Dental Science - Original Article

How and why of orthodontic bond failures:

An in vivo study
R. K. Vijayakumar, Raju Jagadeep, Fayyaz Ahamed, Aprose Kanna, K. Suresh

Department of
Orthodontics, Sri
Ramakrishna Dental
College and Hospital,
Avarampalayam,
Coimbatore, Tamil Nadu,
India
Address for correspondence:
Dr. R. K. Vijaya kumar,
E‑mail: vijiviji05@yahoo.com
Received : 30-03-14
Review completed : 30-03-14
Accepted : 09-04-14
ABSTRACT
Introduction: The bonding of orthodontic brackets and their failure rates by both direct and in‑direct procedures
are well‑documented in orthodontic literature. Over the years different adhesive materials and various indirect
bonding transfer procedures have been compared and evaluated for bond failure rates. The aim of our study
is to highlight the use of a simple, inexpensive and ease of manipulation of a single thermo‑plastic transfer
tray and the use the of a single light cure adhesive to evaluate the bond failure rates in clinical situations.
Materials and Methods: A total of 30 patients were randomly divided into two groups (Group A and Group B).
A split‑mouth study design was used, for, both the groups so that they were distributed equally with‑out bias.
After initial prophylaxis, both the procedures were done as per manufactures instructions. All patients were
initially motivated and reviewed for bond failures rates for 6 months. Results: Bond failure rates were assessed
for over‑all direct and indirect procedures, anterior and posterior arches, and for individual tooth. Z‑test was used
for statistically analyzing, the normal distribution of the sample in a spilt mouth study. The results of the two
groups were compared and P value was calculated using Z‑proportion test to assess the significance of the bond
failure. Conclusion: Over‑all bond failure was more for direct bonding. Anterior bracket failure was more in‑direct
bonding than indirect procedure, which showed more posterior bracket failures. In individual tooth bond failure,
mandibular incisor, and premolar brackets showed more failure, followed by maxillary premolars and canines.
KEY WORDS: Bond failure, split‑mouth design, thermo‑plastic transfer tray

T he bonding of orthodontic attachments to etched enamel

surface is a well‑established clinical procedure. There are at
present direct[1] and indirect[2] procedures to bond the attachments
cure adhesive to evaluate the bond failure rates in clinical situations
when both the procedures are used in split‑mouth design.

to the teeth. The advantages and disadvantages of both the
procedures were tested for bond failure rates for many years with
biased results.[3‑5] The operator preference for direct over indirect
was 13:1 in spite of the advantages of Indirect procedure.[6] Over
the years both indirect technique and adhesive material used have
been constantly undergoing new innovations, but seemingly costly.
Materials and Methods
The armamentarium used were diagnostic instruments,
thermo‑plastic sheets (2 mm), bio‑star machine, light cure
equipment, Transbond XT resin and bonding agent, study casts,
MBT ‑022 brackets and gauge [Figure 1].

Therefore, the aim of our study is to highlight the use of a simple, A total of 32 patients who came for orthodontic treatment,
practitioner friendly, inexpensive and ease of manipulation, of a requiring fixed orthodontic appliance therapy were taken for
single thermo‑plastic transfer tray material along with single light the study. All patients had full complement of tooth, with good
oral hygiene. Patients with deep‑bite, crowns and veneers, and
Access this article online partially erupted cases were excluded from the study. The patients
Quick Response Code: were randomly divided into two groups: Group A and Group B.
Website: A split‑mouth design was used to randomize the study sample.
www.jpbsonline.org

Division of sample
DOI:
10.4103/0975-7406.137394 Patients were randomly divided into two groups (Group A and
Group B). A splitmouth study design was used. For each patient,

How to cite this article: Vijayakumar RK, Jagadeep R, Ahamed F, Kanna A, Suresh K. How and why of orthodontic bond failures: An in vivo study. J Pharm Bioall
Sci 2014;6:S85-9.

