AIN SHAMS DENTAL JOURNAL

JOURNAL
Official Publication of Ain Shams Dental School
September 2020 • Vol. XXIII

Print ISSN 1110-7642

Online ISSN 2735-5039

Evaluation of Segmented versus Full Arch Three

Dimensionally Printed Transfer Tray for Orthodontic
Indirect Bonding: (A randomized clinical trial)
Mariam El Sebaay (1) , Khaled Hazem(2), Amr Ragab El-Beialy (3) and

Mai Hamdi Aboul Fotouh (4)

Abstract
Objective: This study is conducted to overcome the problems of conventional indirect bonding technique,
through investigating accuracy of two novel three dimensionally digitally printed indirect bonding transfer
trays (full arch & segmented) in terms of accuracy of transferring brackets, rate of immediate bond failure and
chair side time.
Methods: Fourteen patients (7 in each group) with mild to moderate crowding, requiring orthodontic treatment
with full set of permanent teeth including second molars, will be selected for this study. A total of 196 brackets
will be used (98 Full Arch Tray and 98 Segment Arch Tray). The same bracket type and bonding material will
used in both groups. The accuracy of bracket transfer will be measured by 3 Shape Ortho planner software
(Bracket Placement Module), rate of bond failure by counting number of debonded brackets upon tray removal
& chair side time by using digital watch.
Results: Linear attachment deviations were within the clinically acceptable range of deviation (+/- 0.5 mm) in
all three planes for both techniques. Both techniques showed no differences in linear directional deviation in
the mesio-distal plane, occluso-gingival and bucco-lingual.
Conclusion: Both techniques appeared to be comparable for the percentage of linear directional deviation.
Segmented tray technique showed less bond failure rates compared to the full arch tray technique; however the
percentage of tube failure was higher than bracket failure in full arch bonding techniques. The chairside time
difference between the two indirect bonding techniques was statistically significant, with the full arch tray
technique taking less chairside time than segmented tray technique.

1. Master’s degree Student Orthodontic Department, Faculty of Dentistry, Cairo University

2. Professor of Orthodontics Orthodontic Department, Faculty of Dentistry, Cairo University
3. Associate Professor of Orthodontics Orthodontic Department, Faculty of Dentistry, Cairo University
4. Lecturer of Orthodontics, Faculty of Dentistry, Cairo University
 ASDJ September 2020 vol XXIII Orthodontics and Pedodontics' section 88

