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A COMPARISON OF BRACKET FAILURE RATE BETWEEN DIRECT AND

INDIRECT BONDING TECHNIQUES: A PROSPECTIVE CLINICAL STUDY

Article  in  Al-Azhar Journal of Dental Science · January 2020

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 Al-Azhar Journal of Dental Science Record 1110-2624 | the ISSN Portal
Vol. 23- No. 1- 79:86- January 2020 portal.issn.org

A COMPARISON OF BRACKET FAILURE RATE BETWEEN DIRECT AND

INDIRECT BONDING TECHNIQUES: A PROSPECTIVE CLINICAL STUDY

Ahmed Basheer Ayyed*, Ramadan Yousef Abu Shahba**, Mohamed Helmi Saleh**, Farouk Hussain**

ABSTRACT
Objective: The aim of the present study was to make a clinical comparison of bracket position accuracy and failure rate
between direct and indirect bonding techniques. Subjects and methods: Thirty patients were selected. Patients divided into two
groups according to the technique, each group consist of 15 patients. Group A included the patients that treated with direct bonding
technique. Group B included the patients that treated with indirect bonding technique. Check-up was carried out every 3 weeks
and a special sheet was used to record the failure rate of the brackets. Results: 294 brackets were bonded in a group A (direct
technique), and only 39 brackets were debonded. 290 brackets were bonded in a group B (indirect technique), and only 47 brackets
were debonded. Conclusion: Generally, there is not clinically significance in the failure rate between direct and indirect bonding
techniques.

KEYWORDS: Bracket, failure, direct, indirect, bonding.

INTRODUCTION Indirect bonding method became very popular

after it was first described by Silverman and Cohen
One of the aims of orthodontics is improving the in 1972. This technique was proposed due to its many
dental health; this is achieved through positioning advantages, it is more time-saving as it optimizes
the teeth into the best functional balance. Another the use of the orthodontist’s time, removal of flash
aim is to obtain the maximum esthetical outcome to the bracket bases which can promote plaque and
for the patient. By far the most commonly used calculus formation. In addition to minimizing the
appliance in fixed orthodontic treatment is the patient’s discomfort and increasing the stability
dental brackets (1). of the treatment as the most valuable goal of
orthodontic treatment is to create permanent results.
There are numerous techniques regarding the The indirect bonding technique play an important
bonding of the brackets, including direct and indirect role in enabling the clinician to modify the bracket
bonding techniques. Traditional direct brackets position according to the patient’s need especially
placement involves placing each bracket directly in deep-bite cases (2-12).
on the tooth by operator. While the indirect bonding There are various techniques of indirect bond-
technique is executed by attaching the brackets on ing, according to bracket base preparation (standard
dental casts in the laboratory then transferring these or customized), transfer mask type (single jigs or
brackets to the patient’s teeth through transferring full arch) and transfer tray material (acrylic resin,
trays (2). silicone, thermo-printed material) (2,14,16).

* Graduate Students, Department of Orthodontics, Faculty of Dentistry, Al Azhar University

** Assistant Professor, Department of Orthodontics, Faculty of Dentistry, Al Azhar University
80 Ahmed Basheer Ayyed, et al. A.J.D.S. Vol. 23, No. 1

Brackets failure considered to be a major con- and Girls Branches. Thirty orthodontic patients both
cern during orthodontic treatment with fixed appli- males and females are selected and treated by the
ances, as it can be upsetting and, in some instances, researcher. Sample size calculation was undertaken
critical in the overall success of the treatment. The according to previous study.
detachment of the brackets during corrective proce-
Inclusion criteria: The age should be ranging
dures may also lead to an increase in the duration
between 14 and 24 years, also both sexes are
of the treatment, damage to tooth enamel, and in-
included. This orthodontic treatment should be
creased chairside-time due to re-bonding procedure.
Hence, it could also elevate the costs of the over- the first orthodontic treatment for the patient. The
all orthodontic treatment, consequently multiple patients should have a good general health and oral
studies have reported varying incidence of bracket hygiene. The patients should have a permanent
failure following orthodontic brackets bonding. dentition with minimal to moderate crowding. Also,
Multiple studies have reported varying incidence the patients should have normal enamel.
of bracket failure following orthodontic brackets Exclusion criteria: Patients that may need an
bonding, while other studies compared various tech-
extra oral appliance, also the patients have retained
niques of orthodontic bonding and rates of brackets
deciduous teeth or having dental morphogenesis
failure.(16-26)
anomalies. Patients with attrition, fractured/restored
The indirect technique was considered inferior incisal edges or cusp-tips. Uncooperative patients
due to the high number of brackets lost, in addition who miss two successive appointments or didn’t
to the increased time that required for procedure of follow the operator’s instructions. The patients have
bracket placement and removal of excess adhesive systemic or genetic disease that could interfere with
flash around the bracket bases. The reasons of orthodontic treatment.
that high failure rate were thought to be due to
Ethical considerations: An informed consent
the chemically-cured composite adhesive that
form that explains every step in the research was
was used and it may back to the variations of the
given and discussed carefully with the patients
technique. Several studies have been conducted
in order to evaluate the effectiveness of indirect before participation in the study and was signed
technique. Hence, only few reports evaluated the freely. The objectives of the study were discussed
clinical reliability of the indirect bonding technique and explained with the patients and / or guardians
compared with the direct bonding technique (2,24). as well.

