Introduction

Esthetics constitutes an important consideration in Orthodontics. Demand for

esthetics in treatment has been the reason for change in bracket morphology and

material. Mini sized steel bracket, lingual Orthodontics and polycarbonate brackets

resulted from the demand for esthetics in treatment. Ceramic introduced in 1987

and today more than a decade later it has found wide acceptance. Ceramic bracket

technology has evolved rapidly. The number of problems such as excessive bond

strength, enamel fracture on debonding, brittleness of the bracket and surface finish

have been largely addressed in the second generation of ceramic brackets..

The appearance of fixed orthodontic appliances has always been of particular

concern to many patients. The development of appliances which would combine

both acceptable aesthetics for the patient and adequate technical performance for

the orthodontist has remained an elusive goal. Three methods of achieving these

criteria have been attempted.

Altering the appearance of or reducing the size of stainless steel brackets.

Repositioning the appliance onto the lingual surfaces of the teeth.

Changing the material from which brackets are made.

Early attempts to coat metal brackets with a tooth coloured coating were

unsuccessful due to failure of the coating to adhere and its translucence. There has

1
recently been a firm trend towards the development of smaller stainless steel

brackets but although these generally provide the technical performance required by

the orthodontist, they offer little aesthetic advantage over conventionally sized

appliances.

Lingual orthodontics satisfies aesthetic criteria by repositioning the fixed appliance

on the lingual surfaces of the teeth, but in doing so produce a significant decrease in

the performance of the appliance. Lingual orthodontics consequently has gained

only a limited following.

Early attempts produce brackets of different material included the use of

polycarbonate. These brackets, while aesthetically satisfactory in the early stages of

treatment, deteriorated in appearance with time and were insufficiently strong to

withstand long treatments or transmit torque. More recently, ceramic reinforced

plastic brackets have become available and while these seem more durable than

polycarbonate brackets, their ability to maintain their integrity over long treatments

remains suspect.

An attempt to improve esthetics while maintaining bracket strength has resulted

recently in the development of a ceramic bracket. The introduction of ceramic

brackets to orthodontics is only part of the rapidly expanding ceramic technology in

many industries. The ceramics are renowned for their hardness and for their

resistance to high temperatures and to chemical degradation. The atomic structure

2
that imparts these advantages also accounts for their brittleness which is the most

glaring fault of ceramics. All the currently available ceramic brackets are composed

of aluminum oxide as polycrystal alumina or single crystal alumina. Several authors

have already investigated the bond strength of edgewise ceramic brackets.

3
Classification

Ceramic brackets may be classified based upon :

The crystal structure into monocrystalline brackets. The material used is alumina.

It may be classified depending on its retentive mechanisms into :

A. mechanical

B. Chemical

Combination – mechanochemical.

Based on the material constitutents into :

Pure ceramic

Laminated brackets.

An emerging trend possibly necessitates yet another classification based on the

material constitutent into :

Alumina based

Zirconia based materials

4
Ceramics

Ceramics are materials which are first shaped and then hardened by heat. This

includes clays, glasses, some precious stones, and metallic oxides. The ceramic

material used in orthodontic brackets is alumina, either in its polycrystalline or

monocurystalline form. The advantages of using alumina for orthodontic brackets is

that is appearance is very good, its chemical resistance is excellent, and it is both

hard and strong. The disadvantages are that it lacks ductility, and is difficult and

expensive to manufacture.

Ceramic brackets are now available from the following manufacturers or suppliers:

Manufacturer / Supplier Bracket Material

A Company Starfire MCA (monocrystalline alumina)
American Orthodontics Silkon Plastic/PCA
American Orthodontics 20/20 PCA (polycrystalline alumina)
Class One Orthodontics Contour PCA
Dentaurum Fascination PCA
GAC Allure III PCA
Hudson Orthodontics Harmony Not known
Lancer Orthodontics Intrigue PCA
Masel Eclipse PCA
OIS Orthodontics Magic Touch PCA
Ormco Gem MCA (no longer manufactured)
Orthodontic Organisers Illusion PCA
Orthodontic Partners Ultra PCA
Rocky Mountain Quasar PCA

Orthodontics
TOOC Crystal PCA

(The Orthodontic Company)

Unitek 3M Transcend PCA

5
Ceramic brackets come in a variety of edgewise morphologies including true

siamese, semi-siamese, solid, and Lewis/Lang designs. Many brackets are made

by specialist ceramic manufacturers and sold under proprietary names by

manfacturers of orthodontic products or orthodintic supply companies. Some

brackets from different manufacturers may, therefore, be almost identical products

such as Intrigue, Illusion, and Quasar brackets.

