Comparison of Shear Bond Strength of Orthodontic Brackets Using Direct and Indirect Bonding Methods in Vitro and in Vivo

ORIGINAL PAPER

Comparison of Shear Bond Strength of Orthodontic

Brackets Using Direct and Indirect Bonding Methods
in Vitro and in Vivo
Kenan Demirovic1, Martina ABSTRACT
Aim: Aim of article was to compare the shear bond strength of indirectly and directly bonded ortho-
Slaj2, Stjepan Spalj3, Mladen
dontic brackets. Materials and methods: The experimental in vitro study included 60 maxillary and
Slaj2, Sedin Kobaslija4
mandibular premolars. Teeth were mounted on cold-cure acrylic blocks for each tooth separately
1
Private Practice for Orthodontics and and divided into two groups: directly bonded brackets (30 teeth) and indirectly bonded brackets
Dentofacial Orthopaedics, Sarajevo, Bosnia (30 teeth). Brackets (Discovery, Roth 0.022”, Dentaurum, Ispringen, Germany) were bonded using
and Herzegovina
Transbond XT (3M Unitek, Monrovia, CA, USA) in direct method, while in indirect technique, a
2
Department of Orthodontics, School of combination of Transbond XT and Sondhi Rapid Set (3M Unitek, Monrovia, CA, USA) was used. The
Dental Medicine, University of Zagreb, shear bond strength and adhesive remnant index (ARI) were evaluated. The in vivo study included 30
Zagreb, Croatia
subjects - 15 with indirectly bonded brackets and 15 with directly bonded brackets. Survival rate was
3
Department of Orthodontics, School of assessed during the period of 6 months. Results: No statistically significant difference in the shear
Dental Medicine, University of Rijeka,
bond strength was found in direct (7.48±1.61 MPa) and indirect labial bonding methods (7.8.2±1.61
Rijeka, Croatia
MPa). Both methods produced very similar amount of adhesive remnant on tooth surface (median
4
Division for Preventive dentistry and
= 1; interquartile range 1–2). There were no significant differences in bracket survival rate between
Pedodontics, Faculty of Dentistry,
methods. Conclusion: Regarding the shear bond strength, adhesive remnant on tooth surface, and
University of Sarajevo, Sarajevo, Bosnia
survival rate, both indirect and direct methods of orthodontic bracket bonding seem to be equally
and Herzegovina
valuable methods in clinical practice.
Corresponding author: Kenan Demirovic, Keywords: Shear bond strength, Direct bonding, Indirect bonding.
MSc in Orthodontics, Private practice for
Orthodontics and Dentofacial Orthopaedics,
Sarajevo, Bosnia and Herzegovina. ORCID
1. INTRODUCTION After removing the transfer tray from
ID: https://orcid.org/0000-0002-5267-7676 The development of adhesive tech- the model, the brackets with polym-
E-mail:kenandemirovic@hotmail.com nique leads to transition from banded erized composite base adhere to the
to bonded edgewise appliances. The teeth with two components of sealant.
minimum shear bond strength range Introduction of custom base indirect
doi: 10.5455/aim.2018.26.125-129
of 6-8 MPa is often cited in the liter- technique enabled unlimited operating
ACTA INFORM MED. 2018 JUN; 26(2): 125-129
ature as necessary to avoid bracket time and greatly reduced the problem
Received: Apr 07, 2018 • Accepted: May 22, 2018 deboning during application of ortho- of excess adhesive. However, one of
dontic forces (1). Silverman and Cohen the limitations is the possibility of bond
first introduced the indirect bracket failure because of inadequate share
bonding technique in 1972 (2). They bond strength between custom base
bonded plastic brackets on the plaster and adhesive primer (3). A recent devel-
model using a methyl methacrylate opment of orthodontic adhesives espe-
adhesive, while adhesion between the cially designed for the usage with the
etched tooth surface and preset ad- indirect bonding technique has helped
hesive on the bracket was achieved a greater applicability of this tech-
using unfilled Bis-GMA resin. Rev- nique in orthodontics (4, 5). The direct
olution in the indirect technique was bonding implies a direct fixation of the
made by Thomas who introduced a brackets using orthodontic adhesives,
© 2018 Kenan Demirovic, Martina Slaj, Stjepan Spalj, method called custom base indirect while with the indirect bonding tech-
Mladen Slaj, Sedin Kobaslija
bonding technique (3). The main char- nique the brackets are first placed on the
This is an Open Access article distributed under the acteristic of this technique is the for- plaster model and later on transferred to
terms of the Creative Commons Attribution Non-
Commercial License (http://creativecommons.org/ mation of Bis-GMA composite layer the teeth using transfer tray. The indi-
licenses/by-nc/4.0/) which permits unrestricted non- (custom base) at a bracket base, shaped rect method of bracket bonding enables
commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited. according to belonging tooth surface. orthodontists to visualize the tooth in

