Indirect Bonding: A Comprehensive Review of

the Literature
John T. Kalange and Royce G. Thomas

Indirect bonding when described in the strictest sense, is a technique in

which orthodontic brackets or other attachments are transferred from den-
tal casts (otherwise described as working models) and bonded onto the
dentition using a transfer device. This article will present a review of the
literature, and a discussion of pertinent issues relative to the development
and utilization of indirect bonding. (Semin Orthod 2007;13:3-10.) © 2007
Elsevier Inc. All rights reserved.

ndirect bonding was first described in detail as a means of facilitating indirect bracket place-
I as a concept in 1972 by Silverman and Co-
hen.1 Interestingly enough, some of the initial
ment.11,12
In reviewing the articles that have been pub-
trials used a softened Sugar Daddy® candy lished concerning indirect bonding, it becomes
(Tootsie Roll, Inc., Chicago, IL) as a means of apparent that the topics fall into certain catego-
attaching the brackets to the working models ries. In terms of the types of chemicals used to
before transfer tray fabrication.2,3 Additionally, bond the brackets, this concept can be broken
others have used water-soluble adhesives4 and down into three distinct categories: chemically
even sticky wax5 to attach the brackets to the cured, light-cured, and thermally cured bases. In
models. Eventually this concept evolved to in- addition to these, separate categories can be
clude application of various adhesive-coated used to discuss articles related to bond failure
brackets as a means of creating custom bases to rates, accuracy of direct versus indirect, certain
aid in the bonding process.6,7 management and cost effectiveness discussions,
It is fascinating to note that Cohen and Sil- and specific techniques for bracket placement
verman suggested the possibility of a completely measurements. Also, there are certain develop-
indirect bonded practice as early as 1974, and ing technology-based applications, and miscella-
the idea of an emphasis on indirect bonding neous articles that do not fit into any of the
continued in certain circles throughout the above-mentioned categories.
1970s.8 This concept was even extended to the With reference to methods for bracket attach-
possibility of attaching face bows to bonded buc- ment for indirect bonding, chemically cured
cal tubes. Silverman and Cohen further stated, composites were the choice for some of the ini-
“It should take no longer than twenty minutes to tial trials. As early as 1974, Newman discussed
complete a full strap-up in the mouth in both the use of acrylic-based adhesives to direct and
arches, including second molars if desired.”9 indirect bond plastic and mesh base brackets.13
Modern techniques have expanded on this con- Thomas discussed a modification of the Silver-
cept and have utilized precision bracket place- man and Cohen technique in which Concise®
ment techniques10 and “high tech” composites
(3M Unitek, Monrovia, CA) or Dyna-bond® (3M
Unitek) were used to form a custom base.14 This
From the private practices of Dr. John T. Kalange, Boise, ID and technique was the first to describe the construc-
Dr. Royce G. Thomas, Saint Peat Beach, FL. tion of these custom composite bases, and uti-
Address correspondence to John T. Kalange, DDS, MS, 136 E. lized a two-part liquid sealant to bond the brack-
Mallard Dr., Boise, ID 83706. Phone: 208-342-0212; E-mail: ets to the dentition with the aid of a clear
john911sc@aol.com
© 2007 Elsevier Inc. All rights reserved.
vacuum-formed transfer tray.
1073-8746/07/1301-0$30.00/0 Fried and Newman discussed the use of a
doi:10.1053/j.sodo.2006.11.003 no-mix adhesive in indirect bonding in the liter-

