By Dr. Ed Lin
Indirect bonding was first introduced to orthodontics over 20 years ago and has become an integral part of many orthodontic practices and orthodontic labs worldwide. The four reasons/advantages for its inception are: 1) Indirect bonding has been widely viewed as giving the orthodontist the ability to achieve more accurate bracket placement on a static model and not having to deal with the clinical challenges with direct bonding on a patient, 2) The doctor can perform the final check for bracket placement at his/her own leisure and not under a set clinical schedule, 3) To improve clinical efficiency with decreased doctor chair time at the full bonding appointment, and 4) Finally, for improved patient comfort due to decreased time which the patient is in cheek retractors.
Having utilized indirect bonding in our practices for over 17 years now, these four reasons/advantages are without a doubt why all four doctors in our practices utilize indirect bonding for all of our patients. However, there are some disadvantages that are also present with conventional indirect bonding such as: 1) Distortion of the impressions leading to inaccurate models/trays, 2) Distortion of the pour up of the impressions resulting in inaccurate models/trays, 3) Short clinical crowns are not ideal for conventional indirect bonding and need to be direct bonded especially in the mandibular arch, 4) Brackets can be bumped prior to curing on the model leading to incorrect bracket placement, and 5) Seating of the indirect bonding tray is technique sensitive and can lead to over seating or under seating of the trays resulting incorrect bracket placement.
With the advancements of technologies in dentistry with intraoral scanning, 3D digital virtual bracket placement software, and 3D printing, these technologies have now given us the capabilities in orthodontics to improve upon conventional indirect bonding with 3D digital indirect bonding. Currently, there are 4 companies that I am aware of in the US market that offer 3D digital indirect bonding: OrthoSelect’s Digital Indirect Bonding System (DIBS), Arcad Digital Indirect Bonding System, Great Lakes Orthodontics’ Exceed, and SureSmile’s Elemetrix 3D Printed Indirect Bonding System. All four of these companies have proprietary cloud based software for management of patient case submissions and all of them accept intraoral scans.
For Arcad and Great Lake Orthodontics, upon final approval of the virtual bracket positions in their proprietary software, they will 3D print the models with specific indexes for very precise and accurate bracket placement on the 3D printed models. Once the brackets are placed manually on the 3D printed indexed models, their labs will then create an indirect bonding tray through conventional lab techniques and are then ready to be utilized for indirect bonding for the patient. The advantages with both systems are that they are dealing with digital data with an intraoral scan so there are no issues with a poor impression. Also, with 3D printed models, there are no issues with a poor model with air bubbles or blebs on the model. As a result, the conventional indirect bonding trays are more accurate and precise.
For OrthoSelect’s DIBS and SureSmile’s Elemetrix indirect bonding systems, upon final approval of the virtual bracket positions in their proprietary software, both of these companies will 3D print the indirect bonding trays. The brackets are then manually placed into the 3D printed indirect bonding trays for both systems and are then ready to be placed on the patient. OrthoSelect’s DIBS and SureSmile’s Elemetrix systems have the same 2 advantages as Great Lakes and Arcad’s systems, as they are only dealing with digital data with an intraoral scan, so there are no issues with poor impressions or poor model pour ups. However, since only the indirect bonding trays are 3D printed, both OrthoSelect’s and SureSmile’s systems have 2 advantages over Great Lakes and Arcad – 1) There is a significant time savings on the lab side of things since there are no 3D printed models, only the indirect bonding trays are 3D printed and 2) There is no human error brought into production of the indirect bonding trays since they are 3D printed.
Our practices are now making the transition from conventional indirect bonding to 3D digital indirect bonding with SureSmile’s Elemetrix 3D printed indirect bonding tray system so I will give a brief overview of how we utilize this in our practices. We have a 3 Shape Trios 3 intraoral scanner at each practice location. With the “Insane Mode” of the Trios, we can intraoral scan 2 arches with a digital bite registration in a total of 1 minute. We then upload the intraoral scan through the cloud to SureSmile. SureSmile will then segment, clean up, and create the 3D digital model and we will receive the digital model back on our end in 1-2 business days. We then assign the virtual brackets (.018 American Empower stainless steel or clear) and virtually position them on the digital models. Upon final approval of the virtual bracket placements, we then order our SureSmile 3D printed indirect bonding trays. The indirect bonding trays are then 3D printed and then shipped to us. We currently schedule 15 days between the intraoral scan for indirect bonding and the full bonding appointment to allow time for setup and approval, 3D printing of the trays, and for shipment to us. In the future, I hope that we will have the capabilities to 3D print our own indirect bonding trays in house, which will give us the capabilities to have quicker turnaround time with the indirect bonding trays and we will not have to deal with any shipping issues. Because SureSmile’s 3D printed indirect bonding trays are rigid, there is also an added benefit with their indirect bonding trays as we do not have to worry about over seating or under seating of their trays as you do with conventional indirect bonding trays, which are softer, as a result of the silicone and polyvinyl siloxane materials which are used to make them. The total cost for a full indirect bonding case with SureSmile’s Elemetrix Indirect Bonding System is $105 which is very affordable and attractive to me especially considering the added benefits which I have stated above.
My personal opinion is that any of the 4 digital indirect bonding systems, which I have stated above, are a step above and are an improvement upon any conventional indirect bonding systems currently available. If you are currently utilizing conventional indirect bonding or are considering transitioning to indirect bonding in your practice, I would strongly encourage you to evaluate the digital indirect bonding systems which are currently available today. As with all other aspects of our lives, technology is changing the way we all live and is helping to improve how we do things in everyday life as well as with our practices.
Dr. Lin, thank you for your excellent article, and especially for your positive mention of DIBS by OrthoSelect. We too are excited about the intersection of technology and indirect bonding. Finally IDB can be produced with a high level of precision, quality and consistency.
Keying off of the excellent points you made, another factor interested doctors should consider is software cost. Our DIBS software, compared to other similar software, is a fraction of the cost at $300– which essentially covers our cost to install and provide a tutorial. We don’t charge this fee until the doctors begins his/her second case. The first DIBS case is always free.
Chris Derieg
VP, Business Development
OrthoSelect
I also have used indirect bracket placement for many years, initially with models scanned from my impressions and for the last six years, from an intraoral scanner. The accuracy is high and I spend less time with detailing in the final wires (unless my patient loses multiple brackets). I use Arcad and have been very happy with the service.
Thank you for your update on indirect bonding. Nicely done. Having used it for longer than I care to admit, I have found that indirect bonding is without question more accurate.
One point which I believe is worth mentioning is that indirect bonding is even more accurate with custom bracket bases. A custom bracket base is created by using a virtual archwire on a virtual setup and then using the bonding material to adapt the base to the tooth. Tip, torque and in-out can be individualized for a specific patient.
Both Arcad and Great Lakes Orthodontics use this technique prior to fabricating the indirect bonding trays. It is a subtle but important detail.