ORIGINAL PAPER / ACTA INFORM MED. 2018 JUN; 26(2): 125-129 125
Comparison of Shear Bond Strength of Orthodontic Brackets Using Direct and Indirect Bonding Methods in Vitro and in Vivo

three dimensions, which allows a more accurate placement Specimens were randomly allocated in two groups - direct
of orthodontic brackets. The indirect bonding also optimizes technique group (N=30) and indirect technique group (N=30).
the doctor’s time spent in the clinic, improves the patient’s In the direct technique group, buccal surfaces of teeth crowns
comfort, and allows a convenient removal of excess bonding were cleaned using polishing rubber cones mounted on low-
material (6). Despite the fact that indirect technique elimi- speed drill without abrasive paste usage, followed by rinsing
nates most of the limitations of direct technique, indirect and drying with oil-free air. Buccal enamel was etched with
technique has not been widely applied in clinical practice. It 37% phosphoric acid Unitek etching gel (3M Unitek, Mon-
is supported by the extra expenses and duration of labora- rovia, CA, USA) for 30 s followed by flushing (5s per tooth)
tory phase, sensitivity of the multiphase technique, where the and drying (10s per tooth). Brackets were bonded on teeth
error in any phase leads to the weakening of bond strength. using light cured Transbond XT primer and adhesive (3M
Several studies have been published on the analysis of both Unitek, Monrovia, CA, USA) according to the manufactur-
direct and indirect techniques in relation to the share bond er’s instructions and polymerized by LED curing unit Unilite
strength of orthodontic brackets (7-10). Variations in mean II (Bien Air, Bienne, Switzerland) for 20 s from mesial and
bond strength obtained in different studies could be at- distal aspect. Excess adhesive material was removed prior to
tributed to the fact that many in vitro studies fail to report test polymerization.
conditions that could significantly affect their outcomes (11). In the indirect technique group, alginate impressions of
A meta-analysis of in vitro orthodontic bond strength testing each tooth in acrylic block were taken and outpoured in hard
revealed that each second of photo polymerization time in- dental stone Rapidur (Dentaurum, Ispringen, Germany). All
creased bond strength on average by 0.077 MPa, water the bumps from the surface of each tooth plaster model were
storage decreased bond strength by 10.7 MPa, and each mil- removed, and isolation varnish Isolant/C.M.S (Dentsply De
limeter per minute of greater crosshead speed increased bond Trey, Weybridge, England) was applied and dried for 24 h.
strength by 1.3 MPa (11). Recent systematic review on effec- Brackets were bonded in proper position on plaster casts using
tiveness of different bonding materials pointed out generally Transbond XT adhesive and placed into a Triad light-curing
poor quality of the clinical trial reports (12). unit (Dentsply, International, Inc) and cured for 10 minutes.
The aim of this study was to assess the differences in share Each cast was set in a vacuum former machine Form 110Vac
bond strength, failure mode, and survival rate between Former (Discus Dental, Culver City, CA, USA). Transfer
brackets bonded by direct and indirect techniques. We hy- tray for indirect technique was formed by heating and vacu-
pothesized that both techniques produce similar bonding uming thermoplastic translucent silicone foil dimensions 5” ×
strength in both in vivo and in vitro conditions. 5” × 0.40” (Discus Dental, Culver City, CA, USA) over each
cast with bonded bracket according to the manufacturer’s in-
2. MATERIALS AND METHODS structions. Plaster block was placed in lukewarm water for 30
In experimental in vitro study, 60 maxillary and mandib- min. Translucent foil with bracket was removed from model
ular first premolars with intact buccal enamel surface, ex- (Figure 1). Excessive foil material was removed, and each
tracted for orthodontic purposes were used. Teeth with transfer key was cleaned using brush and detergent, flushed
caries, fillings, fissure sealings, enamel defects, and bleached with water, and dried thoroughly. Buccal enamel surface
teeth were excluded. of teeth was cleaned, etched, flushed, and dried in the same
Twin stainless steel premolar brackets Discovery Roth manner as direct technique group. Chemically cured Sondhi
0.022’’ (Dentaurum, Ispringen, Germany) with clean la- Rapid-Set Resin A (3M Unitek, Monrovia, CA, USA) was
ser-treated mesh base of average surface of 14.7 mm 2 were applied on etched surface and Resin B on a composite base
used. Maxillary first premolar bracket width was 3.4 mm and of bracket fixed in each transfer tray, and tray was placed
mandibular width was 3.3 mm. on tooth in acrylic block for polymerization process and re-
After tooth extraction, residual periodontal ligament tissue moved after 30 s (Figure 1). Tooth specimens with brackets
was removed from the surface of the roots using periodontal from both bonding technique groups were kept for 72 h in
scalers; teeth were rinsed with strong jet of water and stored distilled water at a temperature of 37°C.
in 0.1% thymol solution at a temperature of 4°C for 7 days. Shear bond testing was performed with a universal testing
Afterwards, teeth were stored in distilled water in a refriger- machine Zwick 1435 (Zwick, Ulm, Germany (Figure 2). Ap-
ator at 4°C until the experiment. Distilled water was changed paratus was calibrated by ZAG, Slovenia, and the accuracy
every week. Teeth whose holding period in distilled water is was Class 0.5 (i.e., possible 0.5 % deviation in measurement),
longer than 12 weeks were not used in the experiment. Be- and the measurement area was from 0 to 5 KN. Following the
fore placing in the acrylic blocks, the teeth were cleaned with specimen fixation with a pair of clamps in the lower part of
dental brush mounted on low-speed drill with water cooling. the testing machine, the force administration from the upper
Along the tooth root, the groove is made to prevent possible part of testing machine was performed with the 0.17×0.25
separation of the teeth from the acrylic block during applica- inch wire applied between the bracket base and bracket wings
tion of force to the bracket. Each tooth is placed in separate by loading the specimen until bracket detachment. Constant
acrylic blocks with dimensions 10×12×15 mm (width × length loading was achieved at 1 mm/min speed. The force direction
× height) made from cold cure orthodontic acrylic Orthocryl was gingival-­occlusal. The apparatus automatically recorded
(Dentaurum, Ispringen, Germany) in specially designed the force with an accuracy of 0.1 N. The force value was di-
mold and polymerized for 15 min under pressure of two bars vided by the total surface area of the bracket. Values were
in polymerization pressure vessel Polyclav (Dentaurum, Is- presented in N/mm2, i.e., MPa.
pringen, Germany). The enamel surfaces after bracket removal were examined