This study aimed to create a make a clinical Patient allocation: The patients were randomly
comparison of failure rate between direct and divided equally into two groups according to the
indirect bonding techniques. type of bonding technique that was used. Group
A (direct bonding group) this group included 15
SUBJECTS AND METHODS patients treated with direct bonding technique.
Group B (Indirect bonding group) this group include
The design of this study was a randomized 15 patients treated with indirect bonding technique.
clinical study. The unit of analysis and randomization
is the individual patient. This longitudinal study Preparation for bonding: According to
was conducted on patients seeking orthodontic previous study, a similar method was employed to
treatment in the outpatient clinic, Faculties of prepare the teeth for bonding whether a direct or
Dental Medicine, Al-Azhar University, Cairo, Boys indirect technique was to be used. Each arch of teeth
A.J.D.S. Vol. 23, No. 1 A COMPARISON OF BRACKET FAILURE RATE BETWEEN DIRECT 81

was prepared and bonded separately to decrease the The indirect bonding technique (laboratory
risk of moisture contamination. Teeth were polished stage): Models were cast on the same day as
for five seconds each using a bristle brush in a slow impression taking to ensure accurate fit of the
speed hand piece with a slurry of pumice and water. transfer trays and trimmed to allow easy use of the
The teeth were then rinsed with an air/water spray vacuum forming machine. The appropriate bracket
until all traces of pumice had been totally removed. (Versatile Roth American orthodontics – Low
A cheek retractor and a flexible saliva ejector were profile master series.) was selected for each tooth
used to provide a control for moisture, and cotton and a small amount of composite material (3M
wool rolls were placed in the buccal and lingual Composite TransXT), was placed onto the base. The
sulci to improve isolation. The teeth were then dried separating medium (Sphinx Alexandria) applied on
with oil-free compressed air for 5s each and etched the teeth and left for 7 minutes to get dried. Each
for 20s a with 37% phosphoric acid*, in accordance bracket was then positioned on its tooth and the
with the manufacturer’s instructions. Each tooth adhesive was light cured after fully insurance that
was rinsed thoroughly for 15s until all the traces of the bracket placed in it’s ideal position, using light
the blue etching gel were removed before they were cure device (Woodpecker Curing light led.B). Trays
dried again with oil-free compressed air until they were made using a .040” (1mm) thick blank of
exhibited a frosty white appearance with no traces transparent tray material. A square blank was draped
of moisture. over a dry model and brackets. The blank was first
heated and then closely adapted to the model by
The indirect bonding technique (Impression means of negative pressure using a vacuum forming
taking stage): A plastic tray was used for this apparatus. After cooling of the model, it trimmed
procedure, first the operator got ensure that the with a hot instrument and removed from the model
tray is totally fitting patient arch without any along with the brackets that were contained within
interference. Condensation silicones** was used as it. The bases of the bracket got cleaned using
an impression material to ensure that there were not distilled water and tooth-brush. Finally, the tray was
dimensionally changes may take place. trimmed to be ready for clinical stage (fig. 1).

FIG (1) Casts after trimming the trays.