Seminars in Orthodontics, Vol 13, No 1 (March), 2007: pp 3-10 3

4 J.T. Kalange and R.G. Thomas

ature in 1983.15 The brackets in this approach Read and Pearson, in 1998, were the first to
were attached to the working models with a discuss the use of a light-cured, lightly filled
soluble wallpaper paste. The brackets were then sealant to attach brackets with a custom resin
attached to the teeth by placing the no-mix paste base to the teeth via an indirect method.25 In
adhesive in a Centrix® (Centrix Inc., Shelton, 2001, White used a self-etching primer and a
CT) syringe and injecting this material onto the quick cure composite adhesive in indirect bond-
brackets in the transfer tray. Final curing oc- ing.26 In this technique, a power slot light-curing
curred when the paste material contacted the tip was used on each of the teeth in the tray for
primer, which had been previously applied to 3 seconds per tooth. This power slot tip is
the teeth. As early as 1984, the concept of a broader at the end and concentrates the light
rapidly setting curing system took place when for more rapid curing of the adhesive.
Aguirre experimented with varying setting times As one can imagine, the advent of newer com-
by changing Concise catalyst/base composi- posites for use in restorative dentistry and in
tions.16 direct bonding of brackets in orthodontics
Generally, bis-GMA-based adhesives have spawns ideas that ultimately become useful in
been used in chemically cured methods. How- indirect bonding. As an example Filtek Flow®
ever, other chemical compositions have been (3M ESPE, St. Paul, MN), a filled flowable com-
tested and include the use of resin-reinforced posite developed for use in restorative dentistry
glass ionomers,17 acrylated epoxy adhesives,13 for air abrasion, tunnel preparations, shallow
and cyanoacrylates.18-20 Class V cavities, and as a fissure sealant, was first
Subsequent to the use of chemically cured incorporated into an indirect bonding tech-
nique by Miles in 2002.27 The proposed advan-
composites for bonding, light-cured composites
tage of this material is that it reduces voids, it is
became available and were used as an adjunctive
fluid but viscous enough for good handling
material for indirect bonding. The use of light-
characteristics, it allows for controlled applica-
cured materials was mentioned as early as 1972
tion, and it has a command set based on selec-
in the original Silverman and Cohen technique1
tive application of the curing light. In this tech-
and elaborated on by them in 1974.21 They used
nique, it is reported that a first molar–to–first
a material developed for use as a pit and fissure
molar indirect bonding can be accomplished in
sealant for sealing of the tooth surface before
approximately 8 minutes.
indirect bonding with a chemically cured two-
One of the disadvantages of the use of light-
part adhesive. This material was activated with cured composites for construction of the custom
an ultraviolet light-sensitive benzoin methyl bases is the inherent limitation of working time
ether component. because of the effect of ambient lighting. As a
In 1990, Read and O’Brien used a visible result of this constraint, composites based on a
light-cured adhesive in indirect bonding on foil thermally cured concept have been developed
mesh-based brackets.22 Hamula discussed the specifically for indirect bonding.28-30
advantages of using light-cured adhesives for in- The future of materials used to bond brackets
direct bonding in 1991.23 He listed several ad- indirectly is preceded by developments in dental
vantages including unlimited working time dur- bonding chemistry. As the components involved
ing bracket placement, less bracket drift on the in the bonding of brackets have evolved, so have
working models, and less patient discomfort be- the materials used for construction of the trans-
cause of the acceleration of bracket bonding. fer trays. There are a prodigious number of
Following the introduction of Adhesive Pre- materials and techniques involved in the con-
coated Brackets (APC®) (3M Unitek), Cooper struction of the transfer trays.
and coworkers described the use of these pre- One might think that the concept of a clear
coated brackets in indirect bonding and listed transfer tray would logically follow the develop-
consistency of coating, ease of cleanup, and ment of light-cured composites. However,
elimination of waste as benefits.24 One year later Thomas, in his original thesis, discussed the use
Cooper and Sorenson used a modified Thomas of a vacuum-formed clear “placement tray” as
technique to place APC metal and ceramic early as 1979.14 There has been resurgence in
brackets in indirect bonding.7 the use of various forms of clear transfer trays, as
 Comprehensive Review 5