Journal of Pharmacy and Bioallied Sciences July 2014 Vol 6 Supplement 1 S85 
 Vijayakumar, et al.: How and why of orthodontic bond failures ?: An In-vivo study
both the sides contained, both the groups so that they were
distributed equally with out bias. After initial prophylaxis, both
the procedures were done as per manufactures instructions. All
patients were initially motivated and reviewed for bond failures
and recorded for six months.
Split‑mouth design
Group A: Consisted of fifteen patients with maxillary right
and mandibular left quadrants bonded using direct bonding
technique, whereas contra‑lateral sides were bonded using
indirect bonding technique.
Group B: Consisted of 15 patients with maxillary left and
mandibular right quadrants bonded using direct bonding
technique, whereas contra‑lateral sides were bonded using
indirect bonding technique.
Transfer tray fabrication for indirect bonding
procedure [Figure  2]
A customized method of indirect bonding was followed for
all patients, using transparent thermo‑plastic sheet of 2 mm
thickness. Accurate alginate impressions of both arches were
made and the models were poured with‑out voids or air bubbles.
When the models were absolutely dried, the long axis of the teeth
was marked and MBT bracket positioning gauge was used to mark
Figure 1: Division of samples. Group- A (Green) - Direct bonding
Group B (Red ) - Indirect Bonding
Figure 2: Split- Mouth Technique. Group- A (Green) - Direct bonding
Group B (Red ) - Indirect Bonding
 S86 Journal of Pharmacy and Bioallied Sciences July 2014 Vol 6 Supplement 1
the vertical height for individual teeth. A thin coat of separating
medium (cold mold seal) was diluted with water (1:3 ratio)
applied evenly all over the model and allowed to dry for 24 h.[7]
Transbond XT light cure adhesive was evenly spread over the
bracket mesh and placed onto the dental model with respect
to the long axis and vertical height markings. The excess flash
was removed and each bracket was cured for 20 s each side
(occlusal and gingival) to form the custom base.[8]
Transfer trays were constructed using soft clear thermo‑plastic
sheet of 2 mm thickness in a bio‑star machine.[9] The formed
tray was then dipped in warm water for 30 min allowing the
separating medium to dissolve, which facilitate easy removal
of tray from the model with‑out any distortion. The transfer
trays for all patients were extended 2 mm below the gingival
margin on buccal and lingual/palatal side. The bracket hook
areas be trimmed/cut off the bonding tray to permit easy
removal.[6]
The transfer trays were then gently rinsed with running tap
water to remove the separating medium and allowed to dry for
30 min. Each of custom base was cleaned by applying methyl
methacrylate monomer about 10 min prior to bonding and then
thoroughly dried. Brackets were then bonded to the tooth for
both methods as per manufacturer’s instructions.
Results
A total of 30 patients were included in this study (18 females,
12 males, mean age 21.73 years, range: 15-28 years). A total
of 518 brackets, were bonded, of which 256 were placed using
direct bonding technique and 262 were placed using indirect
bonding technique.
Since the data were paired from contra‑lateral quadrants
in split‑mouth study and the distribution not normal,
statistical analysis involved the use of the Z‑test. A Z‑test
is any statistical test for which the distribution of the test
statistic under the null hypothesis can be approximated by
a normal distribution. Because of the central limit theorem,
many test statistics are approximately normally distributed
for large samples.
For comparing two groups results (failure or success outcomes),
the Z‑proportion test was used. P values were calculated using
standard normal probability distribution functions, used to
reject or accept the hypothesis of equality in proportions of
two independent groups.
Overall failure rate
A total of 50 brackets were debonded from both groups (9.6% failure
rate) over observation period of 6 months. Of the brackets placed
with direct bonding technique, 27 brackets debonded (10.5%
failure rate), whereas 23 brackets debonded (8.8% failure rate)
when using indirect bonding technique [Table 1].
 Vijayakumar, et al.: How and why of orthodontic bond failures ?: An In-vivo study

