Dr Arti Hindocha is working in partnership with DB Orthodontics to spread awareness on how clinicians can improve their orthodontic techniques, working practices, and review the performance of their current products.
In September's Clinical Dentistry magazine, Arti shared her top ten tips for the successful removal of metal and ceramic brackets. Here's the lowdown...
Tip one: How to examine the patient for ortho treatment
Before starting treatment, examine the teeth carefully. Record any enamel damage you can see, especially on anterior teeth. Look for previous decalcification, enamel fractures, tooth wear, fracture lines. Medicolegally, documentation and photos will help if you need to prove that the appearance of enamel cracks/ fractures are unrelated to treatment you carried out.
Tip two: Communication improves rapport with your patient
Warn the patient what to expect. Patients respond better when they know what’s coming. Tell them about the popping/clicking sound the bracket makes during debond, and the pressure/discomfort they may experience. Pain is felt more anteriorly than posteriorly.
Tip three: Allow sufficient time to remove brackets carefully
Factors to note at the time of removal are the time required for removal and damage to the tooth structure. The methods used should return the enamel to its original form without causing iatrogenic damage to its surface during the removal of resin debris/cement from the enamel surface. This is not always possible and may lead to mechanical removal of the enamel, cracks and fractures, causing irreversible damage to the enamel. The technique used for bracket removal can reduce this damage. Removing ceramic brackets can result in the fracturing of the bracket, leaving ceramic fragments on the teeth. It’ll take several minutes to remove these pieces with a high-speed bur.
Tip four: Know your essential products to carry out your chosen technique
Tools available are debonding pliers for mechanical removal, different diamond burs of high and low speed, abrasive discs, rubber tips, ultrasonic units and air abrasion techniques.
Tip five: How to effectively debond orthodontic brackets
Debond the brackets with the ligated arch wire in place to hold the debonded parts. Engage the beaks of the debonding plier (I like Ixion instruments) on mesial and distal sides of the bracket resin interface and not occluso-/inciso-gingivally. Apply an outward force to the bracket to limit enamel damage. Debond metal brackets at the enamel adhesive interface. Debond ceramic brackets at the bracket adhesive interface. Unlike metallic brackets, ceramic brackets do not flex when debonding force is applied. Avoid cutting with gradual pressure from the tips of the twin beaked pliers, as it may result in enamel cracks.
Tip six: Take care when removing resin
Adhesive and enamel surface are similarly coloured, so care is needed when removing the remaining residue. For rapid removal, use a contra-angle handpiece, with a speed of 25,000 to 30,000rpm. Use a fluted, tapered tungsten carbide or diamond finishing bur with a light painting motion, avoiding deep strokes into the enamel. Avoid water cooling as water lessens the contrast with the enamel. Check the gingival tissues for bonding agent and flash. Tungsten carbide burs are faster and more effective than Sof-Lex discs, ultrasonic tools, hand instruments, rubbers, or composite burs. They remove a substantial layer of enamel and roughen its surface, but are less destructive than Arkansas stones, green stones, diamond burs, steel burs, and lasers (all of which should be avoided).
Tip seven: Consider your options for polishing enamel
Ideally, we want to restore the enamel surface to its pre-treatment condition as closely as possible. Removal of resin remnants and tooth surface smoothing helps to minimise the likelihood of accumulation of bacteria. Tungsten carbide or diamond finishing burs can produce grooves/abrasion marks on the enamel, so secondary polishing treatment will be required. Sof-Lex discs and pumice slurry offer predictable enamel polishing.
Tip eight: Use loupes and UV light
Wear loupes, if necessary utilise ultraviolet LED illumination in the debond process to aid visibility of remnants of bonding agent/resin.
Tip nine: Take intraoral and extraoral photos immediately after debonding
Intraoral and extraoral photos can be referred to if patients return with any complaints of irregularities they may notice in the weeks following debond.
Tip ten: Emphasise the benefits of retention
Retention needs to be discussed prior to treatment starting. Avoid relapse with bonded, removable retention or both (double retention). The Maintain Retainer dual retention system from DB Orthodontics is a popular option for Orthodontists and GDPs who wish to use a convenient system that reduces chairtime and reduce the number of appointments. Scans are accepted with brackets still on, enabling the clinician to fit it during the debond appointment.
For more educational blogs from Dr Arti Hindocha, click the links below:
About DB Orthodontics
It is our company mission to become a global leader in orthodontic and laboratory supplies. With over 45 years of experience in orthodontics, we recognise the importance of quality, service and innovation. Working to ISO13485 standards we strive for perfection in all that we do, from unique product design to the excellent service provided by our dedicated customer service and sales teams. We are continually developing our product range, designing innovative products through consultation with leading orthodontists from the world, to ensure that our products meet the high standards expected by today’s practitioners.