light-cured composites became available for use sequent to this, numerous techniques have been
in indirect bonding.7,31 Again, many restorative developed based on indirect bonding from di-
materials including the use of clear impression agnostic setups.43-45 In 1999, Kalange presented
compounds such as Memosil CD® (Heraeus a technique using vertical and horizontal refer-
Kulzer, Inc., South Bend, IN) have been used as ence lines on working models for bracket place-
transfer trays.25,32 Many of the current tech- ment based on level marginal ridges, functional
niques are based on a dual clear tray system, with occlusal contacts, and esthetic surfaces.10 Also,
a soft inner tray and a hard outer tray as pro- Eliades and coworkers validated the importance
posed by Nakaji and Sheffield33 and expounded of reference to marginal ridges versus the center
on further by Hickham.34 of the clinical crown as a reference point, when
There have been a multitude of materials they demonstrated that positioning brackets us-
used for the construction of transfer trays, the ing the center of the clinical crown resulted in
extent of which has been left only to the imagi- marginal ridge discrepancy between the premo-
nation. These have included hybrid systems lars and molars and a lack of occlusal contacts
made of resin and silicone,35 individual dual with the opposing dentition.46 The Ray Set®
silicone/clear acrylic transfer trays for each (Biaggini Medical Devices, La Spezia, Italy) ex-
tooth,36 as well as single tooth opaque light- emplifies the concept of accuracy of bracket
cured acrylic covered by full arch opaque sili- placement in indirect bonding by using a sophis-
cone.37 Most modern techniques involve either a ticated device to bond preadjusted brackets that
dual clear soft inner, clear hard outer tray com- reflect individually prescribed requirements for
bination, or single tray full arch polyvinylsilox- tip, torque, and rotation independent of bracket
ane (PVS) trays. Interestingly, even everyday height or shape of teeth.47 Creekmore and
household materials such as hot glue guns have White also discussed the use of a device called
been used in transfer tray construction!38 the Slot Machine® (Creekmore Enterprises,
Indirect bonding involves many systems de- Houston, TX) for use in customizing individual
signed to precisely place brackets. Therefore, a bracket placements in indirect bonding.48
discussion regarding the need for a controlled There have been relatively few studies done
method of bracket positioning logically succeeds that compare direct bonding versus indirect
the discussion of the transfer tray. To begin this bonding in relationship to accuracy. Gianelly
discussion, we can refer to an interview between stated, “One of most common and universal
Gottlieb and Phillips in 1980.39 As a leading problems that I have seen is incorrect appliance
proponent of indirect bonding during this time placement, with consequences such as the cre-
frame, Phillips described the use of vertical long ation of lateral openbites, and marginal ridge
axis lines on the working models. He stated, discrepancies. The main advantage of an indi-
“You may want to change position of the bracket rect bonding technique is that it reduces er-
on the model. That is the reason I believe the rors.”49 Keim made the observation that indirect
indirect method makes for more precision: be- bonding, “requiring minimal doctor time, has
cause, if it’s hard to do in the laboratory, it’s finally come into it’s own.”50 Unfortunately,
definitely harder to do in the mouth, where you these comments are difficult to validate scientif-
have much poorer access and can’t draw lines ically and are generally anecdotal in nature. For
like you can on a model.”39 In 1982, Myrberg example, Hodge and coworkers conducted a
and Warner40 presented a technique in which randomized clinical trial comparing the accu-
individual bracket placement indicators were racy of direct versus indirect bonding and con-
made for each tooth based on the concept of a cluded, “there was no significant difference be-
dental setup that suits the individual functional, tween the mean errors produced by the two
occlusal, and esthetic requirements for each pa- methods of bracket placement.”51 However,
tient. Similarly, Reichheld and coworkers used these investigators excluded the posterior teeth
individual preformed height gauges to position where errors in bracket placement are more
the brackets on the working models,41 and Hong likely, and also excluded teeth with mesiodistal
and coworkers used transfer wires and Duralay® and angular irregularities and severe crowding
(Reliance Dental Mfg., Worth, IL) transfer trays where the advantage of indirect bonding be-
for individual setups in lingual treatment.42 Sub- comes clearly beneficial. Koo and coworkers
6 J.T. Kalange and R.G. Thomas

