SPECIAL ARTICLE
Orthodontics in 3 millennia. Chapter 16: Late
20th-century fixed appliances
Norman Wahl
Sequim, Wash
Ever since Edward Angle introduced his edgewise appliance in 1925, orthodontic innovators have been
working to improve on not only its original design, but also the method of attachment. Our “strap-ups” have
evolved from banding to bonding, from labial to lingual, and from metallic to clear. But, as Angle would be
pleased to learn, we still call it edgewise. (Am J Orthod Dentofacial Orthop 2008;134:827-30)
I
n Chapters 5 and 6, we learned that the ribbon arch advantage of these winged brackets over the twin is that
(Angle), the edgewise (Angle), the twin wire they do not reduce the interbracket span or impede the
(Johnson), the Begg, and the universal (Atkinson) activation of closing loops.4
were the principal types of brackets in the first half of
the 20th century. Although this chapter will be confined Preadusted brackets
to a discussion of the bracket (specifically the edgewise Several attempts at “building treatment into the
and its derivatives), the bracket does not exist in appliance,” a phrase coined by Joseph R. Jarabak
isolation from its system or technique (edgewise tech- (1906-89),5 were made in the first half of the 20th
nique, universal technique, and so on). The orthodontic century. It was recommended by Angle6 as early as
bracket’s sole purpose is to transmit forces from a 1928. Glendon Terwilliger was one of the first to
traction device, usually an archwire, to the tooth. Thus, attempt soldering brackets into tip and torque posi-
before the invention of enamel bonding, the 4 elements tions.7 Holdaway (1952)8 suggested that the brackets in
of an orthodontic appliance were the band, the bracket, the mandibular buccal segments could be angulated by
the archwire, and the ligature. All the brackets in the an amount proportional to the severity of the malocclu-
following discussion are modifications of the original sion.4 However, in 1959, Ivan F. Lee (1922-) (personal
edgewise design. interview, June 25, 2007) produced a commercially
viable torque bracket for anterior brackets, writing
BRACKETS about it in his thesis for the American Board of
Rotation control Orthodontics. Lee Torque Brackets were marketed by
The narrow width of the original edgewise bracket Unitek (Monrovia, Calif) for about 15 years. At the
limited its ability to control rotation. Soldering eyelets 1960 AAO meeting, Jarabak, with James A. Fizzell,
for this purpose was time-consuming in terms of both demonstrated the first bracket to combine torque and
application and final result, but it was not until mid- angulation.9
century that 2 clinicians brought out different modes of Another 12 years passed before Lawrence F. An-
replacing this chore.1 On the East Coast, Brainerd F. drews10 (1929-) announced an appliance whose brack-
Swain (1911-1999) attached 2 brackets to a single base ets were designed for each tooth so that, on being
and called it the twin, or “Siamese,” bracket. In Seattle, aligned on an unadjusted archwire, the teeth would
Paul D. Lewis (1896-1992)2 soldered curved rotation assume ideal positions. Based on his “six keys to
arms, or “wings,” to a single bracket that contact the normal occlusion,” he called his design the Straight-
inside of the archwire. A modification of the Lewis Wire appliance (“A” Company, San Diego, Calif).5
bracket, designed by Howard M. Lang (1914-94),3 uses Building on the innovations of Lee and Jarabak, An-
straight arms with a hole to increase flexibility and for drews cut the appropriate amount of torque into each
ligature tying. In both devices, the arms can be acti- bracket and also angulated the bracket in relation to its
vated by a simple twist of the pliers. The principal base. It was the first bracket to combine torque,
angulation, in and out, and offset (subsequently modi-
Private practice, Eagle Rock, Calif. fied by Roth11). Unfortunately, the popularity of the
Submitted and accepted, April 2008. term preadjusted appliances caused it to become the
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists. most commonly misused phrase in contemporary orth-
doi:10.1016/j.ajodo.2008.04.016 odontics. Every manufacturer touts its own straight-
827
828 Wahl American Journal of Orthodontics and Dentofacial Orthopedics
December 2008
wire appliance system, regardless of prescription or a seemingly innocuous letter in the American Journal
specifications. Despite widespread use, experience with of Orthodontics and Dentofacial Orthopedics brought
preadjusted brackets has shown that the goals of indi- to light the answer to the question: which experimenter
vidual tooth positions are not always achieved with was actually the first to use a bonded bracket in
straight archwires only and require some wire bending treatment? The controversy began in 1990, when Her-
to achieve ideal results.12 Also, the term straight, as bert I. Cueto21 wrote that his “direct-bonding technique
applied to an archwire, is really a misnomer. Flat or was developed and used for the first time on several
level would be more accurate. patients” in 1966 in the orthodontic department of the
Some claim that preadjusted appliances tend to Eastman Dental Center, using a liquid monomer (methyl-
produce transitional deepening of the overbite during 2-cyanoacrylate) and a silicate filler.
