
vii. Niti spring separators
viii. Kansal separators

11. WHY ADEQUATE SEPARATION IS NECESSARY?
• Average periodontal ligament space- 0.25 mm, placement of a 0.16-mm orthodontic band
without proper separation will risk contact with alveolar bone, producing hyalinization areas and
evoking the pain response hindering patients from performing routine oral functions.
i. According to Oliver, adequate separation reduces physical pains to the lowest possible degree,
ii. prevents injury to the tooth structure from excess pressure,
iii. prevents injury of the soft tissue while forcing band material to place and reduces physical and
mental tensions of the patient by having the band material conveniently carried to place.
iv. It also prevents distortion of the band material by not having to force it unduly toposition
during band construction
(PDF) Orthodontic Separators – A Systemic Review. Available from:
https://www.researchgate.net/publication/277586667_Orthodontic_Separators_-
_A_Systemic_Review [accessed Aug 19 2018].

12. Fabrication of band
• Band material- adequate length- 2 ends brought together-
mesial and distal embrasures
• Free ends held with How plier- buccal surface adapted with
amalgam plugger.
• Band material pinched with How & pinched through Peak
pliers
• Spot welding at lingual joint
• Required inserts spot welded directly over the lingual joint
• Lingual extensions cut and polished.
• Appropriate attachments are soldered or spot welded onto
the band

14. Ideal band
• Buccal groove clearly registered
• Shape of molar evident
• Lingual legs at same level when brought together
• Joint vertical and parallel to tooth’s long axis
• No overlapping of band in mesial and distal aspects

15. ADAPTATION OR FITTING OF BANDS
• Upper molar band is designed to be placed initially by
hand pressure on the mesial and distal surfaces bringing
the band down close to the height of the marginal
ridges.
• Then it is driven to place by pressure on the
mesiobuccal and distolingual corners.
• Final seating is with heavy biting force on the
distolingual surface.

16. • Lower molar bands designed to be seated initially
with hand pressure on the proximal surface- then
heavy biting force along the buccal - not the
lingual margins.
• Upper premolar bands are usually seated with
alternate pressure on the buccal and lingual
surfaces.
• Lower premolar bands are designed for heavy
pressure on the buccal surface only.

17. Attachments to bands
• Horizontal buccal tubes are chosen depending on problem
to be corrected
• For heavy arches, 0.040 or 0.045 inch round tubes used.
• Anterior edgewise- rectangular/edgewise tubes.
• Soldering preferred to welding as solder bulk gives
strength in the heavy stress area.

18. Soldering molar tubes to bands

19. Cementation
• Before cementation- teeth cleaned, pumiced and debris rinsed away.
• Teeth isolated to prevent salivary contamination
• Some dentists- wipe with alcohol and dry with warm air- remove mucin.
• Commonly used cements- zinc phosphate and glass ionomer
• A thick cement mix is loaded into the band in such a way that all the
interior surfaces are totally covered with cement, so that there is no bare
metal.

20. • Burnisher helps in adapting band over tooth firmly
• Small piece of tin or aluminium can be placed to isolate from saliva
• Also permits patient to close mouth and swallow
• Foil is removed & excess cement chipped away
• Excess cement removed with universal scaler parallel to band margin
and not perpendicular
• FROZEN SLAB TECHNIQUE: glass slab & powder refrigerated to
increase the working time
• Current light cure band cementing materials decrease the need to
use the above technique

21. Bands vs bondable tubes
Increase in the gingival inflammation associated with orthodontic
bands (Atack et al., 1996).
i. Orthodontic bands mechanically irritate gingival tissues.
ii. Chemical irritation may occur due to the cement used to retain
the band.
iii. Greater risk of food impaction and hence posterior gingival and
periodontal irritation.
iv. Tendency to clean their anterior teeth more effectively than
their posterior teeth.
v. The use of a buccal tube (bond) instead of a band should
prevent or minimize periodontal changes because the bonds
are positioned away from the gingival margins.
Saudi Dent J. 2015 Jul; 27(3): 120–124.
Published online 2015 Feb 7. doi: 10.1016/j.sdentj.2014.11.010
PMCID: PMC4501438
PMID: 26236124
The effect of orthodontic bands or tubes upon periodontal status during the initial phase of orthodontic treatment
Saud A. Al-Anezi⁎

22. Most overlooked materials in orthodontics.
• The majority of clinicians who banded molars routinely re-
used the bands after they had been tried in the mouth and
found to be the wrong size (95%).
• If trying of the bands is attempted inside the patient’s mouth
and determined that the size is not appropriate, the band
should be decontaminated from saliva and blood, and
autoclaved for future use.STERILIZATION IN ORTHODONTICS- A REVIEW. Available from:
https://www.researchgate.net/publication/308968039_STERILIZATION_IN_ORTHODON
TICS-_A_REVIEW [accessed Jun 20 2018].
Benson, P.E., Douglas, C.W.I. 2007. Decontamination of Orthodontic Bands following Size
determination and Cleaning. Journal of Orthodontics, 34:18–24.

