Clinical treatment with bonded plastic attachments

Clinical treatment with bonded plastic attachments George West

V. Newman,

Orange,

N.

W.W.S.*

J.

T

here is little debate in the orthodontic specialty that the most effective appliance is the one that will move teeth in all three planes of space. Bodily tooth movement and root-torque control are necessary for the achievement of modern orthodontic goals. The bonded plastic attachments to be shown in the following cases will allow for these essential tooth movements. Advantageously, plastic attachments promote minimal soft-tissue irritation, separation is obviated, arch-length loss is avoided, decalcifications are decreased, and esthetics are improved.1-4 However, the attachments are bonded primarily to the upper six anterior teeth, since adhesion is fostered by a readily obtainable dry area during bonding. Permanence and variability of the adhesive bond under aqueous oral conditions remain a problem. The patient’s cooperation is essential in avoiding hard and sticky foodstuffs, and the use of minimal orthodontic forces is advisable to increase duration of the bond. At present the adhesives employed in orthodontics bond readily to plastic attachments (polycarbonate) while metal brackets require extensive surface preparation in order to bond to their surfaces. For this reason, as well as for improved esthetics, I prefer plastic attachments. However, the wings of the plastic edgewise brackets do tend to fracture occasionally. The ilustrated cases that follow demonstrate the use of bonded plastic attachments in clinical practice. Light forces are emphasized to prolong the bond strength of the adhesive joints in the edgewise and Begg techniques. Simplified, readily reproducible mechanical procedures are suggested to decrease undesirable forces upon the attachments and the teeth. Ideal arch form and coordination of maxillary and mandibular arch wires are desirable mechanical procedures. Perhaps by the interchange of treatment procedures as described in this article, methods for treatment will be crystallized in the reader’s mind which will allow him to offer supplementary contributions to this addition to our armamentarium. Presented at the seventieth annual session of the American Association of Orthodontists, Boston, Mass., April 9, 1970. “Adjunct Research Professor, Newark College of Engineering, Chief Orthodontist, Bureau of Health, Newark, N. J.

600

Newark,

N. J.;

Volume Number

60 6

Bonded plustic attachnzents

Fig. 1. Case 1 prior to treatment. Fig. 2. Bonded plastic attachments spaces. cervical

The soldered anchorage.

Fig. 3. After to brackets

Fig. 4. After

removal with 0.008 removal

Class

III

Note

hooks

of the lower inch ligature of

upper

lingually on

upper

on

the

edgewise wire.

attachments.

locked anterior lower

arch

lateral

Note

incisors.

teeth

with

wire

are

appliance, normal,

601

0.018

elastic

thread

to

close

elastics

and

for

Class

III

inch

upper

arch

healthy

enamel

and

wire

tied

gingival

tissues.

A previous article5 on the effect of the adhesive system upon tooth enamel surfaces by means of scanning electron microscopy indicates favorable results. Clinical studies confirm the findings of the scanning electron microscopy study that, clinically, there is minimal ill effect of the adhesive system upon tooth structure, as demonstrated in this article. CASE

1

The patient, a 12-year-old boy, had a moderate Class III malocclusion with lingually locked maxillary lateral incisors (Fig. 1). There was an ANB difference of -1 degree the Frankfort-Mandibular Angle (FMA) wag 32 degrees, and the Y axis was 65 degrees. Appliances and treatment CPPER ARCH. An upper bite plate with oeclusal coverage and auxiliary springs activated against the lingual surfaces of the upper lateral incisors was used to move the lateral incisors into alignment. The occlusal bite plane removed occlusal interferences, allowing the lateral incisors to tip freely into alignment. In addition, this occlusal coverage tended to thrust the mandible vertically and distally, neutralizing the forward growth of the Class III type of mandible. A chin cup with a high-pull headgear was also employed to restrain forward growt,h of the mandible. After the lateral incisors were in correct position, the six upper anterior teeth were bonded with edgewise attachments, and closed coil springs were inserted from the canine attachments to the 0.022 by 0.028 inch first molar buccal tubes, on an 0.018 inch upper arch wire, to maintain arch length. Elastic thread was used to maintain space closure after correction of the Class III relationship (Fig. 2).

