A close-up look at Ormco’s new digital bonding system in the orthodontic clinic.

By Michael J. Mayhew, DDS, MS, MS

Direct bonding has long been the gold standard preferred delivery technique for the placement of orthodontic appliances. While a seemingly simple process, it is actually quite demanding as it requires patient cooperation, clinical time from both the doctor and staff and positioning accuracy to ensure treatment progress. For the past 20 years of my orthodontic career, I’ve had a keen interest in indirect bonding. My goals were to improve patient scheduling and staff utilization through delegation, chairside time management, and case treatment efficiencies. I knew that greater staff utilization would result in many benefits for the practice as well as free doctor time for other priorities.1 Also, improved accuracy of bracket positioning would reduce treatment delays that are often experienced from bracket repositioning and wire bending requirements during finishing.

Ormco Bonding
Figure 1: Ormco Jigs Technology ‘cap’ wraps around the tooth buccally and lingually for stable placement with bracket receivers individually. designed for each tooth bracket.
Ormco Bonding
Figure 2: The jigs allow access to the jig’s three exposed buccal cap edges to minimize flash.

My journey led to the traditional indirect bonding concepts with bracket placement on plaster models2 and experimenting with multiple “carrier transfer” materials and methods.3 However, these approaches displaced our clinical time with other operational tasks. For example, staff would initially place brackets on the plaster models, and the doctor would approve and/or change positioning. Additional steps were taken to complete the traditional indirect bonding process, including multiple lab procedures followed by bracket curing and preparation of the transfer delivery trays. The intraoral bondings were successful, as were the efforts to improve office and clinical efficiencies. It was better than direct bonding, but it required significant efforts and staff to execute the steps.

With the evolution of digital modeling and other software developments, our office began to work with a software company to develop and test digital modeling processes with more straightforward laboratory procedures.4 Eventually, as digital systems such as intraoral scanners, clear aligners, and digital printing were integrated with orthodontics, this spurred the development of digital fixed appliance options. The overall growth of digital orthodontics helped to make the indirect bonding process more palatable for clinicians. But doctors were also seeing the stand-alone benefits of indirect bonding, including improved accuracy and clinical efficiency while eliminating labor-intensive office lab procedures. Recently, I’ve worked with Ormco to develop a digital bonding system powered by the Spark Software Platform and leveraging the Damon Ultima System bracket.

Ormco Bonding
Figure 3: Initial bonding accuracy demonstrated at 0.20 mm (green color range).

The Damon Ultima System, promoted as the “first full expression” orthodontic bracket, is based on center-point slot alignment at the facial axis point along the tooth’s long axis for desired alignment and torque expression. This re-engineered design and new proprietary rounded-edge rectangular wires virtually eliminate play for precise rotation control, angulation, and torque. The Ormco Digital Bonding software digitally determines the ideal landmarks for each tooth for bracket placement, enhancing optimal expression of the wire and Damon Ultima bracket, thereby improving treatment accuracy and efficiency.

Ormco Bonding
Figure 4: Case 1 patient is a 12-year-old female seeking orthodontic treatment to align her teeth and open space for maxillary canines.

Case submission for Ormco Digital Bonding with the Spark Approver software portal streamlines office processes for both aligners and brackets. Doctors can designate staff to follow previously developed treatment plans to enter patient information into the portal. Drop-down menus list thorough information to provide technicians guidance for digital treatment planning. A section is available to offer any additional notations unique to a patient’s plan. Options exist for doctor-determined bracket torques. If not requested by the doctor, the Spark Approver software can assist in torque bracket selections determined by alignment requirements from TO (initial malocclusion) to T1 (proposed finish). Currently, stock Damon Ultima brackets with Snaplink first molars and Mesh Mini tubes for second molars are available. Ormco technicians mesh treatment plans and bracket selections to provide optimal setups based on tooth landmarks.

Figure 5: Tooth landmarks located with Spark Approval Software determined bracket placement by facial and long axes.
Figure 6: Damon Ultima retrocline torque brackets on the upper anterior and the lower incisors and procline brackets placed on the maxillary canines.

Achieving true software-based landmark positioning with a bracket system is revolutionary as now we can develop a digital plan with outcomes viewed pre-treatment. The orthodontist determines the final approval of bracket positioning and digital diagnostic treatment options, similar to aligner treatment approvals.

Approved digital setups are transferred to the patient via 3D printed jigs. The Ormco Jigs Technology ‘cap’ wraps around the tooth buccally and lingually for stable placement with bracket receivers individually designed for each tooth bracket (Figure 1). The receivers firmly hold the brackets while providing full bracket base access to place bonding composites. User-defined segmentation of the jigs can be requested or done chairside with scissors. Each jig has an occlusal flat surface plane for ease in handling and seating pressures. A unique aspect of the jigs is the ability to access the jig’s three exposed buccal cap edges to minimize flash. A sponge tip wet with a liquid bonding agent promotes flash removal before light curing (Figure 2). Any flash from the fourth occlusal or incisal surface can be readily removed with a polishing tool in a dental handpiece. Typical full-coverage transfer trays do not allow flash cleanup before light curing, potentially requiring greater chairside time to clean cured adhesive from the bracket and tooth edges.

