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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 4  |  Page : 168-171

Digital technology in the refining of protocols for the bonding of orthodontic brackets


Department of Pediatric Dentistry and Orthodontics, Division of Pediatric Dentistry, School of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil

Date of Web Publication28-Aug-2018

Correspondence Address:
Dr. Natalice Sousa de Oliveira
106, Monte Azul Street, Belo Horizonte, Minas Gerais 30315240
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_143_18

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  Abstract 

Evaluating the quality of individual positions of the attachments will make it possible to foresee positions that may lead to undesirable orthodontic movements, thereby being of direct benefit to both the professional and patient. The purpose of this study was to list imprecision factors associated with traditional bonding methods, as well as present evidence about the software systems that incorporate digital technology to vestibular bonding. The electronic databases PubMed, MEDLINE, Cochrane, and Google Scholar were searched for available data. The following terms were used in the literature search: accuracy, orthodontic brackets, direct bonding, indirect bonding, and virtual orthodontic attachment bonding. Although the technological interface has optimized protocols, especially in planning and laboratory stage, digital systems did not demonstrate to guarantee accuracy. However, virtual orthodontics is now an irrevocable trend, for enabling more efficacy and therapeutic control. It is plausible that soon all orthodontic brackets will be placed digitally.

Keywords: Accuracy, direct bonding, indirect bonding, orthodontic brackets


How to cite this article:
de Oliveira NS, Pretti H. Digital technology in the refining of protocols for the bonding of orthodontic brackets. J Int Oral Health 2018;10:168-71

How to cite this URL:
de Oliveira NS, Pretti H. Digital technology in the refining of protocols for the bonding of orthodontic brackets. J Int Oral Health [serial online] 2018 [cited 2018 Sep 24];10:168-71. Available from: http://www.jioh.org/text.asp?2018/10/4/168/240013


  Introduction Top


The fitting of a fixed appliance is a complex process that aims at the leveling of the marginal ridges and contact points, in addition to the points that define the ideal overbite, the incisor exposure, and the smile arc.[1],[2],[3],[4] However, reaching these objectives becomes impracticable because of hitherto available bonding techniques, regardless of being direct or indirect methods.[5],[6] Although studies show more uniformity and consistency of positions with indirect method, current evidences do not support its recommendation as an alternative to the direct bonding method since both techniques fail to reach accuracy.[7],[8],[9]

Therefore, new perspectives on the refining of protocols have been indicated, especially by the incorporation of digital technology to bonding processes. Specialized laboratories have enabled customized service packages that allow potentially more precise computerized bonding procedures.[7],[10],[11] The assorted commercial software systems are multifunctional and generally integrate three-dimensional (3D) digital models, setup and virtual bonding procedures, and prototyped transfer trays.

It is plausible that soon all orthodontic brackets will be placed digitally. The purpose of this study was to list imprecision factors associated with traditional bonding methods, as well as present evidence to the software systems that incorporate digital technology to vestibular bonding.


  Search Strategy Top


The electronic databases PubMed, MEDLINE, Cochrane, and Google Scholar were searched for available data. The following terms were used in the literature search: accuracy, orthodontic brackets, direct bonding, indirect bonding, and virtual orthodontic attachment bonding. During the search, the following filters were applied: (1) language: English language, (2) human, animal, in vitro, ex vivo studies, and (3) type of article: randomized controlled trial, clinical trials, systematic reviews, case series, and experimental studies.


  Development Top


A wide range of factors hinder the achieving of accuracy such as variation in teeth morphology and in intermaxillary relations of a single individual and among different individuals, which requires individualized procedures on each case and on each tooth;[1],[12],[13],[14] malocclusion complexity;[15] bracket type (customized or not, self-ligating or conventional);[16] transfer tray design (single jig or entire arch);[11] the material used to produce it (acrylic resin, silicone, and thermoplastic material);[9],[17] and variation in the perception of the ideal position,[16],[18] among others.

