Cer amic Br ack ets:

A Clinical P erspectiv e
Samir E. Bishara, BDS, DDS, DOrtho, MS1

As the number of adults seeking orthodontic care has increased, orthodontists have felt the
need to provide their patients with a more esthetically “appealing” appliance. This per-
ceived need has motivated manufacturers to create acceptable esthetic brackets, including
ceramic brackets. The characteristics of ceramic brackets that are of particular interest to
the clinician are described in this article. In addition, factors that may significantly influence
bond strength and bracket removal are identified. It is hoped that this information will
enable the clinician to debond ceramic brackets safely, using the available scientific infor-
mation. World J Orthod 2003;4:61–66.

s the number of adults seeking orthodontic care OPTICAL PROPER TIES OF

A has increased, orthodontists have felt the need
to provide their patients with a more esthetically ap-
CERAMIC BRACKETS

pealing appliance. This perceived need has moti-
vated manufacturers to create esthetically accept-
able brackets, including ceramic brackets.1
Ceramics are materials that are both rigid and brit-
tle, ie, nonductile.2 Therefore, debonding pressure on
the bracket base often results in partial or complete
bracket failure, ie, fracture. The bracket remnants are
frequently removed with a diamond bur in a high-
speed handpiece, which causes significant appre-
hension for the patient, as well as the clinician.
Currently, the removal of most ceramic brackets
is accomplished by specially designed instruments,
such as pliers; some are removed by electrothermal
and ultrasonic methods.3 There is also the experi-
mental laser-debonding approach.
Enamel fractures, cracks, and flaking have been
reported as complications, particularly during the
mechanical debonding procedures.4 On the other
hand, pulp irritation is a potential complication of
the heat-producing devices.5 Therefore, tooth and/or
pulp tissue damage are major concerns for clinicians
using ceramic brackets.
The optical esthetic properties of ceramics provide
the only advantage over stainless steel brackets (Fig
1).6,7 The larger the ceramic grain, the greater the
clarity. Yet, when the grain size reaches about 30
µm, the ceramic material becomes weaker.
The grain boundaries and impurities that are pre-
sent in polycrystalline ceramics reflect light, result-
ing in some degree of opacity (Fig 2). Monocrys-
talline brackets, on the other hand, are essentially
clear. This clear appearance is the result of two fac-
tors: (1) reduction of grain boundaries and (2) the
introduction of fewer impurities during the manufac-
turing process (Fig 3).2
Whether the difference between the optical prop-
erties of the opaque and clear ceramics is signifi-
cant from an esthetic point of view is a matter of per-
sonal preference. This is particularly true since
ceramic brackets in the oral environment can be
affected by color pigments in tea, coffee, and wine.
THE EFFECT OF CERAMICS ON
OR THODONTIC TREATMENT

Research has identified four important side effects that

1Professor, Department of Orthodontics, College of Dentistry, Uni-
versity of Iowa, Iowa City, Iowa, USA.
REPRINT REQUESTS/CORRESPONDENCE
Dr Samir E. Bishara, Department of Orthodontics, College of Den-
tistry, University of Iowa, 220 Dental Science S, Iowa City, IA
52242-1001, USA. E-mail: linda-keller@uiowa.edu
ceramic brackets can have on orthodontic treatment:
1. Ceramic is the third hardest material known to
man.2 Therefore, brackets in contact with oppos-
ing teeth can cause wear of the relatively softer
enamel.8,9

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Fig 1 Various ceramic brackets avail- Fig 2 Polycrystalline bracket is Fig 3 Monocrystalline bracket is
able on the market. opaque white in color. translucent.