23. BONDING –GENERAL PRINCIPLES
• History
• Ideal bonding systems
• Fundamentals of bonding
• Bonding technique

24. HISTORY
• 32nd annual meeting of the International Association for Dental Research
1954- MG Buonocore, for the first time, suggested -etching enamel with
85% phosphoric acid solution- adhesion of acrylic resin that lasted 1070
hours when stored in water.
• Further development of orthodontic resins (diglycidyl ether of Bisphenol-A
with a polyamide curing agent) by Newman in late 1960s, replaced banding
with bonding
• Currently available bonding agents offer bond strength of 12 -20 MPa
which exceeds the minimum shear bond strength requirements of an
orthodontic attachment

25. Ideal bonding systems
• Biologically safe in oral cavity and should generate minimum bond strength of 7-15
Mpa
• Handling properties- adequate fluidity and wettability, easy to manipulate with
adequate working time but quick setting time and an adequate shelf-life
• Clinical performance:
i. attain optimum strength quickly for early wire placement.
ii. withstand stresses of masticatory forces and thermal recycling in oral cavity
iii. dimensionally stable with minimal shrinkage.
iv. minimal expansion and water absorption.
v. produce a durable bond.
vi. induce enamel remineralization.
vii. antimicrobial properties or at least poor biohostility.
viii. have similar refractive index as of attachment like plastic and ceramic bracket.

26. Advantages of bonding
• Aesthetically superior to banding.
• Faster and simpler, easy to manipulate
• Less discomfort to patient since it does not require separation of
teeth for seating of bands
• Reduced caries risk under loose band.
• Archlength is not encroached since no band material needs to be
inserted on interproximal surfaces.
• Consequently no band spaces are present at debanding
• Proximal stripping is possible if required during treatment.
• Interproximal areas are accessible for composite built- up.
• Brackets can be attached on partially erupted or fractured teeth.
• Relatively less oral hygiene problems due to miniature size of
brackets.
• Use of ceramic and lingual brackets became reality due to feasibility
of bonding.

27. Disadvantages of bonding
• Weaker attachment than cemented band.
• Technique sensitive procedure
• Enamel demineralization and white spots around bonded attachments
• Smaller size of brackets and better access to tooth cleaning surfaces
does not guarantee better gingival health.
• Loss of enamel with etching and during debonding although recovery is
a possibility with re-mineralization
• Bracket bond failures do occur and subsequent bonds are not equally
strong.
• Attachment may not be suitable for orthodontic forces such as Kloehn
headgear.
• More complicated for lingual auxiliaries.

28. Types of bonding material
• Essentially two types of bonding material are available:
• Self-cure bonding materials
• Light cure bonding materials.
• The orthodontic bonding agents can also be grouped as those used for
directly bonding attachments or those used in indirect bonding.
• Commonly used bonding agents - two-component system containing a
primer which is essentially a bifunctional monomer like HEMA, (hydroxyethyl
methacrylate) or NPG (N-phenylglycine) and the adhesive which may be an
unfilled or partially filled bis GMA plus TEGDMA based resin. Examples are
Transbond XT*, Enlight**.
• Recent advances- primer containing 4-methacryloxyethyl trimellitate
anhydride (META)- act as universal bond promoter and can be used on alloys
also.
• Self-etching primers (SEP) - recent additions to the bonding armamentarium-
reduce time-single step adhesive- etches, primes and bonds in a single step.

29. Armamentarium

30. Patient evaluation prior to bonding
• Oral hygiene, caries status, enamel health and any restorations/ fracture cusps/incisal edges and pathological
conditions of enamel such as fluorosis or hypocalcifications.
• Non-vital teeth, teeth with root canal treatment and large restorations such as crowns/metal/metal ceramic/
ceramic/composite laminates or other restorations.
• Mucosal disease and sensitivity to any medication/ drugs, flexibility of cheeks and lips, and gagging reflex.
• Technique sensitive procedure. A successful bonding requires a pleasant working environment, a trained
assistant besides well- functioning dental unit and proper armamentarium
• Fluorosis/or other enamel defects would require modifications/ alterations of the standard bonding
procedures.
• Reclining patient position, with both operator and assistant on their respective stools in a comfortable position
and free access to the required materials and equipment.

