1 Indirect bonding technique in lingual orthodontics: the HIRO system

Indirect bonding technique in lingual orthodontics: the HIRO system

Toshiaki Hiro*, Fernando de la Iglesia**, Puigdollers Andreu***
*DDS, PhD, EBO. **DDS, PhD, Professor Orthodontics of the University International Of Catalunya. ***DDS, PhD, Chairman of Orthodontics of the University International Of Catalunya.
Correspondence to: Fernando de la Iglesia C/ Emancipacin 20 11 Barcelona 08022 SPAIN

Introduction
In the early 70`s, lingual orthodontics made a sensational debut, and the number of initiated cases increased exponentially. A few years later, the number of lingual orthodontic cases decreased greatly 1. The reason was very clear; most doctors could not achieve satisfactory results with lingual orthodontics. Since then, there are a few who practice lingual orthodontics and there are limited numbers of finished treatments. As time passed and problem solving associated with lingual orthodontics were improved, lingual orthodontics expanded around the World, specifically in European and Asiatic

The indirect bonding technique is pivotal for success in lingual orthodontics. There are different laboratory techniques available for indirect positioning and bonding of lingual brackets. The HIRO system is one of the most used and easy to perform. In this article the HIRO laboratory and bonding technique and the different innovations and improvements made to the previously described technique are presented.

Hiro T, De la Iglesia F, Puigdollers A. Indirect bonding technique in lingual orthodontics: the HIRO system. Prog Orthod 2008;9(2):34-55.

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Indirect bonding technique in lingual orthodontics: the HIRO system 2

countries. Today, lingual orthodontics is no longer a technique for limited numbers of orthodontists2. One of the most dramatic changes can be found in the evolution of the bonding procedures. Current bonding procedure is totally different from that of ten years ago. In the 90s orthodontists favoured the use of the silicone tray indirect bonding system. However, this technique didnt satisfy many orthodontists because of its lack of accuracy in indirect bonding. Other techniques began to develop and were based in an ideal arch to perform indirect bonding3. Dr. Hiro developed at the beginning of 1990 a laboratory system and indirect bonding technique that was published in 1998 4. The author described this technique as the Resin Core Indirect Bonding System (RCIBS). This techni-

que had a great impact in the lingual orthodontic world and was called the HIRO System. Every single laboratory and indirect bonding technique must match the following objectives: easy to make, provide accurate bonding, free from bonding failure, rebondable

and low cost. In this article we will explain the HIRO laboratory and bonding technique and explain the different innovations and improvements made to the previously described technique4. The laboratory and indirect bonding HIRO technique.

Fig. 1 Hard plaster models.

La tecnica di bonding indiretto un elemento fondamentale per la riuscita di un trattamento ortodontico linguale. Esistono attualmente diverse tecniche di laboratorio per il posizionamento e il bonding indiretto dei bracket linguali. Il sistema HIRO rappresenta una delle soluzioni di utilizzo pi frequente ed agevole. Il presente articolo illustra la tecnica HIRO e i numerosi miglioramenti ed innovazioni apportati alla versione precedentemente descritta.

Key words: Lingual orthodontics, Lingual Indirect Bonding technique, HIRO system.

1. Impressions of the patients mouth (Fig. 1) The impressions of the patients mouth can be taken with silicone, polyether or alginate if you can use a vacuum mixer. The models should be poured with hard plaster. 2. Setup (Fig. 2) Next fabricate the setup with a three point articulator. 3. Prepare the ideal archwire (Figs 3-4) Once the setup has been finished with wax, begin to bend an ideal archwire using the same width as the slot of the brackets that are going to be used (example: with a slot .018 bracket, we will use a .018 x .025 ss archwire). The bended archwire must follow the lingual arch form and must be as symmetrical as possible.

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3 Indirect bonding technique in lingual orthodontics: the HIRO system

Fig. 2a,b Models setup.

Fig. 3 Bending the wire.

by grinding or bending it. The brackets must be positioned in the gingival or inferior third of the tooth. This positioning will help the patients speech and occlusion by not creating any interferences. If we observe that the premolars have a very short clinical crown, a vertical step-down can be made on the archwire to compensate; another option is to build up the lingual cusp with composite resin.