Background

Indirect bonding technique was first introduced From the main disadvantages of indirect
in 1972 by Silverman, Cohen, Gianelly and bonding technique is bond failure. It was found
Dietz. Their technique depends mainly on that the percentage of bond failure is 3.54% for
bracket positioning on dental cast and their direct technique, 5.79% for indirect one.5A
transfer intraorally by means of transparent modified technique was then introduced called
vacuum tray.1The popularity of indirect modified Fantozzi technique which involves 2
technique increased recently because of its trays of different materials, the inner one is soft
advantages over the direct one which include: while the outer one is rigid. This technique
more precise bracket positioning, which decreases rate of bond failure during removal of
eventually will decrease the need of finishing soft tray and at the same time more precise &
bends and length of orthodontic treatment. stable bracket placement which is achieved by
Moreover, it reduces chair side time and thus it rigid tray.6
is considered a more comfortable technique for Several studies were conducted to reach a
the patient.2 reproducible technique with standard results;
The accuracy of indirect bonding however none have reached to the most reliable
technique depends greatly on transfer tray. Thus, technique because of the human factor that can’t
different materials of transfer tray were be excluded starting from bracket placement and
introduced since 1999 including: hybrid systems ending with bracket transfer using transfer tray.7
made of resin and silicone, either for full arch or Digitization was recently introduced in
segmented trays. In an attempt to reduce bond orthodontic field with the evolution of 3D
failure, segmentation of the indirect bonding imaging & printing machinery. These new
tray was a suggestion, and segmented tray was technologies offer superb accuracy as well as
found to be more efficient in controlling elimination of errors emerging from human
isolation and tray placement when compared to variations. Intraoral scanner devices offer
full arch tray, and hence reduces bond failure.3 numerous applications in orthodontics such as
Segmented tray was introduced either fabricated digital storage of study models and advanced
of two segments only (one for each quadrant) or software for bracket placement, enabling
three segments (one anterior and two posterior fabrication of three dimensionally printed
segments) for each arch. bracket transfer tray.8 Therefore, utilization of
Concerning accuracy of bracket 3D imaging and printing techniques can help the
positioning using indirect bonding technique, orthodontist to reach the most precise and
this may be attributed to any contamination that reproducible indirect bonding technique with
may occur during transfer, thickness of bonding more accurate and standard results.
material between teeth & brackets or any error Thus to overcome previously mentioned
that occurred during transfer tray fabrication. problems of conventional indirect bonding
However, segmented trays showed high technique, this study is conducted in an attempt
accuracy of bracket positioning during transfer to investigate accuracy of two novel three
reaching 98% regarding buccolingual & dimensionally printed indirect bonding transfer
mesiodistal dimension.4 tray (full arch & segmented) in terms of
accuracy and immediate bond failure.
Material & Methods the Department of Orthodontics, Faculty of
Dentistry, Cairo University after clinical and
This randomized controlled trial was approved radiographic examination proved them eligible
by the Research Ethics Committee of the Faculty for a non-extraction based orthodontic
of Dentistry, Cairo University. Patient selection treatment. Eligible patients were enrolled in a
for this trial was done in the outpatient clinic of consecutive series. Non-syndromic, non-

EVALUATION OF SEGMENTED VERSUS FULL ARCH THREE DIMENSIONALLY PRINTED TRANSFER TRAY FOR
ORTHODONTIC INDIRECT BONDING: (A RANDOMIZED CLINICAL TRIAL) | Mariam El Sebaay et al Sep2020
 ASDJ September 2020 vol XXIII Orthodontics and Pedodontics' section 89

extraction with 2-4 mm crowding cases were (preoperative scan) by intraoral 3D scanner
included. All patients will be treated by fixed of 3Shape Company (Copenhagen,
orthodontic appliances using indirect bonding Denmark) & 3D model will be used for
technique (Silverman, 1972).The key of digital bracket placement.
modification is digital bracket placement using 2. Fabrication of trays: 3D printing of
bracket placement module of 3 Shape Ortho segmented digital bracket transfer tray (two
planner Software (3Shape Company- segments; splitted at the midline) ,as shown
Copenhagen, Denmark) instead of manual in figure 2, for patients of treatment group &
bracket placement directly on study model, and full arch tray will be fabricated for control
fabrication of segmented digital bracket transfer group as shown in figure 1. Trays will be
tray using bracket transfer module of same printed using Dent 1 3D Printer (Mogassam,
software instead of vacuum transfer tray. Cairo, Egypt) with XY resolution 50 um & Z
Regarding control group, all patients of this layer thickness 25 um and capability of
group will follow same steps of indirect bonding printing up to 3 cm per hour. The printer also
procedure as treatment group but the tray allows the use of any kind of printing resin
fabricated will be full arch tray instead of
segmented one. Chairside time will be recorded
& number of debonded brackets will be recorded
following tray removal. Comparison between
position of brackets on pre & post-operative scan
will be done.