126 ORIGINAL PAPER / ACTA INFORM MED. 2018 JUN; 26(2): 125-129
 Comparison of Shear Bond Strength of Orthodontic Brackets Using Direct and Indirect Bonding Methods in Vitro and in Vivo
Figure 1. Removal of translucent trans

TECHNIQUE n min max M SD Me TECHNIQUE N min bonded

max Mon tooth
SD mounted
M in acrylic
e

DIRECT 30 4.62 10.65 7.48 1.61 0.29 DIRECT 30 0 2 1,2 0,6 0,1
INDIRECT 30 5.30 11.56 7.82 1.61 0.29 INDIRECT 30 1 2 1,3 0,5 0,1 from plaster
Table 1. Shear bond strength values of brackets bonded with direct and Table 2. Adhesive Remnant Index (ARI) scores by technique
indirect technique - in vitro study in a patient
fear that it does not provide suf-
a) b)
ficient shear bond strength of
bracket with the tooth. Voids
can be found in composite base Figure 2. Un
in two-thirds of indirectly Germany) f
bonded brackets, which can
cause up to 50% lower share
bond strength of indirectly 1.
bonded brackets (13). Until re- 0

c) d)
cently, the indirect technique
0.
used adhesive bonding systems 8
originally intended for use in
direct bracket placement tech- 0.

