Trends Biomater. Artif.

Organs, Vol 20 (2), pp 000-000 (2007)

http://www.sbaoi.org

Ceramic Brackets: In search of an ideal!

Pawan Gautam and Ashima Valiathan*

Dept. of Orthodontics Manipal College of Dental Sciences, Manipal. Karnataka. 576104

* Corresponding Author Best Paper Award: National Conference on Ceramics for Medical Applications CMA2005, IIT Chennai, September 2005 Since their introduction to orthodontics in 1986, the Ceramic Brackets have become popular as esthetic appliances. The newer designs of ceramic brackets offer excellent optical properties and the promise of additional esthetic appeal without significant functional compromises. Ceramic brackets are durable, allow adequate force control over long treatment periods, and their risk for discoloration is minimal. The introduction of Ceramic brackets was a muchheralded development in the orthodontic treatment of adult patients. Their acceptance by these patients has been unprecedented in the practice of orthodontics and contributed significantly in the expansion and development of contemporary orthodontic therapeutic modalities. Apart from offering esthetics, ceramic brackets exhibit excellent biocompatibility. There has been much concern regarding the allergic and cytotoxic effects induced by constituents and the corrosion products of the stainless steel brackets. Nickel and Chromium are the most common causes of metalinduced allergic contact dermatitis in man. Nickel has recently been reported to be moderately cytotoxic. Hence the advantages offered by the Ceramic brackets namely excellent esthetics, biocompatibility, corrosion resistance, stability in the oral environment and non toxic nature has made them an integral part of the orthodontists armamentarium.

Introduction Characteristic of an ideal orthodontic appliance include good esthetics and optimum technical performance. An increase in the number of adult patients led to the development of various esthetically superior appliances. Ceramic brackets were introduced to orthodontic specialty in 1986 and since then have become an integral part of the orthodontists armamentarium. Since their introduction, product design and clinical performance has greatly improved. The superior aesthetics of ceramic brackets compared to conventional stainless steel brackets is not only well accepted by the patient, particularly adults, but are positively sought for1. Ceramics - material science Ceramic brackets are composed of aluminum oxide .Polycrystalline alumina &

monocrystalline alumina are the two most common varieties. Another category that is being developed is the Zirconium brackets. Monocrystalline brackets manufacturing process It is manufactured by heating aluminum oxide to temperatures in excess of 2100 C. The molten mass is cooled slowly, and the bracket is machined from the resulting crystal. Polycrystalline brackets Manufacturing process Manufactured by blending aluminum oxide particles with a binder, the mixture can be formed into a shape from which a bracket can be machined (sintering process). Temperatures above 1800 C are used to burn out the binder and fuse together the particles of the molded mixture. Then it is

heat treated to remove surface imperfections and relieve stresses created by the cutting operation. The presence of pores, machining interferences, and propagation lines contribute to compromises of bracket use anytime during clinical use2. Optical properties and strength are incompatible for polycrystalline ceramics. The larger the ceramic grains, the greater the clarity or translucency. However, the material tends to become weaker when the grains reach a size of about 30 microns. Polycrystalline brackets begin as aluminum oxide particles of about .3 microns, which are fused to produce ceramic grains of 20-30 microns. Heat treatments after machining must be carefully controlled to prevent further grain fusion, which could detract from physical properties. The main advantage of the polycrystalline manufacturing process is its ability to mold brackets a relatively inexpensive operation that yields large quantities. The disadvantages of this molding process are the presence of structural imperfections at grain boundaries or of trace amounts of impurities. Impurities in quantities as minute as .001 percent or slight imperfections can serve as foci for crack propagation under stress. An alternative method of making polycrystalline brackets is injection molding. This process does not require the brackets to be machined and thus eliminates structural imperfections created by the cutting process. The molding process and heat treatment produce fused aluminum oxide with grain boundaries that refract light, resulting in a degree of opacity. The most apparent difference between polycrystalline and single-crystal brackets is in their optical 2 clarity . Single-crystal ceramic brackets are manufactured by an entirely different process. Orthodontic manufacturers purchase these large single crystals and mill them into the shapes and dimensions of various brackets, using ultrasonic cutting techniques, diamond cutting, or a