Newman

602

Fig.

5.

Case

2 prior

Am.

to treatment.

6. During treatment. with loops is 0.018 inch. elastics were worn to fully

Fig.

Note

7.

After removal of lower edgewise Note space closing and stepped-up retract the incisors.

Fig.

8.

After

treatment.

Class

II, Division

Note

normal

appliance upper 0.018 enamel

surfaces

Ovthod.

1971

I malocclusion.

Note upper bonded plastic attachments. Note torquing auxiliary to effect lingual banded lower edgewise appliance.

wire. and

Fig.

J.

Decenlbe?"

and inch

insertion arch wire and

healthy

The upper root torque.

arch wire Class II

of lower lingual arch with loops to depress gingival

tissue.

LOWER ARCH. Edgewise metal bands and brackets were placed on the anterior teeth, and 0.022 by 0.028 inch buccal tubes were placed on the first molars. Intermaxillary hooks were used for insertion of Class III intermaxillary elastics to the upper arch and for use of the cervical headgear, which was used alternately with the chin cup and high-pull headgear (Fig. 2). Lower arch wires (0.018, 0.020, and 0.018 by 0.025 inch) with stops against the buccal tubes of the lower molars were used. Fig. 3 shows the appearance of the plastic attachments after removal of the lower appliance. The upper coil springs have been removed, and an upper 0.018 inch arch wire has been inserted to test stability. Fig. 4 illustrates the labial surfaces of the anterior teeth after removal of the bonded attachments. Retention. A Hawley bite plate was used in the upper arch for retention. The chin cup with a high-pull headgear, employed in an attempt to restrain the forward growth of the mandible orthopedically, was continued after treatment. CASE

2

An U-year-old girl presented with a Class II, Division 1 malocclusion. There was a moderate overbite, the ANB difference was 5 degrees, and the FMA was a favorable 25 degrees (Fig. 5). This was treated as a nonextraction case. Appliances and treatment UPPER ARCH. Bands with combination tubes were cemented on the upper first molars. The gingival tube was 0.022 by 0.028 inch edgewise, while the occlusal tube was 0.050 inch round. The upper anterior teeth were bonded with plastic attachments. The upper arch was leveled with 0.014, 0.016, and 0.018 inch arch wires. After leveling, the incisors were retracted and depressed with an 0.018 inch (closing) looped upper arch wire and light Class II intermaxillary elastics (2% ounces). An 0.016 inch Kichton torquing arch wire was

Bowled

Fig. 9. A and 8, Note photographs. C, Frontal

reduction photographs

in orofacial showing

pla.stic attachwv~ fs

area in beforeand plastic attachments

after-treatment and wire during

603

profile treat-

ment.

used to effect lingual root torque. A 0.045 inch face-bow was inserted in the occlusal tubr and used as well. Fig. 6 shows the “A” elastic ligatures on the lower incisor brackets. LOWER ARCH. A full-banded metal edgewise appliance was used in the lower arch. The lower arch was leveled with 0.016, 0.018, and 0.018 by 0.025 inch arch wires. Tie-back stops were soldered adjacent to the mesial aspect of the buccal tubes. After a Class I molar relationship was obtained, the lower bands were removed and light Class II intermaxillary elastics were worn, employing a fixed lower lingual arch wire for anchorage (Fig. 7). Fig. 8 shows the excellent gingival tissues and labial surfaces of the upper anterior teeth after removal of the upper appliances, as well as the buccal decalcification of the lower left second premolar. Fig. 9, B and B presents the beforeand after-treatment profile photographs of Case 2, showing the orofacial improvement. In Fig. 9, C the frontal photograph shows the esthetic plastic attachments during treatment. CASE