Survival
6
nique. Currently, there are two
adhesive systems presented ex- 0.

rate
clusively designed for indirect 4
Figure 1. a. Removal of translucent transfer key with bracket from plaster technique. The first system uses
Figure
model1. Removal of Bracket
of tooth; b. translucent transfer
bonded key with
on tooth bracket
in from
Figure
mounted 1. Removal
acrylicplaster c. ofoftranslucent
bloc;model tooth; bracket transfer key with bracket from plaster model of tooth; bracket
thermal-cured, fluoride-re-
0.
2
Removal of translucent transfer key with brackets from plaster model; d.
bonded on tooth mounted in acrylic bloc; removal of translucent transfer key with
placement of transfer key with brackets, on teeth in a patient mouth leasing composite
brackets resin to form
bonded on tooth mounted in acrylic
a custom bloc;
base andremoval
Thermaof translucent transfer key with brackets
Figure 2. Universal testing 0.
from plaster model; placement of transfer key with brackets, on teeth 0
using an optical microscope ZKM 01–250C (Carl Zeiss, Jena, Cure chemically cured adhesive machine Zwick 1435 (Zwick, 0

Germany) at a magnification of ×30 to assess the amount of primer Custom IQ (Reliance

in a patient mouth from plaster model; placement of
Ulm,transfer
Germany)key with brackets,
for assessment on teeth
of shear bond strength
adhesive left. Adhesive remnant index (ARI) scores were Orthodontics, USA). Another
in a patient mouth
used: 0, no adhesive left; 1, less than half of adhesive left; 2, adhesive system developed exclusively for use in the indirect
2. Universal testing machine Zwick 1435 (Zwick, Ulm,
half or more; 3, allFigure adhesives were left on the tooth.
Germany) for assessment of shear bond strength
technique is the Sondhi Rapid-Set, used in this study, where
The in vivo study included 30 subjects - 15 with directly the custom base is formed by light cured Transbond XT com-
bonded brackets and 15 with indirectly bonded brackets. The posite, Figurewhile the adhesive
2. Universal primer
testing consists
machine of two
Zwick 1435 chemically
(Zwick, Ulm,
same enamel surface preparation protocol, brackets, adhe- cured components.
1.
0 Germany) for assessment of shear bond strength
sive types, and transfer tray 0.
were used as in vitro study (Figure TECHN
DIRECT -
IQUE -
INDIRECT
1). Survival rate was assessed during the period of 6 months.
8 IN VIVO
IN VIVO

Subjects were instructed0.6 to avoid eating very hard food (pea- 1.

Survival

nuts, almonds, popcorn, 0.

etc.) and other types of food that 0
rate

could cause bracket loss. 4

0.
TECHN
DIRECT -
Mann-Whitney test, 0.t-test, Kaplan-Meier survival anal- 8 IQUE
INDIRECT
IN VIVO -
2 IN VIVO
ysis, and log-rank test in SPSS 15.0 software (SPSS Inc, Chi-
0.
cago. Ill, USA) were used 0.
for statistical analysis, and signifi-
Survival

0 6
0 2 4 6 8 1 1 1 1 1 2
cance has been predetermined 0 at
0 p<0.05.
0 Time
0 0
0
2
0
4
0
6
0
8
0
0
0
(days) 0.
rate

4
3. RESULTS
0.
Indirectly bonded specimens showed higher mean shear 2
bond strength (7.82±1.61 MPa) than directly bonded speci-
mens (7.48±1.61 MPa), but the difference was not statistically 0.
0
significant. The results regarding the shear bond strength are 0 2 4 6 8 1 1 1 1 1 2
0 0 0 Time
0 0 2 4 6 8 0
shown in Table 1. The comparison of resin remnants between 0 0 0 0 0 0
(days)
the direct and indirect groups suggests no significant differ- Figure 3. Survival rate of directly and indirectly bonded brackets in-vivo in
ence in ARI index scores (Table 2). There were no signifi- a period of 6 months according to Kaplan Meier survival analysis
cant differences in brackets survival rate between methods.
Average survivor time for directly bonded brackets and in- Average values obtained in this study for the indirect tech-
directly bonded brackets was 148.5±14.7 days and 145.1±13.6 nique using Sondhi Rapid-Set and Transbond XT (7.82 MPa)
days, respectively, and survival rate was 98.6 and 98.3%, re- and the direct technique using Transbond XT (7.48 MPa) are
spectively (Figure 3). clinically appropriate in terms of power relationships in ac-
cordance with generally accepted standards (1). The results
4. DISCUSSION of this study coincide with the findings of other studies but
Indirect bracket bonding technique is still not used by a the presented values are much lower. Yi et al. using the APC
large number of orthodontists. One of the reasons could be brackets in vitro for the indirect technique reported 11.2 MPa