combination of the two. After milling, the sapphire crystals are heat-treated to remove surface imperfections and to relieve stresses induced by the milling operations. The primary advantage of single-crystal manufacturing is the elimination of possible stress-inducing impurities or imperfections. The disadvantage is the difficulty and added expense of milling the third-hardest known material. This involves the development of new technology with its inherent new problems. Production of polycrystalline brackets is less difficult, and hence these brackets are more readily available at present. Single-crystal brackets have noticeably more optical clarity than polycrystalline brackets. Whether the difference is significant is a judgment to be made by each clinician Zirconia brackets Zirconia is a mineral extracted from beach sands of Australia. The PSZ (Partially stabilized Zirconium) developed by the Commonwealth Scientific and Industrial Research Organization (CSIRO) as a reliable highly stress-resistant material. A remarkable quality of zirconia -based advanced ceramics is that wear actually makes the material stronger. In theory, the low frictional coefficients achievable with yttria-stabilized zirconia should make it a suitable alternative to alumina for bracket construction. However, zirconia brackets have problems related to color and opacity, which detract from the esthetics, and can inhibit composite photopolymerization. Studies have shown that zirconia brackets offer no significant improvement over alumina brackets with regard to their frictional characteristics. Comparison of properties Production of polycrystalline brackets is less complicated, these brackets are more readily available at present. Single crystal brackets are noticeably clearer than polycrystalline brackets, which tend to be translucent. Both resist staining and discoloration. They come in a variety of edgewise structures including

true Siamese, semi-Siamese, solid, and Lewis/Lang designs. Biocompatibility Nickel(Ni) has been implicated as a toxic material in several dental and non-dental applications. Airborne exposure to Ni in dust has been related to its potential to induce carcinogenesis in nasal and lung tissues. In addition Ni is a common sensitizer. Contact with Ni containing jewelry, button, zippers and clasps on clothing induce sensitization. The prevalence is estimated to be 10% in women and less than 1% in men. Allergic reactions to Ni can be manifested both locally and systemically from contact with skin. Reaction to Ni by the mucous membrane has also been reported. Certain forms of Chromium have been associated with lung cancer in industrial exposures. However, carcinogenesis related to dental and medical applications has not been reported. Chromium has been reported to sensitize individuals and produce a chronic dermatitis. The sensitivity is the result of contact with chrome salts, which result from corrosion of such alloys. Apart from exhibiting excellent esthetics, ceramic brackets are chemically stable and inert in the oral environment, and exhibit excellent biocompatibility with the oral tissues. Ceramic brackets- hardness Due to extremely high hardness of aluminium oxide, both monocrystalline and polycrystalline alumina have a significant advantage over stainless steel. Because ceramic brackets are nine times harder than stainless steel brackets or enamel, severe enamel abrasion from ceramic brackets might rapidly occur, if contacts between teeth and ceramic brackets exist. Ceramic brackets- tensile strength The tensile strength of alumina >polycrystalline stainless steel. monocrystalline alumina, >>

will drastically reduce the load required for fracture. The elongation for ceramic at failure is less than 1% in contrast with approximately 20% of stainless steel, thus making ceramic brackets more brittle. Ceramics have highly localized, directional atomic lattice that does not permit shifting of bonds and redistribution of stress. So when stresses reach critical levels, inter-atomic bonds break, and brittle failure occurs5. Ceramic brackets- fracture toughness Fracture toughness in ceramics is 20 to 40 times less than in stainless steel, making it much easier to fracture a ceramic bracket than a metallic one. Among ceramic materials, polycrystalline alumina presents higher fracture toughness than single-crystal 5 alumina . Semi-twin brackets,( Fascination, Mystique, & Virage) have significantly higher tensile fracture strength than true-twin brackets,( Clarity, lnVu, & Luxi) . Monocrystalline brackets (Inspire) are not fractured easily6. Bond strength Ceramic material does not bond chemically with adhesives Chemical bonding : glass is added to the aluminum oxide base and is treated with a silane coupling agent. Silane bonds with glass and leaves a free end of its molecules that react with any of the acrylic bonding materials. Shiny surfaces of ceramic brackets bonded chemically allow greater distribution of stress over the whole adhesive interface without the presence of any localized stress areas. Significantly greater shear bond is needed to cause debonding and pure adhesive failure with chemical bonding. Mechanical bonding : brackets have retentive grooves in which edge angles are 90. There are also crosscuts to prevent the brackets from sliding along the undercut grooves that have sharp edge angles, thus leading to high localized stress concentrations around the sharp edges and resulting in brittle failure of the adhesive. On application of shear debonding force, part of the adhesive is left on the tooth and part on

