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Laboratory Procedure Indirect Bonding Technique

Anthony J. Belgin Indirect Bonding Consultant

904 North Caroline Street Ebensburg, Pa 15931 814-242-1878 [email protected]

MATERIALS FOR LAB PROCEDURE Product Item# Company Biostar®/MINISTAR S® 016-001 Great Lakes 1mm Mouthguard Material Round 021-030 Great Lakes .75 mm Biocryl Clear Splint 021-024 Great Lakes Cutting Bur 085038 Great Lakes

Telephone 800-828-7626 800-828-7626 800-828-7626 800-828-7626

Flexible Trimming Wheel

1895S

Raintree Essix

800-883-8733

Fine Scotch Brite Brush Wire Brush Wheel on Mandrel Liquid Foil Liquid Foil Aluminum Bracket Height Gauge .018 or .022 slot (whichever you are using)

25125HP 075-008 175-035 175-034

Brasslier Great Lakes Great Lakes Great Lakes Ortho-Quest

800-841-4522 800-828-7626 800-828-7626 800-828-7626 877-678-4696

Doz / 17.50 Gal / 29.95 8oz / 4.50

Express Dental Walmart Craft Department Ultradent Ultradent Reliance Great Lakes Great Lakes Great Lakes Great Lakes Great Lakes Great Lakes Dentalsply/GAC Procter Silex Walmart Walmart Reliance

800-445-5227

23.00

800-552-5512 800-552-5512 800-323-4348 800-552-5512 800-552-5512 800-552-5512 800-552-5512 800-552-5512 800-552-5512 800-786-0085

20 for 6.99 24.99

Crown and Bridge Scissors Wilton Cake Icing White Professional Decorating Consistency Small Plastic Syringe for Cake Icing Ultradent L.C Block out resin Thermacure Model Holder Microetcher II Aluminum Oxide 50 Micron/1 lb 90 Micron/1 lb Micro Cab Silcone Spray Toaster Oven Oven Thermometer (Blue) Ultra Band Lok for Turbo Bites or posterior occlusal buildup Indirect Models poured with Whipmix/Jade Stone/Green #25 lb Mini Bite Ramp Mold Handle for mini mold Light Cure Box (Maxi-Cure)

1.2 ml 240 175-013 190-170 175-049 175-101 190-062 98929

$ Price 2,045.00 Per/12 8.50 11.50 Pkg/6 26.95 Pkg/12 12.95

19.95-24.95

800-323-4348

18570

Patterson

47.95

1521005

Ortho Direct

800-833-7790

33.50

MCLB-110

Raintree Essix

800-883-8733

299.95

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Laboratory Procedure Indirect Bonding Technique I. Material used to pour models 1. Preference: Whip mix jade stone or stone of 6000 psi. II. Technique used to pour models 1. Air dry impression using an air syringe to ensure no water is present in the incisal edges, occlusal surfaces or cusp tips. 2. Using the proper water/stone ratio, (following the manufacturer’s instructions) vacuum mix with clean bowl and spatula and then vibrate into the tooth surfaces of the alginate impression, starting on one side and flowing to the other. • Note: Do not invert the model into a base former. 3. Keep the model upright and add some extra stone to impression. 4. Place a 2 ½″ x 2 ½″ square piece of plastic on top of the extra stone. 5. Push down lightly to make a model base of 1/2” to ¾” thickness. The square plastic is made from 1 mm Essex retainer and can be reused. III. Separate model from impression after using recommended setting time from manufacturer 1. Check model for detail. 2. Check model for any air bubbles, as the models need to be bubble free. If not bubble free, a better technique in pouring models is needed. However, every now and then a small bubble may appear and you can use Blue Blockout® from Ultradent to fill the void. Always over fill the void. This is done after the brackets are placed and cured. IV. Model trimming 1. Base should be 1/2″ to 3/4″ thick. If plastic square was placed correctly when pouring the model, there should be no trimming of model base. 2. Trim the sides of model as close to mucco-buccal fold as possible. At times it will be necessary to remove the model from model trimmer platform and hold the model with both hands. Angle the model to trim as close to the mucco-buccal fold as possible, so no teeth touch the grinding wheel. 3. After the model is trimmed, rinse off all residues. Do not use a toothbrush, it will abrade tooth surfaces. However, a paintbrush with soft bristles may be used. Once all residues have been removed, pat the model dry with a paper towel.