If a step-down is made in the ideal archwire, this bend must be reproduced in the final archwires at the end of the treatment. 4. Position the surgical hooks (Figs 5-6) Once the ideal arch has been done and the brackets are correctly positioned in the centre of the teeth, remove the arch wire from the setup and crimp three surgical hooks on

La technique indirecte de bonding est prioritaire pour le succs dans lorthodontie linguale. Il y a diffrentes techniques de laboratoire disponibles pour le positionnement et le collage indirects des brackets linguales. Le systme de HIRO est une de plus employe et facile excuter. En cet article la technique de laboratoire et de collage de HIRO et les diffrentes innovations et amliorations apportes la technique prcdemment dcrite sont prsentes.
Traduit par Maria Giacinta Paolone Fig. 4 Ideal archwire.

Before doing the premolar bend, it is advisable to position the six anterior brackets initially. This will make the brackets have the smallest possible gap between the mesh pad and the tooths lingual surface. Sometimes, the bracket form does not adapt to the dental anatomy, so we will have to make adjustments to the mesh pad

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Indirect bonding technique in lingual orthodontics: the HIRO system 4

Fig. 5a,b Crimped surgical hooks.

Fig. 6 Bend the surgical hooks lingually.

Fig. 8a,b Stick the dosel pins under the surgical hooks.

Fig. 7 Heat the dosel pins.

the wire. This will help position the archwire in the setup. The hooks will be positioned between the two central incisors and between the

La cementacin indirecta es una tcnica fundamental para el xito en el tratamiento ortodontico lingual. Existen diferentes tcnicas de laboratorio disponibles para el posicionamiento indirecto y la cementacin con brackets de la tcnica lingual. El sistema HIRO es uno de los ms utilizados y fciles de aplicar . En este artculo, se presentan las diferentes innovaciones de cementacin propuestas por el laboratorio HIRO con respecto a las tcnicas descrita anteriormente.
Traducido por Santiago Isaza Penco

first and second molars in both sides. Afterwards the surgical hooks are bent lingually. 5. Position the dowel pins (Figs 7-9) Next, heat three dowel pins and stick them in the wax base just under the surgical crimped hooks. 6. Fabricate the acr ylic resin hoods (Figs 10-11) Once the dowel pins are fixed in the wax the next step is to fabricate the acrylic resin hoods powderliquid that will help position the archwire exactly when rebonding. Use gutta-percha at two points of the arch to keep the wire for a

Fig. 9 Dosel pins positioned.

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5 Indirect bonding technique in lingual orthodontics: the HIRO system

Fig. 10a,b Fabricate the acrylic resin hoods.

Fig. 11a,b Acrylic resin hoods fabricated.

Fig. 12 Block out the molar small grooves with wax.

Fig. 13a,b Soap the casts and polish them afterwards.

short time in its position until the acrylic resin hoods have been finished (observe the detail of the gutta-percha on top of the arch at the canine). When making the acrylic resin hoods the resin must cover the crimped surgical hooks totally and the dowel pins partially. Now the ideal archwire can be positioned exactly in the model at any time thanks to the acrylic resin hoods and the dowel pins. 7. Prepare the models (Figs 12-13) Subsequently, block out the molar

small grooves with wax to prevent them from being retentive when the rigid cores are being constructed. Next soap the casts for 3 to 4 hours and polish them afterwards. Soaping the models is done instead of applying separator. Since the separating layer of soaping is quite thin the brackets can be bonded much more precisely comparing it with applying separator to the model. 8. Transfer the information from the setup to the bracket (Fig. 14) The next step is to transfer all the in-

formation of the setup to the brackets. First we will apply light cure composite resin (Transbond3M) on the bracket bases. Position the archwire in the setup with the help of the acrylic resin hoods. Then cure all the light cure composite resin of the bracket bases. Now all the information of the setup has been transferred to the brackets. 9. Construction of the resin cores (Figs 15, 16 and 17) This is the time to begin the construction of the transfer resin cores.
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Fig. 14a,b Apply light cure composite resin on the brackets bases and position the ideal archwire.