31. Etching: the basis of bonding
• Removes approximately 10 um of enamel surface- creates porous layer of 5 to 50 um deep on the
enamel.
• Demineralization- prism head - type I and when more at periphery - type II acid etching
• Increases surface free energy-microporosities created by conditioning through capillarity or capillary
attraction
• Resin tags are formed into microporosities of conditioned enamel, long-lasting bond by
micromechanical interlocking with this tissue
• Micromechanical retention is also provided by the formation of interfacial resin-enamel interdiffusion
zone-remaining enamel protuberances.
• Incorporation of hydrophilic monomer in enamel bonding agents facilitates resin infiltration of the
etched enamel at prism level, reducing interfacial porosity and thus bonding defects

32. Etching/enamel conditioning
• Etchants -acid gel or an acid solution- Disposable applicator tips/needles
• Restrict area of etching minimum
• Acid gently rinsed off after 15 seconds to -20 seconds- abundant water supply
• Followed with air water mix spray - eventually tooth surface is dried with moisture free,
oil free air.
• High volume suction is to be used
• Excessive powerful rinsing and over drying is not beneficial.
• A dull and frosty white look on the enamel -successful etched area
• Isolation till bonding procedure is completed mandatory.
• Any contamination would require the process to be started all over again.

33. Electron microscope images
Normal Enamel Etched enamel

34. Sealing
• A thin layer of sealant is painted over the entire etched
surface POST ETCHING
• Sealant coating -thin and uniform - prevents bracket drift.
• Gentle air bursts of 1-2 sec evenly spreads sealant
• Self-curing primers may show lower bond strength due to
oxygen inhibition of the curing process
• Sealant increases bond strength, protects enamel from
consequent demineralization caused by acid etching
procedure and improves resistance to micro-leakage.

35. Effect of enamel protective agents on shear
bond strength of orthodontic brackets
• The two protective agents used were resin infiltrate (ICON) and
Clinpro; the two adhesive systems used were self-etching primer
system (Transbond Plus Self Etching Primer + Transbond XT adhesive)
and a conventional adhesive system (37% phosphoric acid
etch + Transbond XT primer + Transbond XT adhesive ).
• Significant increase in the shear bond strength of Transbond XT
adhesive with phosphoric acid and Transbond XT primer when ICON
was used before bonding orthodontic brackets to sound enamel or
even to demineralized enamel . The shear bond strength was also
increased when Transbond Plus Self Etching Primer was used instead of
the conventional phosphoric acid etching to sound enamel
Effect of enamel protective agents on shear bond strength of orthodontic brackets
•Mona A MontasserEmail author and
•Mahasen Taha
Progress in Orthodontics201415:34
https://doi.org/10.1186/s40510-014-0034-0
© Montasser & Taha; licensee Springer 2014

36. Bonding
• Brackets kept ready for placement on bracket holder (s)
preferably with a long handle
• Primer painted on the bracket base mesh -optimum amount of
adhesive applied with applicator
• Bracket placed - predetermined/calibrated area of tooth -
precisely in the first go if possible
• Flat end push scalar or the reverse end of the bracket holder -
orient the bracket parallel to the long axis incisogingivally and in
the centre of the tooth surface mesiodistally by eyeballing
• For vertical positioning measuring devices such as Boon’s gauge
or height guides are used.
• Finally, the bracket is pressed firmly in its desired position with
the same scaler

37. Self cure bonding agents
• Unite*, Rely-O-Bond- quick and swift - ensures correct
bracket placement without significant alterations.
• After placing the bracket on the tooth-5- 10 seconds for
ensuring precise bracket placement.
• Satisfactory position and orientation of the bracket-
gently yet firmly press the bracket against the tooth
surface within this working time.
• Mouth mirror essential - proper horizontal positioning-
eg. rotated premolars.
• The brackets can be ligated after 4-10 minutes

38. Light cure bonding agents
• Excess removal- bonding agent cured - complete
polymerisation 20 seconds per tooth or as recommended
by the manufacturer
• Metal brackets- light gun directed from edges of the
bracket base and lingual sides of the teeth
• For plastic and ceramic brackets, it is directed on to the
brackets

39. Types of light curing sources
• Popular contemporary light curing systems are light emitting diodes
(LED).
• Superior over conventional halogen light curing sources because they
have a much larger working life of about 10,000 hours, produce same
intensity of light and do not get heated up quickly.
• They emit light at 850 wcm2 and take about 20 seconds to cure one
attachment, which means 6.6 minutes for a full mouth bonding.
• Recently, Xenon Plasma Arc curing units have been introduced that are
phenomenally faster than LED.
• These emit light at 1800wcm2 and take about 2-4 seconds per
attachment, which means about 1.3 minutes as an average curing time.
• Authors believe that it is important that the light emitted by the source
is of high and uniform intensity otherwise bond failures will be
frequent.
• Some manufacturers (like SDI) provide intensity indicator with the unit
that keep a check on the effectiveness of the light source.