There are different ways brackets can be dislocated: (1) horizontal errors that lead to rotations; (2) axial or paralleling errors, resulting in incorrect angulation; (3) thickness errors by means of adding more or less material on the tooth surface interface of the bracket; and (4) vertical errors, leading to intrusion or extrusion, alterations in torque, and vestibular-lingual position.[19] That means that inadequate placement can turn even the most customized prescription ineffective.[2]

Deviation in bracket placement can compromise a correct placement and its functional integrity as well as reflect in distortion on the whole mechanics.[1],[13],[20] Unstable dental positions, the absence of root parallelism, food impaction due to discrepancies between marginal ridges, and failure to establish a mutually protected occlusion constitute the main clinical implications associated with errors.[21]

The fitting of a fixed appliance is, therefore, a complex process that aims not only at leveling the tip of cuspids but also at the leveling of the marginal ridges and contact points, in addition to the points that define the ideal overbite, the incisor exposure, and the smile arc.[1],[3],[4]

About 40 years ago, Andrews developed the first straight wire appliance; in other words, he created a 3D appliance, composed by brackets designed with ideal characteristics for each dental element (1st, 2nd, and 3rd orders).[22] Consequently, the consistency of treatment results as well as treatment efficiency increased.[23] The experience with Andrews “prescription,” however, showed that individually programmed dental positions were not always achieved. That is confirmed by the proliferation of additional “prescriptions;” all of them with the common objective of shortening the alignment stages and the orthodontic treatment, minimizing wire bending.[24] A critical element in the success of this type of appliance is that each bracket must be accurately placed on each tooth of the arc, since the excellence of orthodontic bracket placement impacts immensely and directly on the correct dissipation of forces and treatment progression.[2]

There is no common understanding regarding both bracket programming and the ideal bonding positions during appliance fitting. Inherent to each prescription, the orthodontist possesses the bonding arrangement with preset position for each tooth. Over the years, different bracket placement protocols have been recommended for the straight-wire system. Andrews, by analyzing 120 normal untreated occlusion models, determined which positions would be adequate for the teeth, from an anatomical point of view. He defined a reference line on the dental crown, so a correct bracket placement could be done, which he called facial axis of the clinical crown. He advocated that the bracket should be placed exactly on this line at the crown's vertical center. McLaughlin and Bennett proposed a variation in the placement based on different dental sizes and made available a chart containing standard measures that need to be selected according to similarities found among central crown measures obtained clinically. They also advocated for the use of a height gauge to augment vertical precision.[19] Through the Vari-Simplex technique, Alexander prescribed that the placement of brackets should have a predetermined position that varies according to the clinical crown, using the mandibular premolars as a reference.[24] Viazis proposed variation of placement based on different dental sizes, recommending that the bracket position must follow a proportion reducing the height of anterior and posterior teeth.[25]

A study that analyzed the vestibular surface shape of 600 maxillary and mandibular teeth revealed that the magnitude in variation among patients or potential bracket placement positions was incompatible with the torque values of hitherto available prescriptions.[1] That means the parameters that define bonding position seem to establish standardized error.[2] Bracket placement on the center of the clinical crown in the premolar, for instance, can result on marginal discrepancy between these and the molars, for example, unbalanced proximal contacts 1 mm in excess, as well as lack of contact between antagonists.[3] The author credits the discrepancy to the difference of height between the vestibular and lingual cuspid of premolars, as well as the variation in placing a molar tube or band.

Comparing the positioning techniques guided by the center of the clinical crow and by the distance from the incisal border, both required interventions to compensate imprecisions.[26] Confirming these results, models were treated virtually, adopting a bracket placement protocol with fixed values of incisal borders and occlusal surfaces and a single bracket prescription, resulting in significant alterations on the leveling of marginal ridges of upper and lower premolars.[27]