This property also depends on the condition of the surface of the ceramic. A shallow scratch on the surface of a ceramic bracket

the grooved bracket. Mean shear bond strength of the polycrystalline ceramic brackets is significantly greater than that obtained when stainless steel brackets are used. Single crystal ceramic brackets produce the lowest mean shear bond strength values7. Gwinnet8(reported that the mean values for the different bracket types are not statistically significant, but this conflicts with the results of many other studies. Bond strengths are greater with chemical bonding than with mechanical retention which shows bond strengths comparable to metal bracket).Decreasing etching time, (with 37% phosphoric acid) from 30 seconds to 10 seconds maintains a clinically useful-bond strength. Light-cured GICs provide sufficient strength for bonding ceramic brackets, but in terms of bond failure site and bracket fracture, they provide no advantage over composite adhesives. Mean bond strengths of Clarity brackets (polycrystalline) and Inspire brackets (monocrystalline) are found to be comparable. No enamel damage was evident in any specimen when the brackets are removed with the appropriate pliers recommended by the manufacturers9. Frictional Resistance Stainless steel brackets generate lower frictional forces than ceramic brackets, because of their lower surface roughness, which is clearly visible when comparing scanning electron micrographs. Ceramic brackets produce significantly greater 10 friction . Beta-titanium and nickel-titanium wires are associated with higher frictional forces than stainless steel or cobaltchromium wires. Progressively increasing frictional values: stainless steel bracket < ceramic bracket with a metal reinforced slot < and traditional ceramic bracket with a ceramic slot11.Mono-crystalline alumina brackets are smoother than polycrystalline samples, but their frictional characteristics are comparable12.To reduce frictional resistance, development of ceramic brackets with smoother slot surfaces, rounding of slot base or consisting of metallic slot surfaces has been accomplished.

Metal-lined ceramic brackets can function comparably to conventional stainless steel brackets and 18-kt gold inserts appear superior to stainless steel inserts13. Ligation: Usefulness of Teflon-coated ligatures compared to elastomeric ligatures in minimizing the high friction of ceramic brackets when an esthetic appliance is imperative14. Manufacturers have also introduced self ligating brackets15. Base surface characteristics Base surface characteristics involve undercuts or grooves that provide a mechanical interlock to the adhesive. These brackets may have a flat base, covered with a silane layer with recesses for mechanical anchoring. Bracket base having a smooth surface rely on a chemical coating to enhance bond strength. A silane coupling agent is used as a chemical mediator between the adhesive resin and the bracket base because of the inert composition of the aluminium oxide ceramic brackets. The manufacturers of such brackets have reported that they achieve higher bond strength when compared with mechanical retention. Polycrystalline alumina with a rough base comprised of either randomly oriented sharp crystals or spherical glass particles to provide micromechanical interlocking with the orthodontic adhesive1,2. To overcome the potential damage of enamel during debonding16, a ceramic bracket with a thin polycarbonate laminate on the base has been manufactured (CeramaFlex, TP Orthodontics). The bond to the enamel is to the thin polycarbonate laminate. It is suggested that these brackets are as easy to remove as metallic brackets. Ceramaflex brackets have significantly lower bond strength than traditional ceramic brackets. On the other hand, the bond failure location of the Ceramaflex bracket is consistently more favorable, i.e., occurring at the ceramic bracket-polycarbonate base.

Rebonding/ Recycling Ceramic Brackets Gaffey et al evaluated different methods of recycling: silane coupling agent, heat plus silane coupling agent, hydrofluoric acid plus silane coupling agent, and heat plus hydrofluoric acid plus silane coupling agent. Treatment of electrothermally debonded ceramic brackets with silane or heat plus silane resulted in bond strength greater than 9 MPa, which was clinically acceptable. The use of hydrofluoric acid significantly reduced the bond strength below 2 MPa. Previous studies have recommended heating the brackets until cherry red to burn off residual composite resin. Bracket base is then rinsed with 100% alcohol and left to dry. The bond strength of these recycled brackets is about 30% less than new chemically retentive ceramic brackets, yet it might maintain an acceptable bond strength and lead to fewer enamel fractures on debonding. Bond strength of recycled brackets is clinically adequate, although it is lower than that of new brackets. This weaker bond strength after "recycling" of ceramic brackets References
1. 2. 3. 4. 5. 6. 7. 8.
17