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V. Preparing model for bracket placement. 1. Let the models dry completely for 10 to 12 hours. •

A toaster oven may be used to accelerate the drying time. Set the toaster oven at l50° F. Models should be dry in 3 to 4 hours. Drying time depends on the density of the model.

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It is imperative that the models be completely dry before proceeding to the next step. If not, brackets will move on the model when the soft tray is fabricated.

2. Place the bracket height and long axis lines when the models are dry. Rubbing a lead pencil over the Aluminum Bracket Height Gauge will make a graphite mark on the model. Mark all the bracket heights. Complete the bracket height marks mesiallydistally and mark the long axis lines of the teeth using a mechanical pencil. 3. Once all bracket height lines and long axis lines are complete, paint the model with a 50/50 ratio of liquid foil and water. Apply the mixture to all surfaces of the model except the bottom of the base. Let the model dry for 30 to 40 minutes. To accelerate the drying time, use a 6" desktop fan. •

It is imperative that the models be completely dry again after placing the mixture of liquid foil and water. If not, brackets will move on the model when the soft tray is fabricated.

VI. IDB technique using various manufactured brackets. 1. There have been no problems using this IDB technique with self-ligating brackets (leaving the gate open), ceramic brackets, single tie wing brackets with steiner wings, or a standard twin bracket. However, when using self-ligating brackets, after they have been placed on the model and cured, spray the brackets with Dentsply Silicone Spray and then fabricate the soft tray. However, if using a bracket that can not be used with Thermacure according to the manufacturer due to heat sensitivity, then there is no choice then to use a light cure adhesive to bond brackets to the model. VII. Adhesive for bonding brackets to the model. 1. Chemical cure paste 2. Light cure adhesive 3. Thermacure - The preferred adhesive because it has unlimited working time. It will only cure at a temperature of 315°F for 15 minutes. 4. Thermacure is a tooth-shaded material. In the near future, it may also be available in a blue shade so when it is debonded, the adhesive may be easier viewed for better removal. Check with Reliance Orthodontic Products for its availability. 5. Place the adhesive on the bracket base. Spread the adhesive on the base and press into the mesh. Then place the bracket on the tooth. Align the bracket slot with the horizontal line and align the bracket with the long axis of the tooth. 3

6. Press into place, expressing adhesive from the perimeter of the bracket base and then remove any flash from around the base. 7. Once all of the brackets are in place, recheck the bracket heights with the Bracket Height Gauge and recheck that the bracket is in alignment with the long axis of the tooth and is centered mesially-distally. • Note: Unitek offers an offset bracket for the maxillary and mandibular bicuspids. Also, most bracket manufacturers offer a mini second molar bracket used only when unable to achieve a good bracket position with a standard second molar bracket. Sometimes the bracket height desired, can not be achieved due to a low profile crown. Additionally, the option of reshaping the base with a handpiece and heatless stone is possible. At times it will be necessary to recontour a bracket base to better fit the shape of a tooth. This may happen on the 1st or 2nd molars and on bicuspids that are rotated. The closer a bracket base is adjusted to fit the tooth, the stronger the bond. • Note: Lingual buttons, turbo bites and lower 1st molar occlusal buildups are also Indirect Bonded. They are placed at the same time the brackets are placed on the models. The turbo bites and lower 1st molar occlusal buildups are placed after the brackets are cured. VIII. Ready to Cure the Thermacure adhesive. 1. A toaster oven is needed, and an oven thermometer. ($20-25 for toaster oven) 2. Turn the oven on and set temperature for 325°F. When the oven reaches 325°F on the oven thermometer, wait 5 additional minutes to ensure the temperature has stabilized.

3. Once stabilized at 325°F, set the models in the toaster oven for 15 minutes. Use a minute timer to sound when l5 minutes has passed. 4. Remove models from toaster oven after the 15 minutes. They will be warm to the touch but they may be picked up and removed from the toaster oven to cool. It takes about 10 minutes to bench cool or 5 minutes using a 6″ tabletop fan. 5. Once the models are cooled to room temperature, recheck the bracket heights. • Note: I have never had a problem with brackets drifting, but when I put several models at one time in the oven, I may touch a bracket with another model and it will need to be repositioned. 6. If a bracket needs repositioned, just wet the base of the bracket with water using a Qtip applicator or micro brush several times and the bracket will lift off. Do not wet any other bracket base. Once the bracket is off, micro etch the adhesive from the base and place the bracket back on the model with a light cure adhesive. Be sure the tooth is dry before you replace the bracket. A tooth dryer may be used to dry the tooth or place model under the tabletop fan for 5 minutes. 4