The Z‑score was 0.681 and the P value was 0.4965. Since P > 0.05, Table 1: Over all failure rate between the groups
the null hypothesis was accepted. The result was that there was Technique Brackets Failed Failure Z‑test
no statistically significant (P > 0.05) difference between direct (n) brackets (%)
and indirect bonding technique in‑terms of bond failure rate. Direct bonding 256 27 10.5 Z-score=0.681
Indirect bonding 262 23 8.8 P=0.4965 (>0.05)
Overall 518 50 9.6
Bond failure rate for anteriors and posterior brackets
for both procedures
Table 2: Anterior and posterior failure rates between the
In the anterior teeth, 19 brackets failed  (10.8% failure rate) groups
with direct bonding technique and 11 brackets failed  (6.2% Technique Direct bonding Indirect bonding
failure rate) with indirect bonding technique. In the posterior Anterior Posterior Anterior Posterior
teeth, 8 brackets failed (9.8% failure rate) with direct bonding Bonded (n) 175 81 179 83
technique and 12 brackets failed  (14.4% failure rate) with Failed brackets 19 8 11 12
indirect bonding technique [Table 2]. Percentage 10.8 9.8 6.2 14.4

For the anterior comparison, Z‑score was 1.592. The P value

Table 3: Individual teeth failure rates between the groups
was 0.11184. Since P > 0.05, the null hypothesis was accepted.
Direct bonding Indirect bonding Significance
The result was not significant at <0.05. For the posterior
comparison, the Z‑score was - 0.896. The P value was 0.36812. Bonded Failed (%) Bonded Failed (%)
Since P > 0.05, the null hypothesis was accepted. The result Maxilla
Max . 30 1 3.3 30 1 3.3 Z‑score=0
was not significant at <0.05.
Centrals P value=1
Max. 29 2 6.9 29 1 3.4 Z‑score=0.593
Failure rate for individual tooth Laterals P value=0.5552
Max. 30 5 16.6 30 3 10 Z‑score=0.76
Canine P value=0.4472
Individual tooth failure rate showed, in‑direct bonding
Max. 1st 12 1 8.3 13 0 0 Z‑score=1.062
technique mandibular centrals had highest failure rate of 20% premolar P value=0.2891
followed by maxillary canine of 16.6%, whereas in indirect Max 2nd 29 3 10.3 30 5 16.6 Z‑score=0.709
bonding technique, mandibular 2nd premolars had highest Pre molar P value=0.4777
failure rate of 18.8% followed by mandibular 1st premolar and Mandible
Mand. 30 6 20 30 4 13.3 Z‑score=0.693
maxillary 2nd premolar of 16.6% respectively [Table 3]. Central P value=0.4902
Mand. 28 2 7 30 1 3.3 Z‑score=0.655
Since P > 0.05 for the entire individual tooth, the null hypothesis Lateral P value=0.5157
was accepted. The result was not significant at <0.05. Mand. 30 3 10 30 1 3.3 Z‑score=1.035
Canine P value=0.2983
Mand. 1st 17 2 11.7 18 3 16.6 Z‑score=0.414
Discussion Premolar P value=0.6818
Mand. 2nd 21 2 9.5 22 4 18.8 Z‑score=0.819
Bonding of orthodontic attachments to tooth can be pre molar P value=0.4122
accomplished either through direct or indirect methods. The
advent of direct bonding procedure and the light cure resins In this study, both the direct and indirect bonding technique
have given the operator an unlimited working time and ease of were done using split‑mouth design to eliminate the bias
work in minimizing errors during bonding. Direct bonding is between right and left side and between upper and lower
still more preferred procedure than indirect bonding by most of bonding. Forces from mastication and hygiene maintenance
the operators. However, achieving an accurate and consistent can also be an important factor for bond failure between right
bracket positioning for the posterior continues to pose a problem and left side.[12]
because of inaccessibility. A significantly superior, efficient and
effective indirect bonding methods has been developed, which The “On command” curing advantages of light cured resin
has improved accuracy and reduced chair side time for both over auto polymerization resins, in bond failure rates have
patient and the operator over the last three decades.[8‑10] been studied by many authors with no significant difference
between them.[13,14] The bond strength and bond survival rate
In addition to being a highly sensitive technique, indirect of Conventional halogen and high speed curing (light‑emitting
bonding has two significant disadvantages. First, the diode, plasma) were compared, to be of little or no significant
occluso‑gingival insertion of the transfer tray causes the adhesive between them.[15,16]
coated brackets to scrape along the tooth surface resulting in
uneven distribution, rather than perpendicular placement. The transfer tray used in indirect bonding, in this study is
Second, when opaque trays were used the putty covering the 2 mm soft thermo‑plastic sheet. Light intensity is inversely
palatal side prevent the light from entering the palatal and proportional to the square of the distance from light source.
occlusal aspect during curing.[11] The dual trays used in the earlier studies, not only increased

