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Ortho Tribune Middle East & Africa No. 2, 2018

E4 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2018 Efficient Bonding Protocol for the Insignia® Custom Bracket System By Dr. Angle Lee, Dr. Chris Chang & Dr. W. Eugene Roberts, Taiwan Insignia® (Ormco, Glendora, CA), is a computer-assisted design and manufacturing (CAD/CAM) process for producing a specific fixed appli- ance system to treat a malocclusion. Custom brackets and archwires to achieve the prescribed alignment are produced by a reverse engineer- ing process, based on the digital set- up of final intermaxillary occlusion. Precise placement of each bracket is critical for producing a threedimen- sional (3D) alignment to efficiently accommodate the final rectangular finishing wire, with no need for de- tailing adjustments. Positioning jigs for each bracket are fabricated to as- sist the clinician in accurately bond- ing or rebonding the prescribed cus- tom attachment on each tooth.1-3 The purpose of this report is to describe a standardized protocol for efficiently placing the custom appliance in the prescribed position. All orthodontic supplies and auxiliaries described in this article were produced by the same manufacturer (Ormco, Glen- dora, CA), unless otherwise stated. Preparation for Bonding Prior to the installation appoint- ment, the clinician and assistant(s) should inspect the following items in the patient’s kit box (Fig. 1): 1. Custom prescription brackets with well fitted application jigs (Fig. 1c): The brackets for each quadrant are packed together. 2. Six upper and six lower custom archwires with labels (Fig. 1d). 3. A setup of individual replacement jigs for each tooth (Figs. 1e-f): The first and second molars have brackets al- ready loaded. 4. Case paperwork (Fig. 1g): Clinicians are alerted to anticipated bracket interference with occlusion, that re- quires bite turbos or other compos- ite buildup on the occlusal surface to open the bite. If there is substantial crowding some brackets may be des- ignated for placement later in treat- ment. Clinical tip: The custom-fit group jigs should be dry fitted to dental casts of the malocclusion for two rea- sons: (1) check the bonding positions, (2) determine if there is any jig inter- ference when adjacent brackets are properly positioned (Fig. 2) Bonding Process 1. Tray Arrangement: Place the jigs and bonding instru- ments in the desired order, usually in the progression that they are used (Fig. 3). The arrangement may vary according to the desired tray posi- tion relative to the patient, and the handedness of the clinician and as- sistant. 2. Isolation Procedure: Begin moisture control by placing dry aids on the cheek mucosa to block the parotid gland orifice and isolate the soft tissue. Super absor- bent pads are used between lower molars and the tongue to control saliva secretion by the sublingual glands. An OptiView® lip and cheek retractor is positioned to provide a clear view of the entire oral cavity C D G A B E F A B C Fig. 2: Group jigs are placed on dental casts to check the fit. Jig interference (yellow ar- rows) is noted between the lower left canine and 1st premolar, during the prescribed bonding procedure. Both occlusal (a and b) and the left lateral perspectives (c) are shown. It follows that the lower left 1st premolar and 1st molar group jig must be removed be- fore applying the group jig to bond the lower left canine and adjacent incisors. E A C G D Fig. 1: The patient’s kit box shown (a and b) contains custom prescription brackets fitted to placement jigs (c), six upper and six lower custom archwires with labels (d), replace- ment jigs for each tooth if rebonding is required (e and f), and case paperwork describing special treatment procedures (g). B Fig. 3: Ensure bonding instruments are laid out in the desired order: (a) mirror and cotton tweezers, (b) custom prescription brackets with custom fit placement jigs, (c) dry aids and super absorbent pads, (d) scaler, Weingart plier and filling instrument, (e) lip and cheek retractor, (f) bonding agent, etching-gel, microbrushes, (g) adhesives and uni-dose ap- plicator. See text for details. 1 2 3 4 5 6 7 8 9 10 11 12 Fig. 4: Compared to conventional retrac- tion (left), an Optiview® lip and cheek re- tractor (right) is more comfortable for the patient, and improves intra-oral visibility. including the buccal surfaces of the molars (Fig. 4). 3. Step-by-Step Protocol: (1) Dry fit the group jigs to the initial casts to identify any problems in se- quentially positioning the bondable pads on each tooth. (2) Apply etching-gel for 30 seconds to the facial surface of each tooth. (3) Rinse throughly with water spray for a minimum of 5 seconds per Fig. 5: Insignia® bonding procedures are organized into a step-by-step protocol: (1) dry fit the group jigs, (2) apply etching-gel, (3) rinse, spray, and dry, (4) coat etched surfaces with the bonding agent (primer), (5) apply a thin layer of adhesive resin to each bonding pad with a filling instrument, (6) use cotton tweezers to grip the jigs, (7) rotate the pad and jig from the lingual cusp or incisal edge to the facial surface, and apply pressure from a 45-degree angle (yellow arrow), (8) use a microbrush dipped with bonding agent to clean off excess adhesive, (9) spray the jig-bracket assembly with water, (10) use a Weingart plier to release the jig from the brackets on the mesial and the distal surfaces, and then by rolling it gently to the lingual (yellow curved arrows) to remove the jig(s) from the upper (11) and lower (12) arches. tooth and air dry. (4) Apply the bonding agent (Ortho Solo®) onto all teeth to be bonded. No air-drying or light curing step is required. (5) Apply a thin coat of adhesive to each bracket pad with an application instrument such as LiquidSteel Poly- Fill Plasma+® (Carl Martin, Solingen, Germany). (6) Use cotton tweezers to grip the jigs. (7) Roll the jigs, from the lingual cusp or incisal edge, to the facial surface to prevent disturbing the adhesive layer by sliding the pad along the ÿPage E4

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