ORIGINAL PAPER / ACTA INFORM MED. 2018 JUN; 26(2): 125-129 127
Comparison of Shear Bond Strength of Orthodontic Brackets Using Direct and Indirect Bonding Methods in Vitro and in Vivo

and for direct technique of 10.9 MPa, Linn et al. found 13.8 vival rates of direct method were reported in the range 94.7-
and 16.3 MPa, and Klocke et al. found 15.0 and 13.9 MPa, 97.5%, and 86-98.7% for indirect method (3, 23, 24). How-
respectively (7, 8, 14). They reported higher share bond ever, it is difficult to make relevant comparisons, because all
strength of both Transbond XT adhesive in direct technique three studies used different types of adhesives with different
and Transbond XT with Sondhi Rapid Set system in indi- periods of observation.
rect technique compared with thermo cured adhesive systems The results of bond strength in vitro studies often do not
(Therma Cure adhesive and Custom IQ sealant, and Therma correlate with the results from clinical studies; so applica-
Cure in combination with Maximum Cure) (14). On the con- bility of in vitro studies in clinical practice is questionable
trary, Polat et al. presented lower bond strength of Transbond (25). Degradation of composites in the mouth is a set of com-
XT-Sondhi Rapid Set than Therma Cure-Custom IQ and di- plex interactive processes that cannot be reproduced in vitro;
rect technique using Transbond XT (10). hence, it is essential to develop standardized in vitro and in vivo
Similar failure modes in both techniques were found. ARI tests (26).
index values obtained ranged mostly between 1 and 2, which Taking these findings into consideration, the concordance
shows that the detachment was mostly cohesive in character, of findings of our in vitro and in vivo studies indicates the va-
which means that after debonding, a part of the adhesive re- lidity of results. This is claimed by a series of authors who be-
mained on the tooth surface, and part of the bracket base. lieve that the results of in vitro studies serve as a screening test
Similar values of bond strength and similar places where de- and must be confirmed through identical in vivo studies (21).
tachment has occurred in both techniques show that previ- To date, no study compared these adhesive systems (Trans-
ously prepared polymerized composite base in an indirect bond XT and Sondhi Rapid-Set) in the two techniques in
technique is not a weak point in the bracket adhesion. Sim- terms of the oral environment when the quality of interac-
ilar values of ARI index as in our study and insignificant dif- tions was affected by saliva, acids, masticatory, and ortho-
ferences between direct and indirect bonding were reported dontic forces.
previously (7, 8). Still some authors reported differences in
ARI index between two methods after debonding (13-15). 5. CONCLUSION
In one of the earliest in vitro studies in comparison with direct According to in vitro and in vivo study, it can be concluded
and indirect bonding methods, 72% of the indirect bonds and that regarding the shear bond strength, adhesive remnant
56% of the direct bonds fractured mainly at the enamel-resin on tooth surface, and survival rate, both indirect and direct
interface, which is similar to our data (70% indirect and 66.7% methods of orthodontic bracket bonding seem to be equally
direct, respectively) (13). It seems that the failure site of ce- valuable methods in clinical practice.
ramic brackets usually occurs predominantly in the enamel–
resin interface, whereas bond failure with the metal bracket • Conflict of interest: none declared.
is often in the bracket-resin interface (16). It implies stronger • Author’s contribution: Each author participated in each step of manu-
ceramic-adhesive than metal-adhesive bond strength. But, script preparing and gave final approval for publishing.
when bond strengths are high, metal bracket failure tends to
occur more often at the enamel-adhesive interface, which can REFERENCES
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