3

The patient was a 16-year-old girl with a Class II, Division 1 7.5 mm. overjet. Since the lower arch was well aligned and well growth was minimal, and pogonion was prominent, I decided to molars only removed6 (Fig. 10). The FMA was 24 degrees and 7 degrees. The patient requested plastic attachments, since she felt that, did not desire to have metal bands on her upper anterior teeth.

malocclusion positioned have the the ANB because Esthetic

evidencing craniofacially, upper first difference of her plastic

a prewas

age, she attaeh-

604

Am. 3. Orthod. December 1971

Newman

Fig. 10. Case 3 prior to treatment. Fig. 11. During treatment. Note

Note

anterior

overjet.

upper bonded plastic edgewise attachments. The upper main arch wire is 0.020 inch and has space-closing loops between the canines and premolars. The helix of the 0.016 inch Kichton torquing auxiliary straddles the main arch wire and is ligated to it to prevent displacement. The annealed ends of the torqueing auxiliary are looped over the main arch wire between the central and lateral incisors. Note also Class III elastics emanating from the lower sliding hooks and exerting pressure against main arch wire.

the This

lower action

coil springs. The elastics are inserted uprights the lower molars and aids

onto ends in closing

of the

the upper extraction

spaces.

Fig. 12. Normal,

healthy

dental

tissues

after

treatment.

merits tend to help young adults and adults get over the initial hurdle of wearing orthodontic appliances. Treatment and appliances UPPER BRCH. The six upper anterior teeth were bonded with Begg plastic attachments initially. The second premolars were banded with metal bands and Begg Chun-Hoon brackets. Bands with double buccal tubes were placed on the upper first molars. The 0.036 inch round tube was soldered gingivally, while the 0.022 by 0.028 inch edgewise tube was soldered occlusally. Upper horizontal and Class II intermaxillary elastics were employed to retract the protruding six upper anterior teeth. After the anterior segment had been retracted, the Begg brackets were replaced with bonded plastic edgewise twin brackets (Fig. 11). The 0.016 inch upper arch wire was then removed from the 0.036 inch tube and inserted into the 0.022 by 0.028 inch tube. The upper arch was leveled, and the extraction spaces further closed with 0.018 and 0.020 inch upper closing loop arch wires. An 0.016 inch Kichton torquing auxiliary was used to effect lingual root torque. LOWER ARCH. The lower anterior teeth were banded with Begg Chun-Hoon brackets and metal bands. Bands with 0.036 inch tubes were placed on the first molars. A coil spring from the mesial aspect of the 0.036 inch first molar tube to the distal aspect of the canine Begg brackets was placed upon an 0.020 inch lower arch wire and used to maintain space and anchorage for the elastics. Sliding hooks anterior to the coil springs were also used in

yolks.

Bonded plastic attachmnts

“6”

Fig. 13. improvement. arch wires

A and C, during

B, Beforeand after-treatment Frontal photographs showing treatment.

profile bonded

photographs of Case 3. Note plastic edgewise attachments

605

facial and

tandem Class III intermaxillary elastics to aid in closing the upper extraction spaces ztnd to upright the lower molars. Fig. 12 portrays the intraoral frontal view after treatment, Note healthy gingival tissues and enamel surfaces. The beforeand after-treatment profile photographs indicating orofacial improvement can be seen in Fig. 13, A and B. Fig. 13, C shows the frontal photograph and esthetic attaehments during treatment. CASE

4

A 12-year-old girl had a Class I bimaxillary protrusion evidencing a diastema between the central incisors, rotated, crowded, flared upper anterior teeth, and a crowded lower arch (Fig. 14). There was an ANB difference of 6 degrees and an unfavorable FMA of 36 degrees.7 Treatment and upplialtces. Since there was a lower arch-length discrepancy of 7 mm., and since the cephalometric analysis and profile photographs indicated that the patient had a bimaxillary protrusion, it was decided that the maxillary and mandibular first premolars should be removed to accomplish the treatment goals of stability, esthetics, and function. UPPER ARCH. The labial surfaces of the upper anterior teeth were bonded with Beggs plastic attachments, while bands with combination tubes were placed on the upper first molars. An 0.036 inch round tube was soldered gingivally, and an 0.050 inch tube was

Fig, 14. Case 4 prior canine are difficult to Fig.