2. Since aluminum oxide is much harder than stain-
less steel, the slot in the ceramic bracket shows
minimal wear during sliding mechanics. On the
other hand, nicks occur in the relatively softer
metal archwires, which increases friction.
3. When using sliding mechanics, the relatively
rough surfaces of the ceramic slot significantly
increase frictional resistance when compared to
stainless steel brackets.10,11 This property has the
potential for decreasing the efficiency of tooth
movement.
4. The “fracture toughness” (the ability of a material
to resist fracture) of ceramic brackets is much
lower than that for metals. For example, the elon-
gation (deformation) of stainless steel is approxi-
mately 20% before it finally fails, while the elonga-
tion of sapphire before failure does not exceed
1%.6 Therefore, compared to a metal bracket, the
ceramic bracket is more susceptible to fracture
when orthodontic forces are applied. As a result,
stresses introduced during ligation and archwire
activation, forces of mastication and occlusion,
and forces applied during bracket removal (Fig 4a)
are all capable of creating cracks in ceramic brack-
ets, which, in turn, may initiate failure (Fig 4b).
Force magnitudes applied
during debonding
The mean bond strength for the different bracket,
adhesive, and enamel conditioner combinations
range from a low of 4 MPa to highs in excess of 19
MPa. Most debonding stresses are between 6 and
11 MPa,12–14 but other investigators have reported
forces in excess of 30 MPa.15–17
With metal brackets, the clinician asked the criti-
cal question of whether a bond was too weak to
withstand the forces of orthodontic treatment. With
ceramic brackets, clinicians must ask whether a
bond is too strong for safe debonding. Reynolds18
suggested that a minimum bond strength of 6 to 8
MPa is adequate for most clinical orthodontic needs.
But what should be considered the maximum limit
for bond strength? Retief’s research19 indicated that
enamel fractures can occur with bond strengths as
low as 138 kg/cm2 (13 MPa). This is comparable with
the mean linear tensile strength of enamel, as
reported by Bowen and Rodriguez,20 of 148 kg cm2
(15 MPa). Therefore, it would be best to avoid bond
strengths that are greater than 130 kg/cm2 (13 MPa).

Variability of debonding forces

DEBONDING ISSUES
The clinician should be aware of some important
variables that could influence the success of
debonding ceramic brackets.
When the “mean” debonding forces in various stud-
ies were evaluated,12–14 it became evident that most
of the means fall below the upper limits of what is
considered safe.18 However, the potential for clinical
disasters lies in the range of forces that these
means actually describe. The lower values of these
ranges (3 to 4 MPa) pose only one complication,
specifically that the bracket will likely fail during
treatment and will need to be rebonded. On the
other hand, the higher values of the range (24 to 29
MPa) are almost twice as high as the forces that

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VOLUME 4, NUMBER 1, 2003 Bishara

a b

Fig 4 (a) Mechanical debonding with pliers. (b) A ceramic bracket fractured during bonding.

have the potential for causing significant damage to

the enamel surface. It is important to remember that
this wide range of forces occurred regardless of the
adhesive tested or the bracket used. While debond-
ing ceramic brackets, the clinician cannot predict
which of the brackets will have these extremely high
bond strengths. Hence the dilemma! In the same
patient, the clinician could successfully remove all
the brackets except for that on one tooth. On that
one, enamel cracks or tooth fractures could occur as
a result of these excessive bond forces.
Fig 5 Buccal enamel on the maxillary pre-
molars fractured during debonding. Note the
Clinical precautions when using presence of large amalgam restorations in
mechanical debonding techniques these teeth.

Under ideal laboratory conditions, all of the conven-

tional mechanical debonding techniques were effec-
tive. However, the potential for causing damage is
higher if the integrity of the tooth is already compro-
mised from pre-existing developmental defects,
enamel cracks, large restorations, or with the rela-
tively brittle nonvital teeth (Fig 5). Placement of
ceramic brackets should be avoided in these cases.
The debonding forces result in various degrees of
patient discomfort. Clinically, these heavy forces are
transmitted at the end of the active phase of ortho-
dontic treatment, to teeth that are often mobile and
sensitive. To minimize discomfort and pain, the teeth
should be well protected during bracket removal. It is
suggested that either the orthodontist should sup-
port the tooth with his/her fingers or have the
patient bite firmly into a cotton roll to minimize
patient discomfort (Fig 6).
The likelihood of bracket fracture can be mini-
mized if excess composite flash is first removed
from around the bracket, which allows the debond-
ing instrument to be fully seated at the base of the
bracket. This allows the pliers to transmit the
debonding forces through the strongest and bulkiest
part of the bracket, namely, the bracket base (Fig 7).
Bracket fracture, when it occurs, is usually quick.
Consequently, fragments could injure the oral
mucosa or the clinician. Furthermore, whole brackets
or fractured bracket particles could become ingested
or aspirated by the patient, creating a significant
medical emergency. To minimize such occurrences, it
is advisable to remove the brackets with a piece of
gauze behind the teeth, to catch any loose fragments
(Fig 7). In addition, “flying” projectiles may cause eye
injury to the patient and the clinician. Therefore, pro-
tective eyewear should be worn by both the clinician
and patient. Some pliers have a protective sheath
that covers the working end of the instrument (Figs
8a and 8b). This sheath decreases the probability of
any loose bracket fragments becoming accidentally
discharged into the patient’s mouth.
Plier blades (Figs 9a and 9b) progressively lose
their sharpness, especially as the blades are abraded
from contact with the harder ceramic material. As the
plier blades become dull, debonding efficiency is
significantly reduced. Therefore, it is recommended
that blades be replaced after debonding 50 brackets.

