A problem with the modified and standardized indirect bonding technique

We read with interest the article on a modified technique for indirect bonding in the April 2012 issue (Ciuffolo F, Tenisci N, Pollutri L. Modified bonding technique for a standardized and effective indirect bonding procedure. Am J Orthod Dentofacial Orthop 2012;141:504-9).
First, we congratulate the authors for their efforts in describing this technique. We agree with all things they stated about this standardized and effective procedure.
Although the authors gave information about the procedure, they provided nothing about the problems encountered with this technique. For the past 2 years, we have applied a similar technique with a single tray from second molar to second molar. However, we have had a problem. We would like to draw attention to it and get additional information about this technique.
In the direct bonding technique, the excess composite on the base of the brackets can be removed with a sharp-pointed dental scaler. However, with the indirect technique, it is difficult to remove the excess composite, even if only a small amount was placed on the bracket base.
Thus, plaque could accumulate on the mesial and distal bracket margins (especially on the mandibular anterior teeth), under the archwire, and near the apical margins. Enamel demineralization around the brackets could be seen frequently from plaque accumulation.
We have tried to remove the excess composite fromthe base of the brackets with a sharp dental scaler in the indirect tecnique. But we want to learn whether there is a better way to remove this excess. Is there such a method?

Hasan Kamak
Murat Çaǧlaroǧlu
Kırıkkale, Turkey

Author’s response

We appreciate the letter to the editor from Drs Kamakand Caglaroglu.
It allows us to clarify some important aspects of a variable that can influence the efficiency of the indirect bonding technique: the resin excess.
We agree that excess adhesive is removed more easily during direct bonding, and removal is more difficult with the indirect technique. This is especially true when indirect bonding is used with a light-cured adhesive. Since it is impossible to calculate the exact quantity of material, “hard flashes” are unavoidable. In this case, a bur is necessary to remove the excess. We have also found that the degree of light-curing is a variable that can influence the process, because it depends on the operator and is not easy to perform on the posterior teeth, while trying to keep the tray seated.
In our modified technique, the excess adhesive is removed and light-cured on the model.¹ Therefore, the excess is made by the primer and the Sondhi Rapid-Set self-curing resins. At the end of the self-curing process, these resins can be easily removed. The instrument that we use is the scythe of the utility tool, and we proceed manually as follows: (1) we address the occlusal surfaces
using the flat surface of the tool; (2) we proceed around the bases also using the flat portion of the instrument;
and (3) we proceed to the papilla, the embrasure, and the cervical margins using the tip of the instrument.
With this method, the tooth surfaces should be clean. In addition, a rotor brush with polishing paste could finish the cleaning step. Finally, if some resin remains on the tooth surfaces, it tends to change color to yellow with time. It can be quickly removed by using a small Sof-Lex disc (3M ESPE, Seefeld, Germany). However, the most crucial variable in preventing the resin excess
is the quantity of the 2 liquids applied, calculated in a drop of resin A and resin B.
Furthermore, it is well known that demineralization is a side effect of fixed orthodontic appliances.² To our knowledge, it is independent of the bonding technique.
Hence, the prevention strategy must be used in all orthodontic treatments, direct as well as in indirect. We hope that the development of some new products will help to solve this unwanted side effect.²
Finally, we wish to provide a significant technique update regarding the transfer tray. Currently, we use a 0.3-mm thick tray maintaining the same cut, covering the silicone entirely. This change allows for good insertion stability, easier manipulation during the transfer step and no problems in removing the tray.

Fabio Ciuffolo
Pescara, Italy

REFERENCES

1. Ciuffolo F, Tenisci N, Pollutri L. Modified bonding technique for a standardize and effective indirect bonding procedure.
   Am J Orthod Dentofacial Othop 2012;141:504-9.
2. Robertson MA, Kau CH, English JD, Lee RP, Powers J, Nguyen JT. MI
   Paste Plus to prevent demineralization in orthodontic patients: a prospective randomized controlled trial. Am J Orthod Dentofacial Orthop 2011;140:660-8.