40. Comparision of different curing lights

41. Cytotoxicity of orthodontic resins
• Polymerization reaction producing cross-linked polymer matrix from
the dimethacrylate resin monomer is never complete
• The quantity of residual monomers is less than a tenth of the
remaining methacrylic groups, evaluated as 1.5% to 5%, but sufficient
to cause major cytotoxic effects.
• Release ions such as fluoride, strontium, and aluminium-directly
responsible for the cytotoxicity on pulp and gingival cells
• Leaching of some ions also seems to be implicated in cell alterations.
• Depletion of glutathione, production of reactive oxygen species, and a
few other molecular mechanisms have been identified as key factors
leading to apoptosis and pulp necrosis.
• Resin monomers stimulate the development of cariogenic bacteria at
the interface between the material and the walls of the cavity.

42. To reduce cytotoxicity
• Some simple and basic precautions
• First, the amount of composite resin used should be kept at a
minimum, and any excess resin (“flash”) around the
orthodontic attachments should be removed before the resin is
polymerized.
• Minimizing the use of adhesive material may be more
important when bonding fixed orthodontic retainers because
these are left in the oral environment for a long time and are
exposed to the cavity, unlike resin beneath the bracket base.
• Also, the speed of monomer release is maximal in the first 10 to
60 minutes. It might be advisable to have the patients wash
their mouth right after the bonding session, or have them spit
into a disposable cup for the first 30 minutes when resin is used
after topical fluoride applications.

43. Alternatives to acid etching
• Crystal growth technique- Maijer and Smith - 1979- alternative
method to acid etching for bonding brackets.
• Polyacrylic acid solutions - residual sulphate ions + slight
etching= crystalline deposit - bonds composite firmly to the
enamel surface - resists mechanical remova
• Crystals grow in a so-called spherulitic habit- Calcium sulphate
dihydrate (gypsum)
• Tensile bond strength equivalent to -conventionally acid-etched
surface
• At debonding, the fractures - crystal/ resin interface
• Remnants removed easily -ultrasonic scaler and pumice-
leaving fluoride- rich outer enamel surface smooth and intact

44. Advantages of crystal bonding technique
• Minimal effect on the outer (fluoride rich) enamel layer.
• Enamel surface is not significantly damaged.
• Few, if any, resin tags are left behind the enamel
• Adequate bond strength for clinical practice is achieved
• Debonding and cleanup are much easier
• Crystal interface - incorporation of fluoride/antiplaque agents-
anticariogenic action.

45. Clinical trials with crystal growth
conditioning as an alternative to acid-etch
enamel pretreatment• Following conditioning with dilute sulfuric acid which contained
sodium sulfate (to be termed solution A) and in ten patients, 10%
phosphoric acid was added to the dilute sulfuric acid used (to be
termed solution B).
• It was found that the failure rates were significantly higher after
enamel conditioning with solution A than after conditioning with
solution B (P < 0.001)
• Subsequent to solution A conditioning, nearly all the brackets came
loose during the first 2 weeks. When solution B was used, the failures
occurred at a later point of timeAmerican Journal of Orthodontics
Volume 85, Issue 4, April 1984, Pages 333-340
Original article
Clinical trials with crystal growth conditioning as an alternative to acid-etch enamel pretreatment
Author links open overlay panelJonÅrtunSvenBergland

46. Bonding with self-etching primer (SEP)
• No separate acid etching of the enamel and subsequent rinsing with
water and air spray is required
• Liquid component conditions the enamel surface.
• The removed calcium complex - incorporated into the network when
the primer polymerizes.
• Primer- single use -3 compartments blister pack.
• 1st- methacrylated phosphoric acid esters, photosensitizers, and
stabilizers.
• 2nd-water and soluble fluoride.
• 3rd-contains an applicator micro brush.
• Squeezing and folding the first compartment over to the second
activates the system.
• The mixed component then is ejected to the third to wet the
applicator tip.