found similar results in their study, where the part unfilled resin under a filled resin for indi-
only differences found were certain advantages rect bonding and a filled resin for direct bond-
in bracket placement with regard to height in ing to extracted human premolar teeth.55 Milne
indirect bonding versus direct bonding.52 How- and coworkers, when comparing tensile and
ever, it is difficult to make inferences about the shear bond strengths, showed no statistically sig-
clinical usefulness of their results for several rea- nificant difference between direct and indirect
sons. Their study was performed in an in vitro bonding to extracted human incisor and premo-
setting on mannequins. In addition, their study lar teeth.56 Klocke and coworkers used brackets
included bonding from the second bicuspid bonded to bovine teeth with multiple indirect
teeth forward, thus excluding some of the more techniques involving chemically, thermally, and
difficult teeth to accurately bond directly. Fur- light-cured composites and direct bonded light-
ther, due to the nature of their study and the cured composites, and found comparable bond
fact that the clinicians knew they were under strengths for all groups.57 In a follow-up study,
observation, it lacked a fundamental principle of they analyzed three base/composite-sealant com-
research, namely that of not being blinded, and binations in indirect bonding and found that all
therefore introduced the Hawthorne effect.53 combinations showed acceptable bond strengths
Finally, the study was performed on a series of at 30 minutes and 24 hours after bonding. In
models of the same malocclusion. Because mod- 2003, Yi and colleagues demonstrated that the
els of the same malocclusion were used, this bond strengths for indirect bonding averaged
resulted in a lack of heterogeneity. As a result 11.2 Mpa, and 10.9 Mpa for direct bonding,
the standard deviations were artificially nar- above the suggested bond strength value of 5.9
rowed, and the investigators inappropriately re-
to 7.5 Mpa. In addition they reported no statis-
ported a lack of statistical differences when com-
tically significant difference between the directly
paring the accuracy of direct versus indirect
and indirectly bonded groups.58
bonding.
The in vivo studies, on the other hand, are
There are several difficulties associated with
equivocal, and the results and conclusions are
doing accuracy studies in comparing direct ver-
certainly subject to debate. As an example, Zach-
sus indirect bonding. The primary problem is in
risson and Brobakken found a statistically signif-
establishing an adequate definition of where the
icant difference between direct and indirect
brackets should be placed to define “ideal.” A
bonding when comparing bond failures, with
definition for ideal bracket placement is obvi-
ously necessary for comparative purposes. Accu- indirect having greater bond failures (2.5% vs
racy studies need heterogeneity to establish va- 13.9%).59 On the other hand, in a split mouth
lidity and should therefore encompass a broad technique, Polat and coworkers found a lack of
range of malocclusions including extraction, significant difference between bond survival
nonextraction, adults, adolescents, and so forth. rates at nine months for Therma Cure®/Cus-
Unfortunately, existing studies have failed to sat- tom IQ® (Reliance Orthodontic Products, Inc.,
isfy these requirements. Itasca, IL) versus Transbond XT®/Sondhi
Equally controversial are studies related to Rapid Set® (3M Unitek, St. Paul, MN) and both
the bond strength comparisons between direct of these had similar bond strengths when com-
and indirect bonding techniques. There are pared with direct bonding.60 In a similar split
claims of bond strengths adequate to withstand mouth technique, Miles and Weyant61 demon-
the rigors of treatment in cases that are indirect strated a significant difference between Sondhi
bonded from second molar to second molar. Rapid Set and Maximum Cure® (Reliance Orth-
These claims may be attributed to better confor- odontic Products, Inc., Itasca, IL) sealants, with
mation of bracket bases to the teeth, reduction Sondhi Rapid Set having seven times the num-
in chair time, and the reduced risk of saliva ber of breakages (9.0% vs 1.4%) over a 6-month
contamination.54 Bond failure studies have been observation period. However, the authors in this
performed both in vitro and in vivo. study noted that they had 6 years of previous
In in vitro studies, Hocevar and Vincent re- experience with the Maximum Cure material
ported similar bond strengths between direct versus only 4 months for the Sondhi Rapid Set
and indirect bonding methods when using two- material. Bond failure rates reported for in vivo
 Comprehensive Review 7