82 Ahmed Basheer Ayyed, et al. A.J.D.S. Vol. 23, No. 1

The indirect bonding technique (clinical Observations: All patients were provided with
stage): The teeth were prepared as mentioned oral instruction written on a sheet for maintenance
before. A thin layer of adhesive (3M Transt XT of their fixed appliance. In addition, the operator
bond unitek) was applied to the bracket bases and explained the instruction in detail to the patient.
to the teeth in the quadrant to be indirectly bonded. Check-up was carried out every 3 weeks. The
A small amount of light cure orthodontic adhesive patients were recommended to inform the dentist
was placed onto the base of each bracket and the immediately if suspecting a detachment, as all of
that information will be written in special sheet.
tray was seated with even pressure to allow good
Detachment date was registered, and the bracket
adaptation of the brackets to the teeth and an even
was replaced with a new one; in group B, a section
thickness of composite resin. Care was taken to place
of the transfer tray used for the initial bonding has
a minimum amount of composite resin onto each
been used for repositioning when necessary.
bracket base to avoid excessive adhesive flash. Each
bracket was cured using same light curing device RESULTS
that it mentioned before for 20s, 10s on the mesial
and 10s on the distal aspect. Brackets (Versatile The term of anterior segment indicates the total of
Roth American orthodontics – Low profile master central, lateral incisors and canine, while the term of
series) were cured starting with the most posterior posterior segment indicates the total of 1st and 2nd
premolars. Data were collected, revised, coded and
tooth, then moving forwards and the tray was then
entered to the Statistical Package for Social Science
carefully removed using a flat plastic instrument.
(IBM SPSS) version 23. The distribution of quantita-
Excessive adhesive flash was removed using rotary
tive data was tested by Kolmogorov-Smirnov test of
instruments if necessary.
normality. So, the quantitative data were presented as
Direct bonding technique: The teeth were mean, standard deviations and ranges. Also, qualita-
prepared as it mentioned before and adhesive tive variables were presented as number and percent-
bond (3M Transt XT bond) was then painted onto ages as it shows in tables 1 and 2.
each tooth and bracket base. A small amount of The comparison between groups regarding
adhesive composite3( M Composite TransXT) was qualitative data was done by using Chi-square test
applied to each bracket base and the bracket was and/or Fisher exact test when the expected count
then positioned onto the LA point of the tooth. All in any cell found less than 5. The comparison
brackets in the quadrant were positioned and excess between two independent groups with quantitative
composite was removed before the curing light was data and parametric distribution was done by using
applied. Each bracket was cured for 20 s, 10 s on the Independent t-test while the comparison between
mesial and 10 s on the distal aspect. To minimize two independent groups regarding quantitative data
variation in the magnitude of orthodontic forces with non-parametric distribution were done by using
applied to the teeth, a similar initial 0.012-inch Mann-Whitney test. The confidence interval was set
to 95% and the margin of error accepted was set to
nickel titanium (Ortho Organizers Inc.) arch wire
5%. So, the p-value was considered significant as
was used in each case, 16×22 wire will be the last
the following:
wire to use in the end of levelling and alignment
stage. At each visit, a record was kept of the tooth P-value > 0.05: Non significant (NS)
type, date and circumstances of bracket bond
P-value < 0.05: Significant (S)
failures. All subjects were observed over a period of
levelling and alignment. P-value < 0.01: Highly significant (HS)
A.J.D.S. Vol. 23, No. 1 A COMPARISON OF BRACKET FAILURE RATE BETWEEN DIRECT 83

TABLE (1) Comparison of failure rate of right central incisors, lateral incisors, canines, 1st premolars, 2nd
premolars, anterior and premolar segments in both upper and lower arches between group A and group B.

Group A Group B
Right Test value P-value Sig.
No. % No. %
Upper central incisor 2 13.3% 0 0.0% 2.143 0.143 NS
Upper lateral incisor 0 0.0% 0 0.0% 0.000 1.000 NS
Upper canine 0 0.0% 0 0.0% 0.000 1.000 NS
Upper anterior segment 2 13.3% 0 0.0% 2.143 0.143 NS
Upper 1st premolar 2 13.3% 5 33.3% 1.677 0.195 NS
Upper 2nd premolar 4 26.7% 4 26.7% 0.000 1.000 NS
Upper posterior segment 6 40.0% 9 60.0% 1.200 0.273 NS
Lower central incisor 0 0.0% 1 6.7% 1.034 0.309 NS
Lower lateral incisor 0 0.0% 0 0.0% 0.000 1.000 NS
Lower canine 0 0.0% 2 13.3% 2.143 0.143 NS
Lower Anterior segments 0 0.0% 3 20.0% 3.333 0.067 NS
Lower 1 premolar
st
4 26.7% 6 40.0% 0.600 0.438 NS
Lower 2nd premolar 6 40.0% 9 60.0% 1.200 0.273 NS
Lower posterior segments 10 66.7% 15 100.0% 6.000 0.014 S