Monocrystalline versus polycrystalline alumina

Since 1987, both monocrystalline and polycrystalline ceramic brackets have been

available, and varied arguments put forward in favour of one or other material.

Monocrystalline brackets are machined from extrusions of synthetic sapphire.

Polycrystalline alumina brackets, on the other hand, are made by injection moulding

submicron-sized particles of alumina suspended in a resin, sintering them to fuse the

alumina and finally machining the bracket as necessary to produce the finished

article.

The physical properties of the raw materials (as opposed to brackets) compared with

stainless steel are as follows :

Property MCA PCA Stainless steel

6
Hardness 97.5 85.5 5-35

(Rockwell)

Tensile strength 260 55 30-40

(psi x 1000)

Fracture toughness 2-4.5 3-5 80-95

(Mpa Pa)

The figures for hardness show that both monocrystalline and polycrystalline alumina

have a significant advantage over stainless steel, and that for tensile strength

monocrystalline alumina is much stronger than polycrystalline alumina, which in trun

is significantly stronger than steel. This is reflected in the fact that the only true

siamese brackets made from a ceramic material have been made from

monocrystalline alumina. Scott (1988) has pointed out that the tensile strength of

ceramics is dependent on the surface condition of the ceramic, and this can make

tests on bulk samples misleading and irrelevant. In addition, an important physical

property related to the behaviour of ceramics is fracture toughness, the ability of the

material to resist fracture. This is determined by stressing the material by impact

and measuring the size of crack produced. The units of measurement are metres

pascals per square root metre. It can be seen that both types of alumina perform

poorly compared with steel and this reflects their lack of ductility.

7
Kusy (1988) examined the morphology of polycrystalline brackets under a scanning

electron microscope and demonstrated defects, predominantly intergranular

fractures which might have a detrimental effect on bracket performance.

Manufacturing process

There are two types of ceramic brackets, polycrystalline and single crystal alumina,

composed of 99.9% aluminum oxide. The polycrystalline brackets are manufactured

by blending aluminum oxide particles with a binder and molding the mixture into a

shape from which a bracket can be machined. Temperatures in excess of 1800° C

are used to burn out the binder and fuse the particles together, while diamond

cutting tools are used to provide the slot dimensions. Single crystal ceramic brackets

are manufactured by a different process. Single crystal rods with the bracket profile

were grown from a liquid state of raw materials in a special crystal growth furnace

operating at 2100° C. These single crystal rods are milled into the shapes and

dimensions of various brackets. The manufacturing process plays a very important

role in the clinical performance of the ceramic brackets: pores, machining

interferences, and propagation lines may lead to bracket failure at anytime during

treatment.

The most apparent difference between polycrystalline and single crystal brackets is

in their optical clarity. Single crystal brackets are noticeably clearer than

8
polycrystalline brackets, which tend to be translucent Fortunately, both single crystal

and polycrystalline brackets resists staining and discoloration

Monocrystalline brackets are manufactured from larger chunks of alumina called

“boules”. The cutting is effected by means of diamond, rotary saws, laser and

ultrasonic methods. The nature of manufacture leaves behind surface roughness

and micro cracks predisposing to brittle fracture.

Polycrystalline brackets are manufactured by sintering aluminum oxide with particle

size of approximately 0.3microns. The alumina is mixed with a binder. In the older

method the sintered rod is machined to the bracket shape. It is heat treated to

relieve stress and surface imperfections. This method gives an optimal grain size of

about 20 to 30 mirons. The second generation brackets are manufactured by the

injection Moulding process. In this method the alumina mix is injected into a mould

under pressure and then sintered to produce a bracket. This process enables

obtaining complex bracket shapes i.e. the contoured bases to fit the tooth

morphology and tie wings capable of resisting fracture. The surface finish is much

better which clinically permits much lesser friction.

Retention Mechanism

First generation Ceramic brackets depended on silane coating to ensure adhesion.