investigations generally fall within clinically ac- (7.8%).”72 In 1996, however, part 1 of a similar
ceptable ranges of 1.4% to 6.5%.7,22,62-65 survey showed only 7.7% indirect bonded rou-
Furthermore, custom base preaging up to 30 tinely, with 17.2% doing it occasionally.73 Part 3
days (which occurs during the interval between of that study reported, “routine use of direct
custom base fabrication and final bonding of the bonding generally increased, and routine use of
brackets) does not appear to be a significant indirect bonding decreased, with the age of the
detriment, with shear bond strengths values re- practice.”74 The results of part 1 of the JCO 2002
corded exceeding 15 Mpa.66,67 Additionally, the study showed, “somewhat higher percentages
effect of adhesive layer thickness on bond used indirect bonding . . . than in 1996 (9.6%)”75;
strength appears to be a variable factor in indi- and in contrast to the 1990 study, part 2 of this
rect bonding with different adhesives; however, 2002 study reported, “practices with the highest
bond strength depends more on the type of mate- gross incomes were most likely to use indirect
rial than the thickness of the adhesive layer.68 bonding.”76
Bond strength and accuracy studies are anal- There are many proposed advantages associ-
ogous with respect to being problematic in their ated with indirect bonding,77,78 and it has even
interpretation. Bond strength studies generally been proposed as the mandatory mode of place-
represent only one practice or clinical setting ment, especially in lingual cases.79 Many advo-
and not a cross section of the profession. As a cates believe that reduced chair time and dele-
result, this may only serve to illustrate the profi- gation of the procedure make it cost-effective.80
ciency, or lack thereof, of an individual. Authors In fact, Hodge and coworkers investigated the
generally have greater experience with direct cost effectiveness in a hospital dental clinic and
bonding versus indirect bonding61 and, as such, found a significant cost savings when using indi-
introduce a bias into the results. There are to rect bonding versus direct bonding in that set-
date, no long-term studies that evaluate bond ting.81 In addition to cost effectiveness, there are
failure rates in indirect bonding versus direct numerous additional benefits reported.14,82
bonding. At present studies on bond strength These benefits include enhanced patient com-
vary in length of time from 24 hours67 up to 9 fort, elimination of the need for separators and
months61; however, study times should optimally bands, easier ability to rebond brackets, easier
extend over generally expected clinical treat- ability to build in overcorrections, better in/out
ment times. In vitro studies are useful in defin- and better vertical control, and improved oral
ing parameters or in establishing descriptive sta- hygiene because of generally smaller attach-
tistics, but are not useful in extrapolation to ments. Benefits also include optimal use of staff,
clinical situations. In properly designed investi- reduced inventory and associated costs, fewer
gations, isolation of the independent variable is appliance placement and removal appoint-
critical. This has proven to be especially difficult ments, and overall healthier ergonomics. It is
in bonding studies. In addition, there are an interesting to note that the proposed advantages
immeasurable number of combinations of mate- of indirect bonding have persisted for over 30
rials and techniques that make any individual years despite the changes in technology. In a
comparison unlikely to be important when viewed roundtable discussion in 1978, Gorelick and co-
from a global perspective. workers were questioned regarding the potential
The interest in indirect bonding has waxed advantages of indirect bonding versus direct
and waned over the years. In 1979, Gorelick bonding.83 Thomas observed that indirect bond-
reported that 17% of respondents of a national ing takes less chair time and is more accurate
survey preferred indirect bonding and as many because, “it stands to reason when you are hold-
as 10% bonded all of their attachments.69 In a ing teeth in your hand, looking at them from
follow up survey in 1986, Gottlieb and coworkers every angle, from posterior, occlusal, buccal, lin-
reported “less than ¼ (7.8%)” used indirect gual, etc., you can place the bracket more pre-
bonding.70 A Journal of Clinical Orthodontics (JCO) cisely than doing it in a direct manner.”
survey in 1990 reported, “new practices and He also reported a 98% success rate. In this
lower income producing practices appeared to same discussion, Zachrisson acknowledged, “ad-
be more likely to indirect bond,”71 and “routine mittedly, it is superior to position brackets on
use of indirect bonding increased over 1986 models.”83
8 J.T. Kalange and R.G. Thomas

At the present time technology is very rap- jagic and coworkers created custom gold alloy
idly becoming a part of everyday life. In to- lingual brackets that were indirectly bonded
day’s world, we are literally and figuratively with the Lingualcare® (Lingualcare Inc., Dallas,
driven by technology. Orthodontics, and espe- TX) system.99 In addition, even the etching pro-
cially indirect bonding, is no exception. Re- cedure for indirect bonding has been special-
cently, a fascinating high technology comput- ized, with the advent of clear trays with windows
er-driven system was developed that enables the size of brackets to allow for custom-con-
truly customized patient care.84-86 This system, trolled etching.100 Proges and Prucha modified
referred to as SureSmile® (Orametrix, Inc., photographic cheek retractors and a hair dryer
Richardson TX), is based on a white light to improve visualization and isolation for indi-
intraoral scanner that captures real-time, in rect bonding.101 And finally, specialized appli-
vivo images of the dentition. These images can ances have been proposed for use in indirect
be manipulated in the form of a three-dimen- bonding.102
sional digital diagnostic setup. In a relatively
complicated process, bracket positions are es-
tablished, archwire geometry is configured,
and custom indirect bonding trays from the
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