The following steps will be performed for each

patient: Fig. 1 Full arch tray
Initial records:

• Case History: Personal information,

Medical & Dental History.
• Study Model: An impression of upper &
lower arches will be taken using
condensation silicone elastomeric
impression material in a metal tray with Fig. 2 Segmented tray
patient fully awake and without any
anesthesia in a clinical setting. The upper 3. Clinical application of digital tray:
impression will be carefully scanned by
desktop scanner. • Fitting of metal brackets into digital tray &
ensure keeping them in place in their precise
• Photographs: Standardized digital
rooms created for them.
photographs (frontal, profile, oblique) will
be taken with a Canon EOS 750D digital • Teeth to be bonded are polished and etched.
camera (Canon, Tokyo, Japan) for all • Teeth isolation & moisture control are
patients. achieved.
• Panoramic Radiographs: Standardized • Adhesive bond is applied to teeth and
panoramic radiographs will be taken for all composite is applied to brackets (3M Unitek,
patients. Monrovia, California, USA) fitted to digital
• Lateral Cephalometric Radiograph: trays.
Standardized lateral cephalometric • Placement of tray with brackets on prepared
radiographs will be taken for all patients. teeth carefully & ensure complete fitting of
1. Scanning & digital bracket placement: tray.
The upper arches will be carefully scanned
• Start curing of composite.

EVALUATION OF SEGMENTED VERSUS FULL ARCH THREE DIMENSIONALLY PRINTED TRANSFER TRAY FOR
ORTHODONTIC INDIRECT BONDING: (A RANDOMIZED CLINICAL TRIAL) | Mariam El Sebaay et al Sep2020
 ASDJ September 2020 vol XXIII Orthodontics and Pedodontics' section 90

• Chair side time will be recorded. The statistical analysis was performed by
Tray Removal specialized statistician using IBM SPSS
• After complete curing of composite, Statistics Version 20 for Windows.
digital tray will be removed carefully. Table (1): Normality exploration of each
• Number of brackets that will be attachment on each tooth for both groups:
debonded following tray removal will be
counted & recorded. N: Attachments count
• Scanning of bonded teeth (Post-
P - value
operative scan) by intraoral 3D scanner Group I Group
of 3Shape company (Copenhagen, N (Segmented
Tray)
II
(Full
Denmark) & position of brackets will be Arch
Tray)
compared with preoperative scan by Linear Mesio- 144 >0.05 >0.05
superimposition of brackets scanned pre Measurements distal
Deviation
& post-operatively by the aid of colour (X-axis)
Occluso- 144 >0.05 >0.05
map. gingival
Deviation
(Z-axis)
To sum up, participant timeline can be Bucco- 144 >0.05 >0.05
summarized as follows: lingual
Deviation
(Y-axis)
Tip 144 >0.05 >0.05
Angular Difference
Measurements Torque 144 >0.05 >0.05
Difference
Rotational 144 >0.05 >0.05
Difference
Chair side time 144 >0.05 >0.05

Table (2): Percentages of mesial and distal

deviation in group I and II:
Mesial Distal
P-value
Group I 45 % 55% 0.631
(Segmented
Tray)
Group II (Full 40 % 60 % 0.337
Results Arch Tray)
P-value 0.808 0.810
The results of the trial will be presented under
the following headings: Table (3): Percentages of occlusal and
1. Data normality (Table 1).
2. Accuracy of transfer of orthodontic gingival deviation in group I and II:
attachments by the two different digital trays
in terms of mesiodistal (Table 2), Occlusal Gingival
P-value
occlusogingival (Table 3), buccolingual Group I 47% 53 % 0.337
(Table 4) deviations. (Segmented
Tray)
3. Bonding failure of orthodontic attachments Group II 65 % 35% 0.152
between the two indirect bonding techniques (Full
Tray)
Arch

(Table 5). P-value 0.384 0.381

4. Chairside time between the two indirect
bonding techniques (Table 6).
5. Inter-observer & Intra-observer Reliability
(Table 7 & 8).