Some bracket designs had mechanical undercuts in the form of grooves or

recesses. A few brackets had a combination of both. Bond strengths were

9
particularly high leading to fracture at the enamel adhesive interphase and

sometimes frank enamel damage occurred. This problem is solved in second

generation brackets by incorporating a polycarbonate base (Ceramoflex-II) wherein

on debonding failure occurs at the polycarbonate adhesive interphase. It also

eliminates the possibility of brittle fracture of the brackets on debonding. Another

trend is spray the base with atomised glass ,e.g. Transcend 6000. This also

ensures that on debonding the failure occurs at the bracket adhesive interphase.

Friction

Higher friction while using sliding mechanics is an important concern in the use of

ceramic brackets. Clinically both static and kinetic friction are important. A number

of factors determines the friction generated. All other things being equal the

hardness of ceramic brackets and surface finish are the important parameters.

Many studies have shown (invitro) that surface abrasion of arch wires do occur. This

is more in the NiTi wires in comparison to stainless steel wires. This increases

friction. In the second generation ceramic bracket the surface finish is significantly

smoother and friction is only marginally higher than the stainless steel brackets.

Another important factor is the angle of contact between the arch wire and the

bracket edge. In the first generation brackets the edge design was more sharp that

significantly contributed to the frictional problems. In contrast the second generation

brackets have smoother and rounder edges minimising friction.

10
 Recently, polycrystalline zirconia brackets have been commercialized.

Researchers have suggested that brackets constructed from zirconia have low

friction in clinical use. In the only published study that compared the frictional

characteristics of zirconia and alumina brackets, zirconia brackets produced more

friction against cobalt-chromium arch wires

Clinical Application

Bonding

Ceramic brackets derive their bond strength either from the use of a silane coupling

agent in the bracket base or mechanical retention. Some early designs used both

these methods within the one bracket. All ceramic brackets can be bonded

satisfactorily without the use of a special adhesive odegaard and Segner (1988)

have shown that for one make of ceramic bracket, both mix and no-mix adhesives

produced bond strengths that were slightly higher than for mesh backed brackets

although the differences were not statistically significant.

11
There are three different retention mechanisms that are available on the market by

which the base of the ceramic bracket can be made to adhere to the adhesive;

namely, chemical, mechanical, and a combination of both. In addition, there are

essentially two methods of enamel conditioning to allow for the adhesive to be

attached to the enamel surface: acid etching and crystal growth. With the latter

technique, the gypsum crystals formed on the tooth surface allow for a mechanical

bond to the adhesive resin and a chemical bond to the enamel

There are mainly two groups of adhesives that are currently used for bonding

orthodontic brackets to enamel: acrylic and diacrylate resins. The cross-linking found

in the diacrylate resins, together with the filler, contribute to greater strength and less

polymerization shrinkage of these materials. When bonding metal brackets, it was

found that highly filled diacrylic resins give the highest bond strengths. When

bonding ceramic brackets in vitro, surprisingly, unfilled acrylic resins, with a lower

diametral tensile strength, gave the highest bond strengths. Buzzitta explains that

this phenomenon may be the result of the greater penetration of the unfilled

adhesive into the retention areas of the ceramic brackets

Patient selection and mechanical considerations

Ceramic brackets are not aesthetic versions of metal brackets and they require

additional care form both orthodontist and patient if the best is to be obtained from

12
them. Difficulties in the use of ceramic brackets arise from their brittleness and their

hardness.

The brittleness of ceramic brackets and their low fracture thoughness make them

liable to fracture either from external trauma or from occlusal trauma. Patients with

deep overbites where occlusal contact may occur between lower ceramic brackets

and upper teeth may fracture bracket tiewings. Ceramic brackets are radiolucent,

and remnants of fractured brackets may be harmful to the patient and difficult to

detect. Every effort should, therefore, be made to prevent occlusa interferences

either by bonding the upper arch before the lower, the use of a removable appliance

to disclude the incisors or the use of rapid bite opening techniques with sectional

mechanics initially in the upper arch. The problem of bracket fracture may also

occur when placing or removing rectangular archwires which almost completely fill

the slot and the risk of this can be reduced by using a more resilient full size wire

before placing the stainless steel finishing archwire. Placement of additional torque

in archwires may cause tiewing fracture on insertion with ceramic brackets and

consideration should be given to increasing the amount of torque by inverting the

bracket or even by using a torquing auxiliary rather than by incorporating torque in

the archwire.