15.

Upper

wires with loops. and brackets are Fig.

16.

wires with intermaxillary

Stage

bonded

to treatment. bond. Begg

Malaligned

plastic

right

attachments.

Note

Class II elastics (21/z ounces] employed in the lower arch. II Begg

hooks to circles

treatment. receive instead

Arch

wire

lateral

are with

Class II and lower of vertical loops.

worn

incisor

0.016

inch

in Stage

loops

has

horizontal

been elastics.

and upper

I. Begg replaced The

partially and

erupted lower

Chun-Hoon by author

arch bands

plain

arch

now

uses

Fig. 17. Stage III Begg treatment. The upper and lower main arch wires are 0.020 inches. The upper arch wire is in the ribbon arch (Begg) slot while the lower ideal arch wire is in the edgewise slot. Note the maxillary torquing auxiliary used to torque the roots of the incisors palatally. The mandibular uprighting springs have been removed since roentgenograms indicated that their roots have been paralleled. The maxillary uprighting springs were 0.014 inch. Fig. 18. Stage IV Begg treatment. Auxiliary torquing arch dibular uprighting springs have been removed after torquing roots have been completed. Ideal, coordinated maxillary arch wires were inserted for artistic finishing and symmetry. Fig. 19. After treatment. Note maxillary lateral incisors could for a longer treatment time.

healthy tooth enamel have been improved

wire and maxillary and of incisors and paralleling and mandibular 0.020

and gingival by employing

manof inch

tissues. Uprighting of the uprighting springs

Volume Number

60 6

Boded

plastic attachments

607

soldered occlusally. An 0.016 inch looped arch wire with distal tip-backs was inserted in the first stage of treatment. Class II intermaxillary elastics were used to retract and unravel the upper anterior teeth (Fig. 15). After the rotations were alleviated and the bite opened edge to edge, plain 0.016 inch arch wires were inserted and Class II intermaxillary and lower horizontal intramaxillary elastics were continued (Fig. 16). The right central incisor attachment loosened twice and the left central incisor attachment loosened four times during the 16 months of active treatment time. In Stage III (Fig. 17) an 0.020 inch main ideal arch wire was used with bayonet bends in the molar areas. Uprighting springs (0.014 inch) were inserted in the canine and premolar brackets to upright these teeth. To prevent space from reopening between the canines and second premolars, ligatures were tied from the lingual buttons of the second premolars to the arch wire between the lateral incisors and canines, anterior to the intermaxillary hooks (loops). An 0.014 inch Kichton torquing arch wire was used to effect lingual root torque. Uprighting springs (0.014 inch) were also employed to upright the lateral incisors. Finally, in Stage I\‘, the uprighting springs an1 torquing auxiliary were removed and an 0.020 inch ideal main arch wirr with molar bayonet bends and lateral inserts was placed (Fig. 18). It was noted that there was less breakage of the clear plastic brackets in contrast to the pigmented attachments (white or tooth-colored). It was hypothesized that the pigmented brackets tended to absorb more water (saliva) than the clear brackets. lt should be pointed out that the adhesive and attachments portrayed in these case reports are white in color. The white color of the adhesive is due to the fluorides present. In the lasr L’ years 1 have also been using a clear adhesive and plastic attachment which has essentially the same index of refraction as tooth structure and, therefore, is more esthetic. However, the principles of bonding and treatment are similar. LOWER ARCH. The lower arch was banded with metal bands and Begg Chun-Boon brackets. Bands with double buccal tubes were cemented on the lower first molars. The gingival tube was 0.036 inch, while the occlusal tube was 0.022 by 0.028 inch. At the end of Stage I1 the 0.016 inch lower arch wire was removed from the ribbon arch slots and 0.036 inch tubes :~nd inserted into the edgewise slots and 0.022 by 0.028 inch buccal tubes. Lower ideal arch nirchs (0.018 and 0.020 inch) were then used to effect arch symmetry and alignment. Uprighting springs (0.014 inch) were used to parallel the roots of the lateral incisors, canines, on11 premolars. Retention. Healthy dental tissues are shown in Fig. 19. The retainers consisted of ul,l~r and lower bite plates of the Hawley type. CASE