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Bishara WORLD JOURNAL OF ORTHODONTICS

Fig 6 Patient biting on a cotton roll during Fig 7 The blades of the pliers should be
debonding, which serves to stabilize the placed at the enamel-bracket interface to
teeth and minimize patient discomfort. minimize bracket failure (fracture).

Fig 8 (a) Pliers with nonexchangeable

blades and with a plastic sheath to hold
ceramic bracket fragments. (b) Close-up of
the plier blades and plastic sheath.

Pliers with nonexchangeable blades should be sharp-
ened on a regular basis.
New ceramic bracket designs have been intro-
duced in an attempt to minimize some of the prob-
lems that are encountered by the clinician. The new
brackets have a metal-lined archwire slot (Fig 10a). A
stainless steel slot has the advantage of minimizing
the friction that occurs as a result of the archwires
contacting ceramic. Furthermore, the metal slot
strengthens the bracket, helping it to withstand rou-
tine orthodontic torque forces.
One new bracket also incorporates a vertical slot
(0.019 ⫻ 0.018 inch), designed to help create a con-
sistent bracket failure mode during debonding21 (Fig
10b). This design combines the esthetic advantages of
ceramics and the mechanical advantages of metal
bracket removal by squeezing the tiewings mesiodis-
tally with pliers (Fig 10c) available in the clinician’s
armamentarium. The brackets collapse during debond-
ing (Fig 10d) and are designed for single use only.21
These new brackets have shown a greater inci-
dence of partial bracket failure when the Weingart
pliers were used during removal. This is to be
expected because the point of force application is at
the tiewings of the brackets. However, more efficient
tooth movement with sliding mechanics should be
expected with the use of these brackets because of
the metal archwire slot.9,10
CONCLUSIONS
Ceramic brackets have one main advantage: esthet-
ics. On the other hand, they have numerous disad-
vantages, including:
1. Ceramic brackets have a higher incidence of
bracket fracture during debonding (Fig 11), partic-
ularly with conventional debonding techniques
(using pliers).

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VOLUME 4, NUMBER 1, 2003 Bishara

a b

Fig 9 (a) Pliers with sharp exchangeable blades are used to debond ceramic brackets. (b)
Two types of exchangeable blades are available. The narrow blades are recommended for
debonding ceramic brackets (bottom blade in figure).

a b

c d

Fig 10 (a) Ceramic bracket with a metal-lined archwire slot. (b) Vertical slot to facilitate the
collapse of the bracket mesiodistally as pressure is applied on the tiewings. (c) The bracket can
be debonded with either Howe or utility pliers. (d) The two sides of the bracket collapse, allow-
ing for bracket separation from the tooth.

2. Ceramic brackets do not have the ability to with-
stand strong torsional forces, especially if the
bracket surface has been cracked during treat-
ment, unless the bracket slot has a metal liner.
3. The use of ceramic brackets should be avoided
on compromised teeth. Therefore, clinicians
should conduct thorough pretreatment and post-
treatment examinations of the surface character-
istics of enamel, using transillumination (Fig 12).
This can detect cracks, fractures, or other defects
that may become enamel fracture sites during
debonding. This examination is preventive risk
management by the orthodontist.
4. Enamel wear occurs if ceramic brackets contact
opposing tooth surfaces. Therefore, ceramic
brackets are contraindicated on the mandibular
anterior teeth in cases with deep overbite and
minimal overjet. In such cases, sufficient overjet
has to be created before bonding the mandibular
incisors, or metal brackets can be used on the
mandibular teeth. Similarly, during maxillary
incisor retraction, the overbite has to be reduced
first, so that the maxillary incisors do not touch
the mandibular ceramic brackets.
5. Ceramic brackets can cause nicks in the arch-
wires, resulting in more friction between the

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Bishara
Fig 11 Ceramic bracket fractured during
debonding.
bracket and the archwire. This can decrease the
efficiency of tooth movement, unless the slots
have a metal liner.
6. The use of ceramic brackets in patients who will
undergo orthognathic surgery should be discour-
aged. The fracture of the brackets before, during,
or after surgery creates the potential for undesir-
able and avoidable complications.
7. The removal of ceramic brackets should not be
delegated to auxiliaries because of potential frac-
ture of the bracket and/or enamel.
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4. American Association of Orthodontists. Summary of AAO ceram-
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66
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NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM
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WORLD JOURNAL OF ORTHODONTICS
Fig 12 Transillumination should be used
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