Fig. 15 Cover all the brackets with provisional dental resin ( Fermit).

Fig. 16a,b Use a liquid-powder acylic resin to construct the resin cores.

Fig. 17a,b Elastic ring positioning.

Fig. 18a,b Transfer resin cores finished.

First cover all the brackets with provisional dental resin (Fermit Vivadent) paying special attention in not covering the ideal archwire and coPROGRESS in ORTHODONTICS 2008; 9(2):34-45

vering 1-2 mm of the teeth beyond the brackets base. This material adheres to the brackets and its elasticity makes the removal of the resin cores

easy. Do the same for all the brackets and cure the provisional dental resin (Fermit Vivadent). The next step is to mark with a pencil the lingual functional cusps of molars and premolars. This will help as a reference guide for re-checking the height of the brackets. The brackets must never be positioned higher than the functional cusps. Another reason for marking the cusps with a pencil is to leave a small hole in the resin core. This will permit the excess of adhesive to come out. Afterwards use a powder-liquid acrylic resin to construct the resin cores and before the acrylic has harden put an elastomeric ring that will help afterwards transfer the individual resin cores from the model casts to the patients mouth. 10. Polish the resin cores (Figs 18-20) Once all the resin cores have been completed, they are numbered according to the tooth and separated from the setup. Excess resin is ground off and a heated instrument used to cut the elastomeric ligatures. This allows for separation of the resin core from the ideal archwire. At this time, all the transfer resin cores are done and the bonding can begin. 11.- Picture of the transfer resin cores (Fig. 21)

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7 Indirect bonding technique in lingual orthodontics: the HIRO system

Bracket bonding
The bonding technique is simple but has some peculiarities. First, the teeth must be etched with orthophosphoric acid. (Fig. 22). After 15 seconds rinse with water and dry. Apply a thin coat of bond to the etched surface (Fig. 23) and afterwards apply a very small amount of bond and light-curing composite to the bonding surface of the bracket. (Transbond) (Fig. 24). Carefully pick the transfer resin core by the elastomeric ring (Fig. 25) and seat the resin core on the corresponding tooth. Using a light-curing lamp, cure for at least 20 seconds (Fig. 26). Subsequently with a pointed instrument separate the acylic resin from the transfer core (Fig. 27). Then take off the provisional dental resin (Fermit) from the bracket. Now the bracket is rea.

Fig. 19a,b Grind off the excess resins and cut the elastic ligatures.

Fig. 20a,b Transfer resin cores ready to be bonded.

Bracket rebonding
Any indirect bonding technique in lingual orthodontics must be easy and quick to perform when rebonding brackets. With the HIRO system, rebonding of brackets is easy and can be done in the office in a short period time. The transfer resin cores used at the beginning of treatment cannot be used again for rebonding. Firstly, the new bracket is positioned on the ideal wire of the setup with an elastomeric ring. Afterwards seat the ideal wire in the setup using the acrylic resin hoods (Fig. 28). Next, build up the transfer resin core as shown in figures 14-17. First apply light-curing composite (Transbond) in the bonding surface of the bracket, cover partly the bracket with provisional dental resin (Fermit) and subsePROGRESS in ORTHODONTICS 2008; 9(2):34-45

Fig. 22 Etch the lingual surface with orthophosphoric acid.

Fig. 21 Transfer resin cores. Fig. 23 Apply a thin coat of bond to the etched surface.

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Indirect bonding technique in lingual orthodontics: the HIRO system 8

Fig. 24a,b Apply a very small amount of bond and lightcuring composite.

Fig. 25 Pick the transfer resin core.

Fig. 26 Seat the resin core and cure.

Fig. 27 Separate the acylic resin from the transfer core.

Fig. 28a,b Rebonding of brackets. Seat the ideal wire using the acrylic resin hoods.

Fig. 29a,b Transfer resin core finished.