47. Treated Enamel Surface Patterns
Associated with Five Orthodontic Adhesive
Systems—Surface Morphology and Shear
Bond Strength
• Evaluate the influence of three different types of pretreatment
solutions (phosphoric acid, self-etching primers, and polyacrylic acid)
on enamel surface
• SEM observation revealed different etching patterns on the enamel
surface after pretreatment.
• It was found that self-etching primers and polyacrylic acid produced
a less aggressive etching pattern than phosphoric acid.
• Nonetheless, all the five adhesive systems provided acceptable bond
strength and attachment of orthodontic brackets.
•Dental Materials Journal
•Volume 27 (2008) Issue 1
Original papers
Treated Enamel Surface Patterns Associated with Five Orthodontic Adhesive Systems—Surface Morphology and Shear Bond Strength
Makiha SHINYA, Akikazu SHINYA, Lippo V. J. LASSILA, Harunori GOMI, Juha VARRELA, Pekka K.VALLITTU, Akiyoshi SHINYA

48. Bonding on unconventional tooth surfaces
• FLUOROSED TEETH: more resistant to acid etching.
• Even with extended etching times, moderate to severely fluorosed teeth
show only 40% of the normal bond strength.
• In cases of severely fluorosed teeth, option of banding should be
considered.
• NON-VITAL TEETH: The enamel is rendered brittle in non-vital teeth hence
the bond strength may be affected.
• IMPACTED TEETH: Moisture insensitive primer (MIP) has been developed
for bonding in difficult situations where achieving total moisture control is
not possible like partially erupted and surgically exposed teeth.
• These are basically hydrophilic primers that polymerize in the presence of
moisture

49. • Bonding to amalgam and Co-Cr/ Ni-Cr alloys:
i. Sand blasting or surface roughening with a diamond bur,
ii. Use of intermediate resins that improve bond strengths like
All Bond 2
iii. Use of newer adhesives that bond chemically to precious
and non-precious metals like 4-META and 10- MDP bis GMA
resins.
iv. Panavia EX™ which is a filled bisGMA resin has been found
to bond strongly to polished amalgam surfaces which may
be due to a chemical bond

50. • Bonding to porcelain surface:
i. Barrier gel such as Kool-Dam -isolation
ii. Deglaze the area slightly larger than bracket base
by sand blasting with 50 um aluminium oxide - 3
seconds
iii. Etch porcelain with 9.6% HF for 2 minutes.
iv. Carefully remove gel with cotton roll and then
rinse using high volume suction.
v. Dry with air and bond bracket conventionally.

51. Shear bond strength of new and rebonded
orthodontic brackets to the enamel surfaces
Salama F, Alrejaye H, Aldosari M, Almosa N. Shear bond strength of new and rebonded orthodontic brackets
to the enamel surfaces. J Orthodont Sci 2018;7:12
• The bond strength of debonded sandblasted stainless-steel brackets was higher than new
brackets.
• Orthodontic bracket recycling provide a bracket that has ideal qualities comparable to new
brackets, and able to withstand all the forces.
• Recycling orthodontic brackets could be done in the dental office such as sandblasting that
provide higher SBS compared to new brackets due to the roughened surface.

52. SUMMARY
• The availability of custom-made bands has eliminated the need for band
pinching, which is a time consuming and difficult process for both the
operator and the patient.
• Bonding has eliminated need for bands on anteriors, however, bands are
still in use on molars.
• The preformed bands are available in different sizes and in most of the
instances, they fit nicely on careful selection.
• Molar bands may require little modification to suit abnormal morphology
of molars such as short occlusal gingival height of clinical crowns.
• Flawless and useful bonding requires a total understanding of etching
procedures, properties of bonding agents, besides following strict protocol
required, according to bonding, i.e. direct or indirect, and use of material
when could be selfcure or light cure.
• Successful bonding is an art which needs to be mastered in the background
of understanding the fundamentals of bonding and material properties

53. REFERENCES
• GRABERS TEXTBOOK OF ORTHODONTICS by Sridhar
Premkumar – Basic principles and practice 4th edition
• ORTHODONTICS Diagnosis and management of malocclusion
and dentofacial deformities by OP Kharbanda
• CONTEMPORARY ORTHODONTICS by Profitt WR 4th edition
• HANDBOOK OF ORTHODONTICS by Robert E Moyers
• www.indiandentalacademy.com( for usage of pictures)
• https://pocketdentistry.com/adhesives-and-bonding-in-
orthodontics/

54. THANK YOU