leveling and aligning.13 Kesling14 maintained that pre- Two years later, the February issue of the same
adjusted archwire slots set up more anchorage in the journal carried 2 more “first-bonding” claims: David L.
anterior teeth and makes space closure more difficult. Mitchell,22 in “The first direct bonding in orthodontia,
revisited,” and George V. Newman,23 in “First direct
Narrow slots bonding in orthodontia.” Mitchell, a graduate student at
Although stainless steel had been in use in the early the University of North Carolina in 1959, claimed that
1930s in band material and ligatures, it was not until he had treated 5 patients using at least 1 bonded
1953 that Steiner15 brought out the first .018 ⫻ .022-in bracket; this became the basis for his master’s thesis.
bracket to accommodate a like-dimension, stainless- He failed to report it in the literature because he was
steel archwire, greatly improving the elasticity (and afraid of being expelled for using acid etch on hu-
comfort) of working wires. mans.22
This reluctance kept direct bonding from being
Esthetic brackets widely accepted by the specialty until the late 1970s.
In 1963, Morton Cohen and Elliott Silverman16 The matter was apparently put to rest when Newman23
brought out the first commercially available plastic showed photographs of patients dating back to the
brackets (IPB, GAC International, Bohemia, NY). The 1950s in whom he had bonded clear acrylic laminates
ceramic bracket was commercially introduced in 1987.4 carved by hand from either Plexiglas (Rohm & Haas,
Ceramic brackets have some drawbacks: enamel dam- Philadelphia, Pa) or polycarbonate rods, using a cold-
age during debonding, enamel cracking due to silane cure acrylic-type (later, epoxy) adhesive.
coatings on the base, and bracket wing fracture from
the brittle nature of alumina. Plastic brackets also have ADHESIVES MATURE
drawbacks: distortion and color absorption. Both have Since the middle 1960s, researchers have tried other
greater frictional resistance than metal brackets. In the materials to improve on Newman’s acrylic, because,
1990s, these deficiencies were overcome with design first, it could be used only on the maxillary anterior
modifications and the use of reinforced polycarbonate teeth; second, forces generated by rectangular wires
(for plastic) and polycrystalline alumina (for ceramic) caused many bracket failures; and third, too much time
and the addition of a metallic slot.17 was involved in the cementing procedure.24 The first
bonding resins were 2-paste, chemical curing. In 1968,
Bonded brackets Smith25 introduced a polyacrylate (carboxylate) (Dure-
Direct bonding of orthodontic attachments was lon, 3M ESPE, St Paul, Minn). In 1970, Retief de-
probably the most significant development in clinical scribed an epoxy resin system designed to withstand
orthodontics in the second half of the 20th century.18 orthodontic forces.26
The first bonding agent for restorative dentistry, Sevri- As new adhesives, composite resins, and bonding
ton Cavity Seal (Cavity Seal, London, United King- techniques were introduced to restorative dentistry,
dom), was formulated in 1949 by Oskar Hagger, a orthodontists, always looking for innovations from
Swiss chemist working in London, using glycerophos- other scientists, adopted some of these innovations
phoric acid dimethacrylate, an unfilled acrylic resin.19 for their bonding armamentarium. In 1962, bis-
In 1955, Buonocore,20 borrowing the techniques of phenol A glycidyl methacrylate (BIS-GMA) resins
industrial bonding, enhanced the adhesion with the were introduced by Rafael Brown as dental adhesives
phosphoric acid etch. and later applied in orthodontic practice.24 These
Buonocore’s work stimulated efforts to experiment include Concise Ortho Adhesive, the first adhesive
with bonding orthodontic attachments to maxillary with a specific orthodontic formulation (1977) (3M
anterior teeth, but it was not until many years later that Unitek); Nuva-Tach (Caulk, Milford, Del); and Pres-
American Journal of Orthodontics and Dentofacial Orthopedics Wahl 829
Volume 134, Number 6
tige and Restodent (both from Lee Pharmaceuticals, The acid-etched-composite technique has become
South El Monte, Calif). A mixture of BIS-GMA (a the most widely adopted bonding system in contempo-
viscous liquid) with an aliphatic diacrylate (to make rary orthodontic practice, but the system still has some
the adhesive more fluid) is now the most widely used shortcomings, such as loss of enamel after acid etch-
resin.27 ing,36 enamel damage caused by postdebonding clean-
Improvements in composite resins included no-mix up,37 and enamel fracture, particularly with ceramic
adhesives, altered filler packing, higher filler levels, and brackets.34,38 Siomka and Powers (1985)39 and New-
hybrid filler particles. These changes enhanced their man et al (1995)40 found that silanation (by Ortho-
mechanical properties, reduced the coefficient of ther- Cycle, Hollywood, Fla) improved the bond strength of
mal expansion, introduced radiopaque materials, re- new meshed brackets by as much as 21%.41 Based on
duced polymerization shrinkage, and improved esthet- Rafael Bowen’s use of a chelating agent, Sunmedical
ics.28 (Shiga, Japan) introduced Superbond, reported to pre-
Initially used as a direct restorative material, glass vent the risk of postdebonding enamel cracks. It also
ionomer cements (GICs) were invented in the late expanded bonding possibilities to metal, ceramic, and
1960s and developed in the early 1970s by Wilson and plastic brackets.42 As a result, even molar bands, the
Kent,29 becoming popular in the late 1980s for cement- last bastion of banding, began to face obsolescence.