EVALUATION OF SEGMENTED VERSUS FULL ARCH THREE DIMENSIONALLY PRINTED TRANSFER TRAY FOR
ORTHODONTIC INDIRECT BONDING: (A RANDOMIZED CLINICAL TRIAL) | Mariam El Sebaay et al Sep2020
 ASDJ September 2020 vol XXIII Orthodontics and Pedodontics' section 91

Table (4): Percentages of buccal and lingual Table (7): Intra-observer reliability of linear
deviations in group I and II: measurements in both groups
Intra-observer Group I Group II
Buccal- Lingu reliability
out al- in P-value 1 0.96 0.98
Group I 42 % 58 % 0.431
2 0.92 0.94

Mesiodistal
(Segmented
Tray) 3 0.93 0.96
Group II 47 % 53% 0.775 4 0.88 0.91
(Full Arch
Tray) 5 0.95 0.96
6 0.83 0.98
1 0.95 0.96
P-value 0.809 0.849
2 0.96 0.98

Occlusogingival
*Significant difference 3 0.94 0.96

Linear measurements
4 0.97 0.87
%; Percentage, P: Probability level 5 0.95 0.93
Table (5): Total count of attachment failure
of brackets and tubes for both groups: 6 0.97 0.94

1 0.98 0.82

2 0.93 0.94

Buccolingual
3 0.98 0.85

4 0.98 0.841

5 00.95 0.98
6 0.99 0.97

• ≥ 0.5 (reliable=agreement).
Table (8): Inter-observer reliability of linear
measurements in both groups
Intra-observer Group I Group II
reliability
Table (6): Showing means and standard 1 0.95 0.94
Mesiodistal

2 0.99 0.98
deviations in chairside time between 3 0.98 0.97
segmented tray and full arch digital tray: 4 0.92 0.90
5 0.95 0.95
6 0.92 0.94
N 1 0.91 0.9
Group
Occlusogingival

2 0.92 0.9
-Linear measurements

Group I Group II P-
3 0..97 0.93
(Segmented (Full Arch Tray) 4 0.95 0.94
value
Tray) (minutes)
(minutes) 5 0.98 0.93
M SD M SD 6 0.98 0.97

Chair 17.3 0.05

Side
12 15.4 0.02 0.005* 1 0.97 0.78
Time 2 0.92 0.93
Buccolingual

N; Patients Count, M: Mean, SD: Standard 3 0.98 0.95

Deviation, P: Probability level 4 0.96 0.93

*significant difference 5 0.96 0.96

6 0.93 0.98

• ≥ 0.5 (reliable=agreement).

EVALUATION OF SEGMENTED VERSUS FULL ARCH THREE DIMENSIONALLY PRINTED TRANSFER TRAY FOR
ORTHODONTIC INDIRECT BONDING: (A RANDOMIZED CLINICAL TRIAL) | Mariam El Sebaay et al Sep2020
 ASDJ September 2020 vol XXIII Orthodontics and Pedodontics' section 92