FIG (2) Comparison of failure rate of right central incisors, lat- FIG (3) Comparison of failure rate of right anterior and premo-
eral incisors, canines, and 1st and 2nd premolars in both lar segments in both upper and lower arches between
upper and lower arches between group A and group B. group A and group B.
84 Ahmed Basheer Ayyed, et al. A.J.D.S. Vol. 23, No. 1

TABLE (2) Comparison of failure rate of left central incisors, lateral incisors, canines, 1st premolars, 2nd

premolars, anterior and posterior segments in both upper and lower arches between group A and group B.

Group A Group B
Left Test value P-value Sig.
No. % No. %

Upper central incisor 3 20.0% 0 0.0% 3.333 0.067 NS

Upper lateral incisor 2 13.3% 0 0.0% 2.143 0.143 NS

Upper canine 1 6.7% 0 0.0% 1.034 0.309 NS

Anterior upper segment 6 40.0% 0 0.0% 7.500 0.006 HS

Upper 1st premolar 2 13.3% 3 20.0% 0.240 0.624 NS

Upper l 2nd premolar 4 26.7% 3 20.0% 0.186 0.666 NS

Posterior upper segment 6 40.0% 6 40.0% 0.000 1.000 NS

Lower central incisor 0 0.0% 0 0.0% 0.000 1.000 NS

Lower lateral incisor 2 13.3% 1 6.7% 0.370 0.543 NS

Lower canine 0 0.0% 0 0.0% 0.000 1.000 NS

Anterior lower segment 2 13.3% 1 6.7% 0.370 0.543 NS

Lower 1st premolar 0 0.0% 7 46.7% 9.130 0.002 HS

Lower 2nd premolar 7 46.7% 6 40.0% 0.136 0.712 NS

Posterior lower segment 7 46.7% 13 86.7% 5.400 0.020 S

FIG (4) Comparison of failure rate of left central incisors, lat- FIG (5) Comparison of failure rate of left anterior and poste-
eral incisors, canines, 1st premolars and 2nd premolars rior segments in both upper and lower arches between
in both upper and lower arches between group A and group A and group B.
group B.
A.J.D.S. Vol. 23, No. 1 A COMPARISON OF BRACKET FAILURE RATE BETWEEN DIRECT 85

DISCUSSION Linklater et al. reported that the loose brackets

may have been caused by failure during laboratory
The aim of this study was also to measure,
step of group B, poor tooth polishing, failure during
evaluate, and compare the failure rate between
acid etching, poor control of humidity, several
direct and indirect bonding techniques. The present
contaminations (saliva and blood), improper
study found that when using the indirect technique, occlusion (contact of the opposing with orthodontic
the bonding failure rate is not significantly different brackets), repeated trauma (e.g. hard food) and even
when the direct technique is used, these results are lastly enamel quality (33).
in agreement with Deahl et al., Anna et al., and
Thiyagarajah et al (27-29). The results of this study suggest that the bonding
failure rate is comparable in practice that routinely
Respectively, the results of this study differ use these bonding techniques. Therefore, there
from the finding of Zachrisson and Brobakken who should be no long-term difference in the bonding
reported a failure rate of 14% for indirect bonding failure rate when considering the advantages and
and 2.5% for the direct method, the difference disadvantages of indirect bonding. Due to the
(2.5 percent versus 13.9 percent) was statistically presence of multiple variables that affect both
significant (P < 0.01). However, it is difficult to bonding failure rate and treatment efficiency, it
make direct comparisons since this last study used is critical to evaluate these across several studies.
four different combinations of bonding techniques, However, if we put in our consideration the sample
adhesives and bracket bases for each patient (30). size, it will show more reliability.
In the present study the age of the patient and the
level of crowding was determined in the inclusion CONCLUSION
criteria, however the present study didn’t put a Generally, there is not clinically significance in
consideration for the gender of the patient. Anna et the failure rate between direct and indirect bonding
al. in their study they didn’t evaluate gender, age techniques.
and type of malocclusion. Conflicting reports are
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