She had no history of physical trauma to the head or neck. The patient had a convex profile with a symmetric face and lip competence at rest. Intraorally, she had a bilateral Class I molar and canine relationship. She had a correct overjet and 2 mm of overbite. The maxillary arch was Ushaped with mild crowding. The mandibular arch also was U-shaped and had mild crowding. The cephalometric analysis showed a skeletal Class II anteroposterior discrepancy with an ANB angle of 6,2 and a normofacial pattern, as shown by an SNGoGn of 38. The lower incisors were excessively protruded as shown by an IMPA of 101,7. (Fig. 30). The treatment plan was not to protrude the upper and lower incisors and solve the upper and lower crowding. The decision taken was to extract the first upper and lower premolars. Figures 31- 34 shows the patient`s evolution. Orthodontic treatment lasted 20 months. An acceptable occlusion was obtained. Figure 35 shows the three year follow-up. The superimposed cephalometric tracings (Fig. 36) show a correct incisor inclination at the end of treatment.

quently add liquid-powder acylic resin to build up the resin cores . It takes just 3 minutes to build up the transfer resin core (Fig. 29).

Clinical case
A 26-year-old woman was referred for orthodontic consultation. Her chief complaint was her crowded teeth.

Discusion
There are many different indirect

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9 Indirect bonding technique in lingual orthodontics: the HIRO system

Fig. 30a

Fig. 30b

Fig. 30a-c Pretreatment records.

bonding techniques in lingual orthodontics. The HIRO system has some advantages which are1: No electronic equipment is needed for bracket positioning or rebonding, and consequently there is no commercial relationship to any company. There is no need to transfer brackets from the setup model to the original cast (malocclusion model) as in the CLASS system. Extractions, elastic separations,

expansion and/or distalization can be carried out between impressions and bonding. The individual hard tray is very small and rigid, making bonding more accurate. This eliminates deformations and poor adhesion due to excess flexibility. In other indirect bonding techniques the transfer is done with silicone trays, and the bonding is less accurate because the position of the bracket will vary depending on the amount of presPROGRESS in ORTHODONTICS 2008; 9(2):34-45

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Indirect bonding technique in lingual orthodontics: the HIRO system 10

Fig. 31 Records at two months of treatment. Upper and lower 0.12 Ni-Ti archwires.

Fig. 32 Records at 10 months of treatment. Upper .014 ss archwire and lower .016 x .022 TMA archwire.

sure applied to the tray. This excess of flexibility of the silicon trays is corrected by some clinicians with different thermoplastic materials that make the trays harder. The resin core has no relation with tooth alignment, so bracket/tooth fit against it is not affected by tooth movement. Limited composite overflow makes hygiene easier, is more comPROGRESS in ORTHODONTICS 2008; 9(2):34-45

fortable for the patient and also reduces chairtime. In cases of severe crowding, sequential bonding is easier to manage than in other lingual indirect bonding procedures. Rebonding is quick, easy and economic to perform with the setup model and the ideal archwire. Is an easy, economic and accurate system.

It takes approximately ten to fifteen minutes to bond a complete arch, more or less the same time that with other techniques such as the silicone trays.

Conclusions
The HIRO indirect bonding technique is easy, economic and accura-

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11 Indirect bonding technique in lingual orthodontics: the HIRO system

Fig. 33 Extraction spaces closed at 20 months of treatment. Upper .017 x .025 TMA and lower .016 x .022 TMA archwires.

Fig. 34a

Fig. 34b

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Indirect bonding technique in lingual orthodontics: the HIRO system 12

Fig. 34a-c Postreatment records.

Fig. 35 Three years postreatment records.

Fig. 36 Superimposed cephalometric tracings.

te and makes the orthodontist have reliable results in any orthodontic treatment.

References
1. Scuzzo G, Takemoto K. Invisible Orthodontics. Current concepts and solutions in lingual orthodontics. Germany, Quintessence, 2003.

2. Buso-Frost L, Fillion D. An overall view of the different laboratory procedures used in conjunction with lingual orthodontics. Semin Orthod 2006; 12: 203-10. 3. Macchi A, Nidoli G, Lazzati M. Direct or indirect application of the Lingual Brackets. Mondo Ortod 1984; vol. 3: 73-82. 4. Hiro T. Resin Core Indirect Bonding System: Improvement of Lingual Orthodontics. J. Japan Orthod. Society 1998; 57 (2): 83-91.

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