ing bands. Whereas the resin-based adhesives depend The first study on light-curing appeared in 1979, but
on mechanical interlocking, GICs provide a chemical it was not until 1993 that the first commercial product
bond and set under moist conditions. GICs such as came on the market (Transbond XT Light Cure, 3M
Ketac (3M Espe) and GC Fuji Plus (GC America, Unitek).43 That same year, Watanabe and Nakaba-
Alsip, Ill) are silicates of chiefly calcium and alumi- yashi44 developed a self-etching primer—an aqueous
num.29 This material releases fluoride and thus might solution of 2% phenyl-P in 30% HEMA (hydroxy-
reduce enamel decalcification around brackets.30 As methyl methacrylate)—for bonding to enamel and den-
such, GICs lack bond strength, but a newly developed, tin simultaneously.
reinforced ionomer cement, or compomer (Fuji II LC, More recent advances include flowable composite
GC Dental Industrial, Tokyo, Japan), has been reported resins and condensable ones that behave clinically like
to exhibit no significant difference in failure rates amalgam. These resins have a higher filler load and
compared with those using composite resin (System 1 improved filler matrix interface and handling proper-
Plus, Ormco, Glendora, Calif).31 ties.28 In another attempt to save chair time with
During WWII, Harry Coover of the Eastman Kodak simpler bonding procedures, Unitek introduced adhe-
Company, while searching for a material for gunsights, sive-precoated brackets (APCs) in 1991. In addition to
discovered cyanoacrylate, the forerunner of Krazy Glue speed and accuracy, Cooper et al45 listed the following
(Toagosei America, Jefferson, Ohio). During the Viet- advantages of APCs over conventional light-cured
nam War, it was used to hold human tissue together. systems: (1) consistent quality and quantity of adhe-
Today, higher molecular weight cyanoacrylates are sive, (2) easier cleanup after bonding, (3) improved
used in liquid bandages.32 A significant advantage of asepsis, (4) reduced waste during bonding, and (5)
cyanoacrylate adhesives (Locktite, Locktite Corp, better inventory control.
Rocky Hill, Conn) is their ability to polymerize as a It has taken half a century for orthodontic bonding
thin film at room temperature with water as a catalyst.33 procedures to evolve from acrylic to chemically cured
Initially given poor marks, cyanoacrylate was found by (2-phase, then 1) to light-cured to dual-cured (chemical ⫹
Krishnan et al34 to provide good bond strength if the light) to moisture-active to APCs. Even the device that
material is kept in a 37°C water bath for 24 hours, even
threatens to replace conventional brackets altogether—the
without enamel etching.
aligner—relies on bonded buttons, so it appears that some
Using a methyl methacrylate (MMA) resin (Or-
form of bonding will be with us for a while. Yet to come:
thomite [now Super Bond, Morita, Tokyo, Japan]) with
the lingual bracket and the innovation second only to
plastic brackets, Miura et al35 were the first to present
bonding in its impact on orthodontic bracketing: the
materials and techniques that have evolved directly into
self-ligating bracket.
current protocol. Nuva-Tach was another early MMA
adhesive. Further MMA adhesives to appear on the The author thanks Claude G. Matasa for his review
market included Ortho-Concise, Transbond (1987), and of the section on adhesives.
Transbond XT (replacing Concise, 1989) (all from 3M Editor’s note: This concludes the series of articles
Unitek). on orthodontic history.
830 Wahl American Journal of Orthodontics and Dentofacial Orthopedics
December 2008
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