7. Use LC Block-Out Resin from Ultradent® to fill in any small bubbles on the teeth, or any small spaces between the teeth and any undercuts that would interfere with tray placement. If a tooth is partially erupted, block out that area with Blue Block-Out Resin because the tooth could erupt more by the time the IDB trays are placed. 8. Block out the auxiliary attachments to brackets such as hooks used for elastics and steiner wings. Use white decorator icing made by Wilton® normally found at WalMart in the craft section or specialty craft store. Load the icing in a syringe from Ultra Dent along with a syringe tip and apply the icing between elastic hook and model. IX. Placing other auxiliary attachments 1. Turbo bites for anterior bite opening, also referred to as anterior bite ramps, are IDB to the lingual of the maxillary centrals. Ultra Band Lok (Blue) is used to make the bite ramps. When the overjet is 5mm or more, use either a removal anterior bite plane or occlusal bond stops on the distal marginal ridges of mandibular first molars to achieve the anterior bite opening. The occlusal bond stops are made with Ultra Bank Lok (Blue). • Note: I have only used 2 removable anterior bite planes in the last 24 months. You can purchase pre-made anterior bite ramps or order a bite ramp mold and handle from Ortho Direct and make your own bite ramps. This is much less expensive than purchasing pre-made bite ramps. X. Fabrication of IDB Trays 1. To form trays a. Biostar from Great Lakes or a thermoforming machine like a Biostar • Note: A Vacuum Form Machine does not give the adaptation that is needed. 2. Materials (from Great Lakes) a. Soft tray - 1mm mouth guard material b. Hard tray - .075 Splint Biocryl 3. Using the Biostar, place flat metal table over bead cup a. Place model on the table b. Heat mouthguard material to manufacturer recommendations - form and cool c. Unlock handle and trim excess material from base of the model d. Spray mouth-guard material with Dentsply Silicone Spray® e. Place model back on flat metal table f. Heat .075 splint biocryl material to manufacturer recommendations to form and cool. g. Unlock the handle and remove model from the biostar and trim the excess material from the base. 4. Removal of trays from model. a. Using a Bard Parker Knife, a utility knife, or a straight mandrel saw wheel (used in a dental lab hand piece), cut the hard and soft tray 5 mm below the gingivalenamel attachment on the labial, buccal and lingual surface of the teeth. Then remove hard tray from model. 5

b. Using crown and bridge scissors cut the hard tray about 1 mm below the gingival tie wings and at the distal marginal ridge of the last tooth being bonded. Also, cut the tray at the lingual gingival enamel attachments. Remove any sharp edges from the tray. Try the tray back on the model over the soft tray, checking to see how the hard tray releases from the soft tray. It should lift off easily. • Note: If the hard tray is hard to remove, trim the tray in the area of difficulty until it releases easily. c. With the soft tray and the brackets still on the model, re-cut the soft tray, if necessary with Bard Parker knife or a utility knife so that it is cut 5 mm below the gingival enamel attachment and cut at the distal marginal ridge. Additionally, cut the soft tray 5 mm below the lingual gingival enamel attachments and remove excess mouth guard material. d. Place your model with the brackets and soft tray still on the model (the hard tray does not go in the water) in warm water (NOT HOT) for 15-20 minutes. This will reactivate the liquid foil and after 15-20 minutes the soft tray can be removed from the model. If there is resistance from the bond of the bracket from the model, soak the model a little longer. e. With the soft tray removed from the model, use crown and bridge scissors and cut the soft tray at the gingival enamel attachment at the buccal, labial and lingual surface. f. Let the soft tray soak in warm water for 5 minutes to soften the white decorator icing. g. Remove soft tray from water. Use a clean soft bristle toothbrush to remove any of the white decorator icing that is still present. A dental air/water syringe may be used to merge the air and water together to remove the cake icing. When the white decorator icing residue is removed, blot dry the soft tray with a paper towel. h. Lightly micro etch the bracket bases using 50 micron etching material (white). i. Rinse the bracket bases with water to remove micro etching residues, blot dry with a paper towel and dry with an air syringe. j. Place soft tray and hard tray together. k. Removed any rough or sharp, jaggy areas from the hard tray. l. Clean bracket bases with a Q-tip applicator or micro brush with isopropyl alcohol. m. Remove IDB trays from lab and place in a clean and dust free area.

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