Title	Indirect Bonding Does Not Result in More Accurate Bracket Placement Compared to Direct Bonding
Clinical Question	Does indirect bonding result in more accurate bracket placement compared to direct bonding?
Clinical Bottom Line	Indirect bonding does not result in more accurate bracket placement compared to direct bonding. This is supported by randomized clinical trials and an in-vitro study, in which the accuracy of bracket placement was not significantly different between the two techniques. More clinical evidence is needed to determine if the type of malocclusion has an effect on the accuracy of bracket placement in the two techniques.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 31286897 Li / 2019 247 patients in 8 included studies Systematic Review Key results Out of the eight included randomized clinical trials, only two measured the accuracy of bracket placement. These two randomized clinical trials found no significant differences between direct and indirect bonding. Meta-analysis of the bracket placement accuracy was not performed due to the methodological differences and extensive heterogeneity. 15210929 Hodge / 2004 26 patients enrolled in a split mouth design Randomized Controlled Trial Key results Overall accuracy of bracket placement was not significantly different between the two techniques. Vertical placement errors were significantly greater than errors in the mesiodistal plane (P< .05). Error ranges for combined tooth types were smaller with indirect bonding (0.27mm) as compared to direct bonding (1.81mm). 10474109 Koo / 1999 19 duplicate pretreatment models Laboratory study Key results Indirect bonding was on average more accurate in bracket height (P< .05), with no significant differences between the two techniques in terms of angulation or mesiodistal position.
Evidence Search	(((direct bonding) OR indirect bonding) AND accuracy) AND bracket
Comments on The Evidence	Validity: In Li’s systematic review, eight studies were included after a broad search to identify all relevant randomized controlled trials in several databases with no restrictions on language or year of publication. Hodger/2004 used a split mouth technique and enrolled 26 patients with malocclusion from the waiting list of Queens Hospital, Burton on Trent. Cases where the initial malocclusion prevented ideal bracket placement were excluded, and the accuracy of bracket placement was only studied on incisors and canines. Koo/1999 asked nine orthodontists to bond 18 pretreatment models with class II malocclusion form second premolar to second premolar. Each orthodontist performed direct bonding on one model and indirect bonding on another identical model. Each bonded tooth was then sectioned and photographed to measure bracket placement accuracy. Perspective: Several factors should be considered when an orthodontist decides to bond brackets directly or indirectly. These factors may include reducing chairside time, improving clinical efficiency, and reducing overhead cost of the practice. Based on the current evidence, however, achieving accurate bracket placement does not seem to be a significant factor in that decision.
Applicability	The subject pool of the first two studies included people with malocclusions who required treatment with upper and lower full arch fixed appliances. The third study used pretreatment models of patients with class II malocclusion. All studies showed no significant differences in the accuracy of bracket placement between the two techniques. However, the range of vertical placement errors was less with the indirect bonding method. There are several factors to be considered when deciding between direct vs. indirect bonding in orthodontic treatment. Chairside time, treatment effectiveness and efficiency are some examples. However, accuracy of bracket placement cannot be justified as a reason to choose indirect bonding over direct bonding.
Specialty	(Orthodontics)
Keywords	Orthodontics, indirect bonding, direct bonding, bracket placement accuracy
ID#	3419
Date of submission	12/03/2019
E-mail	alsalem@livemail.uthscsa.edu
Author	Mohammed Alsalem, DMD
Co-author(s)	Basil Basha, DDS
Co-author(s) e-mail	basha@uthscsa.edu
Faculty mentor	Ravikumar Anthony BDS, MDS, MS
Faculty mentor e-mail	anthonyr@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available