minimizes the likelihood of unwanted enamel removal during debonding18. Conclusion Ceramic brackets became popular as esthetic appliances and have been available for clinical use for almost 2 decades! The new designs of ceramic brackets offer excellent optical properties and the promise of additional esthetic appeal without significant functional compromises. Ceramic brackets are durable, allow adequate force control over long treatment periods, and their risk for discoloration is minimal. The introduction of ceramic brackets was a much-heralded development in the orthodontic treatment of adult patients19. Their acceptance by these patients has been unprecedented in the practice of orthodontics and contributed significantly in the expansion and development of contemporary orthodontic therapeutic modalities. However, there is still scope for improvement in some of the bracket characteristics before they are able to largely replace the use of metallic brackets, in the manner that direct bracket bonding replaced banding of teeth!!

Karamouzos, Athanasiou, Dent, Papadopoulos. Clinical characteristics and properties of ceramic brackets: A comprehensive review . Am J Orthod Dentofac Orthop 1997;112:34-40. Swartz ML. Ceramic brackets. J Clin Orthod 1988;22:82-8. Birnie D. Ceramic brackets. Br J Orthod 1990;17:71-5. Ghafari J. Problems associated with ceramic brackets suggest limiting their use to selected teeth. Angle Orthod 1992;62:145-52. Johnson G, Walker MP, Kula K. Fracture strength of ceramic bracket tie wings subjected to tension. Angle Orthod. 2005 Jan;75(1):95-100 Ghafari J, Skanchy TL, Mante F. Shear bond strengths of two ceramic brackets. J Clin Orthod 1992;26:491-3. Gwinnett AJ. A comparison of shear bond strengths of metal and ceramic brackets. Am J Orthod Dentofac Orthop 1988;93:346-8. Theodorakopoulou LP, Sadowsky PL, Jacobson A, Lacefield W Jr. Evaluation of the debonding characteristics of 2 ceramic brackets: an in vitro study, Am J Orthod Dentofacial Orthop. 2004 Mar;125(3):329 Nishio C, da Motta AF, Elias CN, Mucha JN. In vitro evaluation of frictional forces between archwires and ceramic brackets. Am J Orthod Dentofacial Orthop. 2004 Jan;125(1):56-64

9.

10. Kusy RP, Whitley JQ. Frictional resistances of metal-lined ceramic brackets versus conventional stainless steel brackets and development of 3-D friction maps. Angle Orthod. 2001 Oct;71(5):364-74. 11. Keith O, Kusy RP, Whitley JQ. Zirconia brackets: an evaluation of morphology and coefficients of friction. Am J Orthod Dentofacial Orthop. 1994 Dec;106(6):605-14.

12. Cacciafesta V, Sfondrini MF, Scribante A, Klersy C, Auricchio F. Evaluation of friction of conventional and metalinsert ceramic brackets in various bracket-archwire combinations. Am J Orthod Dentofacial Orthop. 2003 Oct;124(4):403-9.

13. Hain M, Dhopatkar A, Rock P.The effect of ligation method on friction in sliding mechanics. Am J Orthod Dentofacial Orthop. 2003 Apr;123(4):416-22. 14. Eliades T, Lekka M, Eliades G, Brantley WA. Surface characterization of ceramic brackets: a multitechnique approach. Am J Orthod Dentofac Orthop 1994;105:10 15. Sameer Shaikh, Ashima Valiathan. Self-ligating Brackets: An option for advanced orthodontist. Journ. Indian Orthod. Soc. 1996, 27(4); 137-44 16. Jeiroudi TM. Enamel fracture caused by ceramic brackets. Am J Orthod Dentofac Orthop 1991;99:97-9. 17. Gaffey PG, Major PW, Glover K, Grace M, Koehler JR. Shear/peel bond strength of repositioned ceramic brackets. Angle Orthod. 1995;65(5):351-7. 18. Martina R, Laino A, Cacciafesta V, Cantiello P. Recycling effects on ceramic brackets: a dimensional, weight and shear bond strength analysis. Eur J Orthod. 1997Dec;19(6):629-36.

19. Russell JS. Aesthetic orthodontic brackets. J Orthod. 2005 Jun;32(2):146-63.