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Attachment bonding

Do you sometimes experience attachments debonding from the teeth of a patient in clear aligner treatment?


In this post you'll get a step-by-step guide outlining a 11 step protocol to ensure your attachments never fall off. The protocol can be followed by you or the dental team members to whom you delegagte the task.


Dental assistant bonding clear aligner attachments

Golden standard

I know the frustration related to this as I experienced the same back in 2008/2009 when I started working with clear aligners in my dental practice. That experience made me rethink how I bonded composite to tooth surfaces.


In all honesty, I must admit that I had begun to deviate from the golden standards I had been taught in dental school. It wasn't something I did consciously, but something I became aware that I was doing when my team and I started analyzing our workflow.


If you do the same exercise as I tried, you might realize you're making the same mistake as I did


Use a stopwatch

Simply start using a stopwatch while you perform any bonding procedure in your dental office. If you have years of experience, you may be surprised at how long it takes 30 seconds to pass as you let the acid ethc the enamel or rub in the bonding agent into the dentin.


Years ago I stumbled upon an article, that referred to a study about etch and bond times in dental practices. The study revealed, that the avarage time dentists spend on a 30 second procedure (enamel etching and dentin bonding) was 12 seconds!......


I belived I was spending enough time during each step of my bonding procedure. I guess I don't have to mention - I wasn't. Over the years I have convinced a lot of colleagues to try using a stop watch. Most times the experience results in changes in their bonding procedures.

I guess it is just part of human nature. At least in a dental practice.


Improved workflow

My team and I dissected our entire workflow and started improving each element so that we could deliver better clinical outcomes and thereby reduce expensive chair time spend on reworks.


It is important for me to mention, that the workflow has to be simple and efficient. If it becomes too difficult to handle, too time consuming or too academically in its design. It will fail in 98% of all practices.


Below you will find the workflow that I find works seemless in almost any practice. Wether it is the dentist or a team member performing the attachment bonding procedure.


11 step attachment bonding protocol


  1. Place a drytip in each cheek.

  2. Place an Ivoclar optragate on top of the drytips for isolation and easier mounting of attachments.

  3. Sandblast ALL enamel surfaces to be bonded.

  4. Acid etch the enamel for a MINIMUM of 30 seconds with 30% phosphoric acid (use a stopwatch!)

  5. Bonding is applied for a MINIMUM of 10 seconds. (use stopwatch!)

  6. DO NOT allow moisture to reach the enamel at any point during the procedure after the acid has been rinsed away.

  7. Use a compost with a high filler content. It's easier to manage to avoid excess.

  8. Insert the template and seat it perfectly onto the teeth.

  9. Keep the template in place while light curing every attachment for at least 10 seconds. (Depending on the curing light you have in your practice)

  10. Use a sturdy instrument to "pop off" the template from the composite before gently removing the template starting in the most posterior area.

  11. Inspect the template for any remnants of composite every time you use a different type of composite (some types of composite may bond chemically to the template)


Attachment template

It's worth noting that all aligner systems work with a template, which is used to bond attachments/engagers to the teeth. The template is made of a significantly more flexible, often in a thinner material than the material the aligners are made of.


This is because it makes it significantly easier to remove the plastic template from the teeth than an aligner made from a much thicker material used for the same purpose.


Should the template break during removal. It is usually no big deal as it has no use after the attachments have been bonded to the teeth.


Clinical tip

Some patients produce a lot of saliva. This can create some challenges keeping the teeth dry in the mandible.


Cutting the template in half between the central incisors, will enable you to bond the attachements in one side at a time.


Debonding of attachments

Sometimes dentists get frustrated when they see their attachments detach from the tooth surface and fall off.


Some dentists find that this already happens when the template is removed from the teeth.


When this happens

  1. Inspect the template and the teeth. If there are remnants of composite sitting in the template and correspondingly on the tooth surface. This could indicate that the composite you are using is bonding directly to your template material.

  2. If all the composite is in your template, it's definitely because the bonding protocol has not been followed (either the times have not been adhered to, aprismatic enamel prevents optimal bonding, or saliva has contaminated the area during the procedure)

We recommend sandblasting teeth that are to have attachments/engagers bonded because sandblasting removes aprismatic enamel and increases the bond strength to the enamel.


A stopwatch is recommended when etching the enamel.

30 seconds is a long time for most dentists.

This is probably why the average etching time for a dentist is 12 seconds.

With only 12 seconds of etching the bond strength will be seriously affected.

Conclusion

In wrapping up this post, my aim is to equip you with the knowledge to navigate clear aligner attachment bonding more smoothly in the future.


If you encounter challenges along the way, remember not to be overly critical of yourself. Bonding composite to enamel presents intricate challenges within a challenging workspace, leaving little margin for error.


Mistakes are a part of the learning process; the key is to glean insights from them.

I trust that this blog post has provided valuable lessons from my experiences, empowering you in your journey ahead.


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Jesper Hatt DDS smiling to the camera

Kind regards

Jesper Hatt DDS



Phone: +41 78 268 0078



AlignerService conists of dentists helping dentists create realistic, safe and predictable treatment plans with clear aligners.


Currently, we help approximately 1500 dental practices in 19 different countries. AlignerService is a preferred partner of ClearCorrect.

In addition AlignerService offers treatment planning services with Invisalign, SureSmile, Angel Aligners and Spark.

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