5

A 121/2-year-old girl was referred for orthodontic treatment evidencing a Class 11, Division 1 bimaxillary protrusion and blocked-out upper canines. As a result of the loss of the lower first permanent molars, the lower premolars were distally tipped, drifted, and rotated (Fig. 20). Trentmeat nnd appliances. Since the lower first molars were missing (they had been ln?viously removed because of dental caries), I decided to have the upper first premolars removed in ortler to complete treatment satisfactorily insofar as balance, symmetry, function, and stability were concerned. Lower anchorage was not a problem because of the spacing in the posterior segments. UPPER ARCH. The anterior teeth were bonded with Begg plastic attachments. Stainless steel bands with soldered double buccal tubes were cemented on the first molars. An 0.036 inch tube was placed gingivally for the Begg arch wires, while an 0.050 inch tube was soldered oeclusally to receive a face-bow, for extraoral anchorage, if deemed necessary. The t,hree stages of the Begg technique were employed. Fig. 21 shows the upper anterior teeth protruding excessively. This was due to the patient’s lack of cooperation in wearing elastics as prescribed in Stage I. The reciprocal forces exerted by the loops caused the incisors to tip forward when i.he distal retracting force of the elastics was nullified by the patient’s failure to wear her intermaxillary elastics. Lower horizontal elastics were worn because of adequate arch length, since anchorage was not a problem. As a rule, lower horizontal elastics are not worn in the first stage of Begg treatment. Fig. 22 illustrates the 0.016 inch Michtaa auxiliary

600

Fig. 20. had

Am.

Newman

been

Case 5 prior to treatment. Note blocked-out removed because of carious exposures.

upper

canines.

Fig. 21. Stage

I of Begg treatment. Note the bonded Begg plastic arch wires with loops, and plain mandibular arch wire. Note also elastics. The horizontal elastics are worn to close spaces and support

Fig. 22.

Stage

mandibular employed.

III.

arch Note

Note maxillary wire is in the that the upper

torquing and to prevent spacing. have long lever arms. Short lever

Fig. 23.

After

J. Orthod.

December

treatment.

Note

The

lower

1971

first

attachments, Class II and anchorage.

molars

maxillary horizontal

and mandibular 0.020 edgewise slots and tubes. anterior teeth are ligated

inch main arch wires. The torquing auxiliary together to enhance

The arm

springs coils

normal

maxillary springs labial

with surfaces

uprighting three of

full the

anterior

are 0.014 are equally teeth

after

The is root

inch and effective. removal

of attachments. torquing arch wire and the 0.014 inch uprighting springs for paralleling the canine and premolar roots. The main arch wire was 0.020 inch in diameter. The fabrication of the torquing auxiliary has been described in the literature.9 Fig. 22 reveals that the torquing auxiliary’s coils straddle the main arch wire and that its arms are hooked over the main arch wire distal to the incisor brackets. A ligature is used to tie the coils to the main arch wire to prevent displacement. The four incisors were ligated together to prevent spacing and rotations and to stimulate lingual root torque of the lateral incisors as well as the central incisors. To facilitate hooking of the torquing auxiliary over the main arch wire, it is advisable to soft-anneal the hooked ends by heating them in a flame until cherry red and then dipping the ends in water. LOWER ARCH. The lower arch was banded with metal bands and Begg-Chun Hoon brackets. The second molars were cemented with metal bands to which were soldered double buccal tubes. The occlusal tube was an 0.022 by 0.028 inch tube to accommodate the edgewise slot of the Begg-Chun Hoon bracket, and the gingival tube was an 0.036 inch tube for the ribbon arch (Begg) slot. During Stages I and II an 0.016 inch lower arch wire was used in the ribbon arch slot. In Stage III this arch wire was inserted in the 0.022 inch edgewise slots and tubes. Ideal 0.018 and 0.020 inch arch wires were then used, and 0.014 inch uprighting springs were used on the premolars. After treatment. The after-treatment photograph indicates healthy enamel and gingival tissues. A plastic tooth positioner was used for 4 months, and upper and lower Hawley retainers were employed for one year (Fig. 23).

