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in orthodontic ceramics 3
S. Zinelis, W. Brantley
3.1 Introduction
The demand for esthetic brackets has increased over the last three decades as more
adult patients request orthodontic treatment. To cover this demand the orthodontic in-
dustry has developed plastic and ceramic brackets, lingual brackets, and orthodontic
aligners made of thermoplastic materials. Despite the increased esthetic results, all
of the aforementioned devices have their limitations.
Plastic brackets were introduced in the early 1970s, but they suffered from slot
distortion and creep deformation because of mechanical loading; water absorption
and discoloration were other important limitations.1,2 In the late 1980s, ceramic
brackets made of polycrystalline or monocrystalline (sapphire) alumina, and later
of polycrystalline zirconia, were introduced in the orthodontic market.1,3e5 Ceramic
brackets could successfully withstand orthodontic forces and were free of discolor-
ation and stain complications.2 However, low fracture toughness, increased friction
between ceramic slots and metallic wires, and enamel fracture after debonding
remained among their drawbacks.6,7 Consideration of manufacturing processes,
compositions, and inherent physical and mechanical properties of the ceramic mate-
rials involved is essential to understand several issues related to their clinical
performance.
manufactured by milling with diamond cutting tools, and nally a special heat treat-
ment is applied to remove residual stresses resulting from the milling and surface im-
perfections created during the manufacturing process.1 The single-crystal brackets are
manufactured by milling high-purity single-crystal alumina bars. The milling is
accomplished by diamond cutting, ultrasonic cutting, or Nd:YAG lasers. Similar to
the manufacturing process of polycrystalline alumina brackets, a heat treatment is per-
formed for the single-crystal brackets to remove residual stresses. However, the poly-
crystalline alumina brackets contain more impurities in their microstructure because of
the need for binder to hold the particles together during the sintering process.1
Fig 3.1 illustrates some commercially available ceramic brackets. In an effort to
enhance chemical bonding with adhesive resins, glass phases are added in alumina
brackets to promote bonding with silane-coupling agents.10 The glassy phases bond
chemically with the silane, which also has a free end that can react with acrylic resins.
Representative spectra from X-ray energy-dispersive spectrometric analyses for a pure
alumina bracket are presented in Fig 3.2(a) and for another alumina bracket with Si and
Na additions in Fig 3.2(b). For polycrystalline alumina brackets, internal pores and
other defects have been identied by micro X-ray tomography analysis (Fig 3.3).
These imperfections may arise from incompletely sintered alumina particles, gas inclu-
sions, and other sources during the manufacturing process.
Figure 3.1 Polycrystalline alumina brackets with different levels of optical translucency. (Left
to right: Inspire ICE (Ormco), Virgine (Dentalline), Clarity (3M Unitek), Maia (Natural
Orthodontics), and Terga Ceramic (Royal Orthodontics)).
(a) cps/eV
10 Al
9
8
7
6
5
4
3
O
2
1
0
0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0
KeV
(b) cps/eV
Al
25
20
15
O
10
5 Si
Na
0
0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0
KeV
Figure 3.2 Representative energy-dispersive spectrometric spectra from a pure alumina bracket
(a) and from a bracket with Si and Na in its formulation (b).
optical clarity because of the absence of grain boundaries and fewer impurities arising
from the manufacturing process.10 Fig 3.4 provides a comparison of direct light trans-
mittance for several alumina brackets, and it is evident that the single-crystal brackets
are superior to the polycrystalline brackets.11 The same trend was veried for diffuse
light transmittance, presented in Fig 3.5.12 Both types of alumina brackets provide sub-
stantial stability in light transmission and reection after articial aging.13
However, the optical properties of ceramic brackets, beyond their esthetic appearance,
may adversely affect the properties of light-cured adhesive resins by hindering the curing
due to the scattering of light at the grain boundaries and the reduction in intensity of light
passing through the bracket structure.14 Measurements at the peak optical absorption
wavelength (468 nm) of the photoinitiator camphorquinone indicated that the direct light
transmittance for single-crystal alumina brackets was around 35% and less than 5% for
64 Orthodontic Applications of Biomaterials
2.0 2.0
4.0 4.0
Figure 3.3 Two horizontal layers of a ceramic bracket at different elevations after
microcomputerized X-ray tomography analysis. Both layers contain internal defects, indicated
by the arrows. The red lines in the inset gures indicate the elevation of each horizontal layer.
The vertical and horizontal scales are shown in millimeters.
Figure 3.4 Percentage of direct light transmittance for monocrystalline and polycrystalline
ceramic brackets.
polycrystalline alumina brackets; the latter attributed to light scattering at grain bound-
aries.1 However, when the same products were tested in the diffuse light transmittance
mode at the same wavelength, the percentage transmittance values were increased four
times for the polycrystalline brackets and two times for the single-crystal brackets. It is
worthwhile to note that the bracket products with lower direct light transmittance have
similar low values of diffuse light transmittance. It has been proposed that a critical value
of 30e40% for light transmittance through the ceramic brackets must be achieved for
adequate polymerization of the adhesive resin.1
Structure/property relationships in orthodontic ceramics 65
Transmittance (%)
0 10 20 30 40 50 60 70 80
Crystalline V (Tomy)
Brackets
Monocrystalline
Luxi II (Rocky Mountain Orthodontics) Polycrystalline
Figure 3.5 Percentage of diffuse light transmittance for monocrystalline and polycrystalline
alumina brackets.
3.4.3 Hardness
In general, ceramics are well known for high hardness, and alumina ceramic brackets
are much harder than metallic brackets and tooth enamel.16 The considerable differ-
ence in hardness will induce rapid wear of human enamel when there is contact of
opposing teeth with the ceramic brackets.17,22,23 The enamel damage when the
opposing teeth come in contact with single-crystal alumina brackets is higher
compared to that in polycrystalline alumina brackets.17 It is considered that contact
of teeth with ceramic brackets must be eliminated to avoid abrasion of human enamel,
which can be achieved in two ways. The rst approach is the coverage of the occlusal
surfaces of ceramic brackets with special elastomeric rings. The second approach is the
application of techniques that minimize the adverse effects of parafunctional habits of
patients and thereby eliminate occlusal interferences.16,24
Structure/property relationships in orthodontic ceramics 67
Although these latter strategies have reduced the incidence of enamel fracture, this
complication has still not been eliminated. Manufacturers often focus in product
68 Orthodontic Applications of Biomaterials
(a) (b)
(c) (d)
(e) (f)
Figure 3.6 Bases of ceramic brackets shown in (a), (c), and (e) use various designs of surface
grooves to increase mechanical retention to the adhesive resin (original magnication 25).
(b) Details of surface grooves in (a) at higher magnication (original magnication 78).
(d) Details of the at surface for (c) and (f) details of the at surface for (e), where the grain
boundaries of polycrystalline alumina have been revealed (original magnication 1000).
Structure/property relationships in orthodontic ceramics 69
(a) (b)
(c) (d)
Figure 3.7 Bases of ceramic brackets with rough surfaces, shown at low magnication in
(a) and (c), for promoting micromechanical retention to the adhesive resin. (b) Details of (a),
showing the spherical particles (original magnication 1000). (d) Details of (c), showing the
sharp-edged crystal protrusions used to promote micromechanical retention (original
magnication 200).
problem and can occur during treatment or the debonding process.3,28 Manufacturers
have employed a variety of strategies to minimize the fracture of the ceramic brackets
during debonding. Despite these concerns, the introduction of alumina ceramic
brackets has been an important development that has expanded contemporary ortho-
dontic treatment, notably for adult patients who are strongly concerned about esthetics.
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