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 Vijayakumar, et al.: How and why of orthodontic bond failures ?: An In-vivo study
the distance of the light source from the bracket but may act
as a factor to reduce the light intensity for curing.[7] If a light
cure is used with tray technique, the tray has to be transparent
enough to allow light transmission [Figure 3].[17]
Bond failure rate of direct and indirect bonding methods
have been compared for many decades. In our study,
the overall bond failure rate between direct and indirect
bonding was found to be 10.5% and 8.8% respectively with
no significant statistical difference between the two. The
results of this study were similar to earlier studies[5,18] with
no significant difference between the two methods. In our
study, there was proportionate increase in bond failure rate
of both the methods when compared to the other mentioned
studies, which could be attributed to the dissimilar materials
used, population bias and motivation factor. A bond failure
rate below 10% is clinically acceptable as suggested by
Cal‑Neto et al.[19]
In our study, comparing the anterior and posterior brackets, the
indirect method showed more bond survival rate than direct,
in the anterior than posterior. Though the difference was not
statistically significant, the increase in bond failure could be
attributed to arch alignment discrepancy at the start of the
treatment.[12] Bond failure in posterior segment for indirect
method, was suggested to be due to difficulty in transfer tray
removal and seepage of saliva between the tray and tooth on
the etched tooth. Furthermore, variation in adhesive thickness
during tray insertion, leading to uneven adhesive distribution
could be the possible factor for the bond failure. Adhesive
thickness up to 0.5 mm had no significant effect on bond
strength.[15]
In individual tooth bond failure rate, the mandibular centrals
showed the maximum failure rates. The reason could be
attributed to varying trauma from incisive forces.[12] The
bond failure of mandibular and maxillary premolar brackets
in indirect method showed more failure rates, due to saliva
seepage, [3] variation in adhesive thickness, other reasons
suggested are aprismatic enamel and increased curvature of
buccal surface may affect micro mechanical bond strength of
the brackets.[8,12,15,20]
Figure 3: Related to transfer tray procedures
 S88 Journal of Pharmacy and Bioallied Sciences July 2014 Vol 6 Supplement 1
Conclusions
In this study, Bond failures were observed due to various reasons,
which were found to be in concurrence with other earlier
studies. The bond failure rate was found to be <10% for over‑all
comparison, anterior – posterior comparison, and individual
tooth comparison, which was clinically acceptable. Bond failures
that resulted from transfer tray removal were due to operator’s
error. Debonding of brackets was also recorded due to occlusal
interference from high masticatory load and tooth brushing as
heard from the patients. The operator error could be reduced,
and adequate patient motivation could prevent some of these
avoidable etiological factors in increasing bond survival rate.
Hence, concluding this study, that bond survival rate in both the
methods, using the transparent thermo‑plastic transfer tray of
2 mm thickness, had no significant differences between them.
This transfer tray method was time saving, inexpensive and
ease of manipulation with‑out compromising on the bonding
procedure. Both the technique exhibited their advantages and
disadvantages in the course of this study. Finally, it will be the
operators choice to feel the convenience of procedure to use
them to their advantage.
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Source of Support: Nil, Conflict of Interest: None declared.
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