VoEume Number

Bonded plastic attachnzents

GO 6

409

Fig. 24. A and B, Beforeand after-treatment profile photographs. orofacial fullness to a more pleasant profile appearance. C, Frontal bonded plastic Begg attachments and arch wires during treatment.

Note reduction in photograph showing

Beforeimprovement.

B) reveal treatment.

and after-treatment Fig. 24, C shows

profile photographs the Begg plastic

(Fig. attachments

24,

A and during

the

facial

Summary

Bonded plastic attachments are an esthetic adjunct to our orthodontic armamentarium.lo~ I1 They allow for maximum tooth control, since teeth can be moved in all three planes of space, as demonstrated by the treated cases. Bonding to an individual tooth, temporarily, to aid the eruption of a surgically exposed canine, for example, can be readily accomplished. Acrylic adhesives, however, require a dry field prior to bonding for maximum adhesion. The bonding technique must be carefully adhered to for optimum results.12 Clinically, problems may be encountered, since the bonds may break at undesirable periods during treatment. It is interesting to note that the adhesive joints rarely break during treatment in adults. This may be due to several factors: (1) greater cooperation of adult patients in refraining from hard and sticky foodstuffs and in not unconsciously playing with the appliances, which may tend to break the brackets or bonds, (2) less organic material in tooth enamel, permitting better wetting and adhesion, and (3) greater calcification of tooth structure in adults which decreases ,the

610

Newman

amount of internal bonding, treatment

Am. J. Ovthod. December 1971

enamel fluid that can reach the adhesive joint within period.

a given

REFERENCES

1. Snyder, W. H., Wilson, C. E., Newman, G. V., and Semen, J.: Investigation of fast setting acrylic adhesives for bonding attachments to human tooth surfaces, J. Appl. Polymer Sci. 11: 1509-1527, 1967. 2. Newman, G. V.: Adhesion and orthodontic plastic attachments, AM. J. ORTHOD. 56: 573-588, 1969. 3. Newman, G. V.: Bonding plastic attachments, J. Pratt. Orthod. 5: 231-238, 1969. 4. Newman, G. V., and Rafel, S. S.: Treatment of a pseudo-Class III malocclusion and associated follicular cyst: Report of a case, J. Am. Dent. Assoc. 80: 338-345, 1970. 5. Newman, G. V., and Facq, J.: The effects of adhesive systems on tooth surfaces, AM. J.

ORTHOD. 58: 67-79, 1971. 6. Newman, G. V.: Orthodontic rehabilitation, J. Dent. Child. 26: 343-346, 1959. 7. Newman, G. V.: Treatment of high angle cases with the Begg technique, J. Pratt. Orthod. 3: 176-195, 1969. S. Newman, G. V.: A biomechanical analysis of the Begg light arch wire technique, AM. J. ORTHOD. 49: 7X-740,1963. 9. Kichton, J. F.: The Kichton torquing auxiliary, J. Pratt. Orthod. 1: 72-73, 1967. 10. Retief, D. H., Dreyer, C. J., and Gavron, G.: The direct bonding of orthodontic attachments to teeth by means of an epoxy adhesive, AM. J. ORTHOD. 58: 21-40, 1970. 11. Miura, F., Nakagawa, K., and Masuhara, E.: New direct bonding system for plastic brackets, Aa6.J. ORTHOD. 59: 350-361,197l. 12. Newman, G. V.: Bonding of orthodontic plastic attachments. Audio-Visual Library, American Association of Orthodontists, St. Louis, MO. 659 Eagle

Rook

Ave.