Care should be taken not to scratch the surface of the bracket during treatment.

Careful ligation is necessary and elastomeric rings or coated ligatures (both

conventional and Kobayashi) are recommended to prevent tie wing fracture.

13
Monocrystalline ceramic brackets have a true siamese configuration which allows

the use of ligation methods as used for metal brackets whereas most polycrystalline

brackets have a semi-siamese tiewing design. Semi-siamese tiewing designs may

make it difficult to place both elastomeric chain and ligating modules on the same

bracket due to the reduced depth of the tiewing.

Ceramic is much harder than enamel and may cause serious wear of the enamel on

the upper incisors or canines where occlusal interferences and parafunctional habits

are present (Douglass, 1989). Methods of avoiding this problem include the use of

elastomeric-rings with covers for the occlusal part of the bracket on lower inciosrs

(Alastigards, Unitek/ 3M), and the techniques for eliminating occlusal interferences

mentioned in the previous paragraph. The hardness of the bracket also creates

difficulty in space closure as the bracket may ‘dig into’ the relatively softer archwire.

If sliding mechanics are being used then consideration may be given to using metal

brackets on the premolars to make space closure easier.

Debonding

Removal of ceramic brackets has been an area of significant concern. It is probable

that manufacturers initially overestimated the bond strength required to retain the

bracket through out treatment and did not take account of the differences necessary

in debonding technique between ductile metal and brittle ceramic brackets. Two

manufacturers (A Company and Unitek/3M) have produced special instruments or

14
pliers for debonding their own ceramic brackets, although the A Company Starfire

debonding pliers may be used to remove any bracket. General purpose ceramic

bracket debonding pliers are made by a number of companies.

The brittleness of ceramic brackets has caused the developent of enamel cracks, or

the loss of sections of enamel when brackets have failed during treatment (Swartz,

1989, personal communication) or during debonding at the end of treatment. This

problem seems to affect certain types of brackets more than others and is

presumably related to bond strength. Ceramic brackets should, therefore, be

removed with the greatest care in accordance with the manufacturer’s instructions.

Ceramic brackets that seem particularly difficult to debond should be removed with a

diamond bur.

There are five possible sites at which bond fractures can occur during debonding of

brackets: (1) within the tooth enamel, (2) at the enamel-adhesive interface, (3) within

the adhesive, (4) at the adhesive-bracket base interface, or (5) within the bracket.

Bond failures for stainless steel brackets occur most frequently at the adhesive-

bracket base interface but vary for polycrystalline ceramic brackets.

Different Debonding Techniques

15
Conventional techniques for bracket removal

The degree of force required to achieve bond failure and the sudden nature of the

bracket failure could cause enamel fracture or cracks and raise the risk of aspiration

of bracket fragments by the patient. The probability of damage to tooth structure

would be even higher if the integrity of the tooth structure was already compromised

by the presence of developmental defects, enamel cracks, large restorations, or

non-vital teeth.

In addition, the need for relatively strong forces to obtain bond failure may result in

various degrees of patient discomfort. In the clinical setting, such a force would be

transmitted to teeth that are often mobile and sometimes sensitive to pressure at the

end of the active phase of orthodontic treatment. To minimize such an episode, the

teeth should be well supported during bracket removal. It has been suggested that

the orthodontist have the patient bite firmly into a cotton roll to help stabilize these

sensitive and relatively mobile teeth.

It needs to be pointed out to the clinician that the likelihood of bracket failure can be

minimized if the debonding instrument is fully seated to the base of the bracket and

to the tooth surface. This firm seating allows the forces used for bracket removal to

be transmitted through the strongest and bulkiest part of the bracket— namely, the

bracket base.

Since bracket failure is usally quick and sudden, it could result in injury to the

pericoronal soft tissue, the oral mucosa, the tooth, or the clinician if debracketing is

performed carelessly.