DISCUSSION hypoplasia were excluded to avoid jeopardizing

Placement of orthodontic attachments on bonding ability.
the patient’s dentition is usually accomplished Concerning the accuracy of attachment
by either a direct or an indirect bonding transfer in all three planes was measured using
technique. Indirect bonding was first developed the method that is described by Elnigoumi11
by Silverman and Cohen9 (1972) to reduce which was based on the reliability of 3D models
clinical time and to enhance patient comfort. The in terms of linear and angular measurements. He
indirect bonding technique allows better three- carried out the study using digital scans and
dimensional visualization of tooth positioning digital measurements on (Geomagic software
and, as a result, greater accuracy while version 12). The usage of digital scanning had
positioning orthodontic attachments will be the following advantages: (1) Precise and
achieved. Accurate bracket placement early in reproducible measurements unlike the 2D
treatment will reduce the need for later photography images that were used previously,
repositioning or complex wire bending at the (2) Capturing minute details up to parts of
finishing stage, thus improving efficiency of microns due to the ultimate accuracy of intraoral
treatment and shortening treatment time, which scanners and (3) Prevention of subjecting the
will reduce the complications accompanying patient to any kind of unnecessary radiation such
orthodontic treatment such as white spot lesions as CBCT which was used earlier to test the
and root resorption and will increase patient accuracy of indirect bonding.
satisfaction. Referring to the results of the present study,
Various modifications have been suggested it was essential to highlight the statistical
to improve the indirect bonding technique, in findings of the different outcomes of the current
order to yield better clinical results. With the study. Furthermore, it was mandatory to
evolution of 3D imaging techniques and 3D compare them to the findings of similar studies
printing methods, the use of digital models in in the previous literature.
diagnosis and treatment planning has been a As for accuracy of attachment transfer,
routine clinical procedure due to ease of storage, linear measurements were done for each
longevity and comparable accuracy to the plaster attachment. Any deviation in the attachment
models which expected to be replaced by digital position (linear and/or angular), refers to the
study models. Such evolution also used while positioning of the attachment itself. For
measuring different outcomes that are used to example, a value of 0.1 mm in a certain plane
evaluate any novel indirect transfer tray. As would reflect that the tube was bonded 0.1 mm
Grunheid et al10 (2016) used CBCT to scan the away from the position it was originally intended
models and polyvinyl siloxane as a transfer tray based on the working model. For linear
to be the only in vivo study carried out, while all measurement deviation, the readings were
other studies where in vitro. Thus unfortunately, compared relative to the accepted range of +/-
no sufficient evidence compared the accuracy of 0.5 mm which was reported by Grunheid et
different transfer tray and their designs. al10.
Design of current study was chosen as Regarding the chairside time between
randomized controlled trial because such design the two used indirect bonding techniques, there
is at the top of hierarchy of evidence, providing was a statistically significant difference, where
highest level of evidence. the mean clinical chairside time of full arch tray
All the participants were encouraged to was (15:4 minutes), while the segmented tray for
make full mouth scaling and polishing prior to the full arch was (17:3 minutes). This finding
bonding taking in order to ensure a healthy was similar to Bozelli et al.12 (2013) who came
periodontium and provide a clean tooth surface up with the conclusion that the clinical time for
ready for bonding. Moreover, any chipped bonding using segmented tray (6.3 minutes per
incisal edges were smoothened in order to allow segment, 12.6 minutes per arch) and full arch
for maximum precision and tray seating during tray (14.8 minutes). Such difference in clinical
bonding. However, teeth with enamel time can be explained that latter study has not

EVALUATION OF SEGMENTED VERSUS FULL ARCH THREE DIMENSIONALLY PRINTED TRANSFER TRAY FOR
ORTHODONTIC INDIRECT BONDING: (A RANDOMIZED CLINICAL TRIAL) | Mariam El Sebaay et al Sep2020
 ASDJ September 2020 vol XXIII Orthodontics and Pedodontics' section 93

included tubes during bonding. Regarding bond failure rates compared to the full arch tray
clinical time of full arch tray, the finding of technique, however the percentage of tube
present study was similar to Yildirim and failure was higher than bracket failure in full
Adinatay13 who reported their chairside time in arch bonding techniques. The chairside time
indirect bonding technique to be (15 minutes). difference between the two indirect bonding
Moreover, considering the indirect bonding techniques was statistically significant, with the
techniques themselves, there was lack of full arch tray technique taking less chairside time
sufficient evidence comparing the chairside time than segmented tray technique.
between indirect bonding techniques.
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EVALUATION OF SEGMENTED VERSUS FULL ARCH THREE DIMENSIONALLY PRINTED TRANSFER TRAY FOR
ORTHODONTIC INDIRECT BONDING: (A RANDOMIZED CLINICAL TRIAL) | Mariam El Sebaay et al Sep2020
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EVALUATION OF SEGMENTED VERSUS FULL ARCH THREE DIMENSIONALLY PRINTED TRANSFER TRAY FOR
ORTHODONTIC INDIRECT BONDING: (A RANDOMIZED CLINICAL TRIAL) | Mariam El Sebaay et al Sep2020