Figure 7: Initial bonding, digitally planned placement, and actual bonding. Color dots on actual brackets show specific torques selected.
Figure 8: Progress at 4 months. Two months each of .014 CuNiTi and .018 CuNiTi wires with .014 x .0275 CuNiTi placed at this appointment.

During the initial clinical trials of this process, after appliances were bonded, intraoral scans were taken to evaluate accuracy via colorimetric best-fit superimposition, comparing the initial setup to the actual bracket bonding (Figure 3). Most results were recorded in the +/- 0.2 mm range, matching previously reported data from in-vivo studies.5

Figure 9: Final adjustments.

Case 1

A 12-year-old female sought orthodontic treatment to align her teeth and open space for maxillary canines (Figure 4). Tooth landmarks located with Spark Approval Software determined bracket placement by facial and long axes (Figure 5), guided bracket positioning, and the final proposed treatment. Damon Ultima retrocline torque brackets on the upper anterior and the lower incisors and procline brackets were placed on the maxillary canines (Figure 6). The prediction of bracket positioning compared well with the actual bonding (Figure 7). After 4 months of treatment with 2 months of 0.014 CuNiTi and 2 months of 0.018 CuNiTi wire alignment, a 0.014 x 0.0275 CuNiTi wire was placed to obtain rotation corrections and begin torque changes. Alignment progression required one repositioning on tooth #8 (Figure 8). Final adjustments included an occlusal step for tooth #28 (Figure 9).

Figure 10: Initial and final records at 13 months treatment.

The patient was debonded, and final records were taken after 13 months of treatment (Figure 10). Permanent bonded retainers were delivered with removable vacuum-formed retainers for nightwear at this appointment.

Figure 11: Case 2 patient is a 20-year-old female who presented with a Class III skeletal pattern and recursive upper and lower incisors.

Case 2

A 20-year-old female requested orthodontic treatment for alignment and bite correction. She presented with a Class III skeletal pattern with retrusive upper and lower incisors (Figure 11). Procline brackets were placed on the upper anteriors to correct the incisor angulation and create space to align teeth, as demonstrated by the proposed alignment (Figure 12). Tooth #7 was extruded digitally for future contouring to match #10 incisal edge height.

Normal wire progressions, from 0.014 CuNiTi (Figure 13) to 0.018 CuNiTi to the rounded edge rectangular wires, 0.014 x 0.0275 and 0.018 x 0.0275 CuNiTi were utilized to achieve initial alignment followed by 0.018 x 0.0275 TMA. After 7 months of treatment, it was determined that the maxillary incisors were too proclined. Retrocline torques were placed to aid in uprighting the incisors. All lower incisors were retrocline torques to prevent the proclination of incisors during alignment.

Figure 12: Proposed alignment shows procline brackets placed on the upper anteriors to correct incisor angulation and create space to align teeth.
Figure 13: Initial bonding and placement of .014 Cu wire.

At 11 months, the lower central incisor brackets were changed to procline due to the facial root prominence noted clinically, anticipating moving the roots lingual with further wire progressions. All appliances were removed at 16 months, and bonded retainers were placed in both arches with vacuum-formed removable retainers delivered for night wear (Figure 14).

Figure 14: All appliances removed at 16 months.

Conclusion

The accuracy and efficiency of the Ormco Digital Bonding system coupled with the Damon Ultima System provides a revolutionary improvement in the computer-assisted design and manufacturing of orthodontic appliances. Working within one platform for Spark Clear Aligners and Ormco Digital Bonding cases streamlines practice efficiency from initial case submission to treatment completion. It also increases the flexibility of treatment options. Specifically, the option for hybrid treatments, utilizing both aligners and braces for a patient, can be readily facilitated. The potential for using aligners in the maxillary arch for esthetics and braces for increased mechanical efficiency in the mandibular arch or switching from one treatment method to another can be managed seamlessly powered by the Spark Software Platform. OP

Michael J. Mayhew, DDS, MS, MS, received his dental degree, certificates, and master’s degrees in pediatric dentistry and orthodontics from the UNC School of Dentistry. Mayhew was the first dual-trained and dual board-certified practitioner in North Carolina active in both specialties, practicing in Boone and North Wilkesboro, NC. Disclaimer: Mayhew is a paid consultant for Ormco. The opinions expressed are those of Mayhew. Ormco is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own professional judgment in treating their patients. Teeth images have not been altered. Patient results may vary.

References:

  1. Please follow local regulations regarding staff supervision restrictions.
  2. Silverman, E., Cohen, M., Gianelly, A., Dietz, V. A universal direct bonding system for both metal and plastic brackets. Am J Orthod, Vol 62, 3:236-244, September, 1972.
  3. Nawrocka, A. Lukomska-Szymanska, M. The indirect bonding technique in orthodontics-a narrative literature review. Materials. 2020:13(4).
  4. Mayhew, M. Redmon, R. The Cutting Edge: Computer-Aided Bracket Placement for Indirect Bonding. J Clin Orthod. Volume 39 : Number 11 : Page 653 : Nov 2005.
  5. Mario, P., Petra-Julia, K., Paul-Georg, J., Giorgio Alfredo, S., Alessandro, V., Patrizia, P., and Luca, L. Accuracy of indirect bracket placement with medium-soft, transparent, broad coverage transfer trays fabricated using computer-aided design and manufacturing: An in-vivo study. Am J Orthod Dentofacial Orthop 2023;163:33-46.