The intra- and interprofessional variability of the perception of ideal positioning also endorses the list of numerous factors associated with errors in bonding positions, especially when determining the long axial axis of the clinical crown in comparison to the center of the clinical crown.[18] In judging between the angular and linear dimensions, the imprecision is larger in the former, with more variation in angulation, compared to height[28] Regarding the influence of operators, it was observed that clinical experience time does not seem to influence in the accuracy of bracket positioning.[26] In the studies of the interaction between variables in the positioning with the use of a measurement device, experience time did not alter the pattern of failure tendency.[29] Similar result was found when only visual perception was used.[26]

The accuracy of vestibular positioning methods has shown variable success among the investigations. Unfortunately, the results indicate that both traditional bonding techniques, direct or indirect, fail to achieve accuracy,[5],[30] although the latter is more consistent and allow more standardizing of positions.[8],[31] In the attempt to solve the problem of accuracy, research directed to the refining of indirect protocols becomes more popular.[7],[10],[27],[32]

In virtual vestibular bonding, results diverge and seem to depend especially on the type of software system investigated, as well as on methodological study design.[33],[34] The methodologies of protocol investigation converge to the assessment of quality of appliance fitting on a subsequent phase, when quantifying the posttreatment clinical benefits.[7],[35],[36] A clinical case study described the impact of this approach, in which two types of malocclusion were successfully treated with the software system OrthoCad.[33] Other authors employ the same software system on laboratory tests; nevertheless, results did not establish more precise positioning in comparison to traditional indirect bonding techniques.[7]

By comparing ending results of 62 and 62 patients using the software system SureSmile (OraMetrix, Richardson, Tex) and the conventional method, respectively, the computer-assisted treatment presented lower average score – four points less – according to American Board of Orthodontics criteria.[37] Likewise, ending results of 63 and 69 patients, respectively, presented significant lower scores in first-order alignment and interproximal space rotation and closing.[38] By analyzing clinical outcomes of individual dental positions of 23 patients in relation to the ones estimated in virtual planning, the latter varied according to tooth type and movement dimension.[39] Discrepancies exceeded clinical limits (0, 5 mm e 2nd, linear and angular dimensions, respectively) on all teeth, except for torque in mandibular second premolars and angulation in mandibular second premolars and mandibular first molars.

Resolution for a complex orthosurgical clinical case – open bite, Class III patient – was possible through bonding mediated by the software system 3Txer (Orapix, Seoul, Korea).[10] In a laboratory experiment, using the same software to assess the effect of height in posterior teeth cuspids, discrepancies between the digital position and guided postbonding real position were found, indicating that a more substantial tendency to error when cuspids are higher has to be considered in a virtual setting.[36]

Recent clinical studies have shown that virtual protocol designed to optimize surgical orthodontic diagnosis and treatment plan allows high-precision planning of orthodontic-surgical therapy and optimization of each treatment phase, with consequent advantages in clinical practice.[11]

The incorporation of technological advances in the field of clinical orthodontics to increase treatment efficiency has led to the development of customized appliances and the production of devices to enhance tooth movement.[40] In the past decades, by incorporating new technologies to orthodontics, different commercial software systems have been made available, including multifunctional software systems that generally integrate 3D digital models, setup and virtual bonding procedures, and prototyped transfer trays.[35],[36],[37]

By determining the tendency for the purpose of greater therapeutic effectiveness and control, virtual orthodontics is an irreversible step. In a short time, all orthodontic accessories will probably be positioned in a digital manner. Overcoming the learning curve, mainly of those concerned with the academic education of future orthodontists, will perhaps be the great challenge. Another, not less important challenge, is to transform the accuracy of digital tools into determining the correct positioning of accessories.


  Conclusion Top


Although the technological interface has optimized protocols, especially in planning and laboratory stage, digital systems did not demonstrate to guarantee accuracy. However, virtual orthodontics is now an irrevocable trend, for enabling more efficacy and therapeutic control. It is plausible that soon all orthodontic brackets will be placed digitally. The technological advances directed to the integration of software systems that capture 3D virtual images of the craniofacial complex are developing rapidly. The innovations converge to growing individualized assistance, substantiated by the use of preadjusted appliances with customized.

Financial support and sponsorship

All costs related to the development and publication of this study are being borne by the authors themselves.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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