16
Ultrasonic bracket removal

Although bracket removal is not as fast with the ultrasonic debonding method as with

the conventional or electrothermal debracketing methods, effective bracket removal

can be achieved with this technique. The advantages of the ultrasonic debonding

approach include a decreased chance of enamel damage and a decreased

likelihood of bracket failure. In addition, adhesive removal after debonding can be

accomplished with the same ultrasonic tip. Another advantage of the ultrasonic

debonding method includes the ability for the removal of the residual adhesive with

the same instrument after debracketing.

The amount of force needed for the ultrasonic approach was low compared with that

needed for the conventional methods of bracket removal; hence there was no

incidence of bracket failure.

There are a number of disadvantages associated with the ultrasonic technique,

including

A significantly increased debonding time compared with the other techniques tested,

Excessive wear of the expensive ultrasonic tips,

The need to apply moderate force levels, which could create some discomfort to

sensitive teeth,

The potential for soft tissue injury by a careless operator, and

The need for a water spray to reduce the heat build-up and to minimize any

possibility of pulpal damage.

17
Since the ultrasonic method is effective but time consuming, its use might be

indicated when a ceramic bracket fractures while the conventional method is being

used and part of it remains attached to the tooth The ultrasonic approach would be a

useful alternative, compared with the removal of the bracket remnant by means of a

high-speed instrument and a diamond stone.

The orthodontist should balance the relative safety of the ultrasonic method with the

additional time (3-5 minutes for the removal of six brackets) and the additional

expense for the ultrasonic instrument and tips.

Electrothermal debonding (ETD)

The electrothermal debracketing instrument is a relatively new development that is

being considered for clinical use. In its present form, this instrument is compatible

only with the Starfire bracket series, but it is an effective means for removing these

ceramic brackets.

Much attention has been given recently to the difficulty and potential hazards of

debonding ceramic brackets. Raising the temperature of the bracket/adhesive

interface by 52 °C has been shown to reduce the force required for debonding by

approximately one-half, which could make removal of ceramic brackets easier, safer,

and less painful.

This temperature elevation can be achieved by applying dry heat to the bonded

bracket with a Handi-Dri tooth dryer. Simply hold the dryer 3-4mm from the tooth and

18
direct the heated air at the bracket for 10-15 seconds. Remove the bracket as

prescribed by the manufacturer.

The maximum temperature of the dry air stream is 65°C, which is less than that of a

hot cup of coffee and is well tolerated by patients. This method can also be used for

removal of stubborn metal brackets.

The advantages of the ETD method include a reduction in the incidence of bracket

failure compared with the conventional bracket-removal methods and a relatively

short debonding time, which does not differ significantly from that observed with the

debonding pliers. The reduced incidence of bracket failure is attributable to the small

amount of force required to break the bond after the heat-inducing tip has promoted

bond failure. The minimal potential for enamel damage with this removal method is

directly related to the type of bond failure that occurs during debonding— i.e., failure

at the bracket-adhesive interface.

The disadvantages of electrothermal bonding include the following:

1. Limited applicability in the clinical setting, since it can be used only with the

Starfire ceramic bracket series that incorporates a vertical saddle in its design.

Unlike the slots on the Transcend and Allure brackets, this saddle allows for the

proper fit of the heating tip. Since the size of the slots on most brackets is more

universal, an instrument with a tip that can be introduced into the bracket slot, rather

than into the bracket saddle, will be of much wider use in a clinical setting.

19
2. A potential for pulpal damage that still needs to be definitively assessed.

3. An increase in the temperature of the cone part of the handpiece, which has the

potential to cause patient discomfort or mucosal irritation if carelessly used.

4. The still-bulky handpiece design, which makes its intraoral use difficult in the

premolar region.

5. The possibility of deformation during debonding of the small wire loops that hold

the bracket. Deformation of these wires could result in the release of a hot bracket

into the patient's mouth.

The advantages and disadvantages of each debonding technique suggests that

clinicians contemplating the use of ceramic brackets should consider the information

presented on the advantages and limitations of the presently available brackets and

bracket-removal techniques.

Laser debonding technique

Until recently, the application of laser technology to dentistry was not considered

practical because early research had shown that laser irradiation of teeth generated

too much heat, which resulted in pulpal damage and enamel fracturing. Within the

past few years, significant advances in laser technology and in our understanding of

how the energy in a laser light beam interacts with materials has greatly decreased

undesirable thermal effects and resulted in the successful application of lasers to

dentistry. Ablative decomposition of materials, which is accompanied by very little

heat buildup, has been used to remove PMMA bone cement during orthopedic

20
surgery, and decomposition of polymeric intraocular lens implants has been

observed during laser procedures. This new knowledge may allow the selection of a

laser with the proper characteristics to assure rapid debonding of ceramic brackets

without damaging either the tooth, the bracket, or the supporting structures. Should

such a system be developed, bond strengths could be maximized, facilitating both

the development of new treatment modalities and the use of small brackets and

large forces without fear of undesirable sequelae during debonding.

Since laser debonding would allow the superior potential bond strength of ceramic

brackets to be used, laser debonding could facilitate the use of brackets in situations

involving lingual bonding and extraoral traction. In addition, smaller, more esthetic

brackets could be developed without incurring a higher incidence of spontaneous

debonding during orthodontic treatment.

Laser-initiated debonding mechanisms :

Any process that degrades the bonding resin will facilitate debonding. Laser-initiated

degradation can occur as the result of thermal softening, thermal ablation, and

photoablation. Thermal softening, which occurs at relatively low rates of laser energy

deposition, heats the bonding agent up until it softens, and the brackets debond by

sliding off the tooth. Heating could occur directly in the resin or in either the bracket

or tooth, depending on how these components absorbed the light energy. Since the

process is relatively slow, we would expect this type of debonding to result in a large

rise in both tooth and bracket temperature.

21
Thermal ablation occurs when the rate of energy deposition, and therefore heating,

is fast enough15 to raise the temperature of the resin through its fusion range and

into its vaporization range before debonding by thermal softening occurs. Although

no measurements were made, we expect that the bracket geometry would result in

the maximum light transmittance, and therefore ablation, occurring near the center of

the fitting surface of the bracket, a location from which the gas formed by the

ablation process could not easily escape. The rapid buildup of gas pressure along

the bonding interface will explosively "blow" the bracket off the tooth, independent of

any externally applied debonding force. Both the speed at which the ablation

proceeds and the rapid removal of heat energy by the ablating material results in

very little heat diffusion, and the bracket and tooth remain cool. since the resin may

contain a readily vaporizable constituent, such as water or residual monomer,

thermal ablation could occur after only a single pulse, if the pulse energy is high

enough.

Photoablation occurs when very high energy laser light interacts with a material. The

excimer lasers and Q-switched Nd:YAG lasers operate with very short pulse

durations, instantaneous power levels of between 8 and 23 megawatts are

generated. When a high energy pulse is absorbed, the rate of energy deposition into

a specific atom or molecule may exceed its thermal relaxation time. During lasing,

the energy level of the bonds between the bonding resin atoms rapidly rises above

their bond disassociation energy levels, and the material decomposes. High gas

pressure would rapidly develop within the interface, and the bracket would be

explosively blown off the tooth after just a single light pulse. Like thermal ablation,

22
the debonding would be independent of any externally applied debonding force.

since the time for this event to occur is less than the thermal relaxation time, neglible

heat diffusion can occur, and the bracket and tooth remain cool. Although one would

expect a transparent material, such as the bonding resin, to merely pass the light

right through, such high energy light impacting on a normally transparent material

can cause structural changes at the atomic level in susceptible materials, which

greatly increases their light absorption, thus facilitating ablation..

Thermal softening will result in the bracket sliding down off the tooth under the

influence of gravity, whereas ablation will cause the bracket to be blown off the

tooth.

If the pulse energy is great enough to cause photoablation, debonding will require

only a single pulse, and the debonding times will be insensitive to pulse frequency.

Should decreasing the pulse frequency increase the debonding time, then

photoablation is not the mechanism causing debonding. A material containing

substances that are easily volatilized may debond by thermal ablation after a single

pulse, and debonding times will be insensitive to pulse frequency.

23
Advantages of Ceramic Brackets

It is esthetic. Ceramic brackets are either transparent (MC) or opaque (PC) which

accounts for their “invisibility”.

It significantly resists discolouration unlike polycarbonate brackets.

Marginal benefits include use in patients undergoing MR Imaging and also in

patients who are allergic to nickel.

Disadvantages of Ceramic Brackets

Enamel abrasion of opposing teeth such as in deep bite cases.

Brittleness of the bracket in treatment leading to fracture.

High bond strength particularly with silane primed ceramic bases leading to enamel

fracture on debonding.

Brittle fracture of the bracket on debonding makes debonding, technique sensitive.

24
Due to the inherent nature of the material accurate bracket positioning is a

demanding exercise.

Frictional resistance to sliding.

High cost of the material.

To be termed a real advancement the advantages over traditional stainless steel

brackets have to increase, while disadvantages are minimised. The first generation

ceramic bracket had number of short comings cited above as disadvantages and

evoked the criticism that market considerations – economic considerations prompted

marketing before the technology was perfected. A significant number of the short

comings have been minimised in the second generation brackets.

25
Summary

Ceramic brackets have been understandably welcomed by patients they are the best

attempt so far at producing an orthodontic appliance which combines the aesthetic

needs of the patient with the technical performance required by the orthodontist.

Nevertheless, the only advantage that ceramic brackets have over stainless steel

brackets is one of appearance and serious questions about bracket fractures and

tooth damage during bracket removal remain unanswered at the present time.

There is considerable interest throughout the world in the industrial development and

us of ceramics and it may be that future generations of ceramic brackets solve some

or all of the problems that currently exist. At the present time, however ceramic

brackets should be used cautiously within the limitations of the material and not

simply as an alternative to metal brackets

26
Since ceramic brackets are nine times harder than enamel, severe enamel abrasion

from ceramic brackets might occur during a single meal, sometimes within a few

seconds.Clinically, damage occurs immediately on tooth contact with these

appliances.

It is important for the orthodontist to inspect ceramic brackets for cracks at each

patient visit. Care should be taken during treatment not to scratch bracket surfaces

with the instruments or overstress when ligating or activating a wire. The patient

should be cautioned against chewing on hard substances.

References

 Phillips HW. The advent of ceramics. J Clin Orthod 1988;22:69-70.

 Kusy RP. Morphology of polycrystalline alumina brackets and its relationship to

fracture toughness and strength. Angle Orthod 1988;58: 197-203

 Odegaard J, Segner D. The use of visible light-cured composites in bonding

ceramic brackets. AM J ORTHOD DENTOFAC ORTHOP 1990;97:188-93

 Odegaard J. Debonding ceramic brackets. J Clin Orthod 1989;23:632-5.

 Carter RN. Clinical management of ceramic brackets. J Clin Orthod 1989;23:807-

9.

 Storm ER. Debonding ceramic brackets. J Clin Orthod 1990;24:91-4.

 Machen DE. Legal aspects of orthodontic practice: risk management concepts,

ceramic bracket update. AM J ORTHOD DENTOFAC ORTHOP 1990;98:185-6.

 Viazis AD, Cavanaugh O, Bevis RR. Bond strength of ceramic brackets under

shear stress: an in vitro report. AM J ORTHOD DENTOFAC ORTHOP

1990;89:194-205.

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 Ostertag AJ, Dhuru VB, Ferguson DJ, Meyer RA. Shear, torsional, and tensile

bond strengths of ceramic brackets using three adhesive filler concentrations.

AM J ORTHOD DENTOFAC ORTHOP 1991;100:251-8.

 Swartz ML. Ceramic brackets. J Clin Orthod 1988;22:82-8.

 Bishara SE, Trulove TS. Comparisons of different debonding techniques for

ceramic brackets: an in vitro study. Part I. Background and methods. AM J

ORTHOD DENTOFAC ORTHOP 1990;98;145-53

 Iwamoto H, Kawamoto T, Kinoshita T. Bond strength of new ceramic brackets as

studied in vitro. J Dent Res 1987;67:928.

 Guess MB, Watanabe LG, Beck FM, Crall MG. The effect of silane coupling

agents on the bond strength of a polycrystalline ceramic bracket. J Clin Orthod

1988;22:788-92.

 Gwinnett AJ. A comparison of shear bond strengths of metal and ceramic

brackets. AM J ORTHOD DENTOFAC ORTHOP 1988;93:346-8.

 Tocchio, Williams, Mayer, and Standing .Laser debonding ceramic brackets AJO-

DO 1993 Feb 155-162.

 Pogonion Dr. K. Joythoindra kumar Recent advances in orthodontic materials.

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