The association between patient’s compliance and age with the bonding failure of orthodontic brackets: a cross-sectional study
Barbosa et al. Progress in Orthodontics
The association between patient's compliance and age with the bonding failure of orthodontic brackets: a cross- sectional study
Isabela Vasconcelos Barbosa
Victor de Miranda Ladewig
Renata Rodrigues Almeida-Pedrin
Mauricio Almeida Cardoso
Joel Ferreira Santiago Junior
Ana Claudia de Castro Ferreira Conti
Background: An efficient orthodontic treatment must aim the best occlusal result in the shortest possible time. One of the factors that can interfere in this goal is the bracket debonding during the treatment. This study aimed at assessing the different factors related to brackets failure, highlighting age and patient cooperation with treatment. Methods: The sample comprised 199 orthodontic patients of both genders (103 women and 96 men); divided into two groups-adolescents (12 to 18 years old, 118 patients) and adults (19 to 59 years old, 81 patients). A questionnaire was applied regarding the motivation of patients to seek treatment and whether they had received information on appliance care; patients also filled out their level of cooperation with treatment in a visual analog scale (VAS). Additionally, other variables were assessed, such as the teeth with bracket debonding, the presence of deep overbite, and the use of bite plate. The Mann-Whitney test was used, and a 5% significance level was applied for analyses. Results: It was observed that 20.1% of patients presented at least one tooth with bracket failure, and the lower arch was the most prevalent site (47.5%). Adolescents presented more debonding (25.4%) than adults (12.3%). Individuals with better VAS scores on cooperation sought treatment on their own (p = 0.042), were adults (p ≤ 0.001), and showed lower rate of failure of brackets (p ≤ 0.001). The factors related to malocclusion and treatment performed had no statistical significance. Conclusion: Greater cooperation was expected from adult individuals who sought treatment on their own and presented low rate of bracket failure.
Motivation; Corrective orthodontics; Malocclusion
All orthodontic advances of the last decade focus on
optimizing the orthodontic treatment. The search for such
efficiency, accounting for protocols for finishing treatment
in less time, but also achieving the best possible outcomes
have guided recent clinical researches. Besides the
treatment duration, replacing brackets requires chair time and
presents high cost, since it is not always possible to
replace the same bracket [
]. This bracket failure may
occur because of several factors, from occlusal trauma to
inappropriate bonding techniques [
Patient motivation for orthodontic treatment arises as
an important factor, especially when considering time
and even quality of the results. When the orthodontist
cannot get the patients to adhere to treatment, they
become less concerned and do not properly follow the
instructions for appliances use and care, increasing the
chances of appliance breakage thus compromising the
treatment outcomes [
]. Moreover, patients that
are less committed to treatment and present higher
bracket failure rate could have longer treatment duration,
a situation that affects patient quality of life, considering
financial and satisfaction aspects [
2, 10, 12, 15, 16
Nowadays, the search for shorter treatment duration
is one of the main objectives of the health care
system due to its implication on a better cost-benefit
]. In this context, the present research aims
to identify the patient profile more susceptible to
appliance breakage. In this way, the professional could
establish more effective protocols to prevent this
problem in those patients.
This cross-sectional study was approved by the Research
Ethics Committee of the (XXXX) University under
protocol #1.090.493. The sample included 199 patients
from 12 to 59 years old, 103 women and 96 men, during
active phase of fixed orthodontic treatment with metallic
brackets, from two post-graduation clinics and two
private orthodontic clinics located in the same city, from
August 2015 to July 2016. Those clinics were chosen
because two faculty members worked in the same
institution and they are the owner of the private clinics, so a
standardized bonding technique was applied for all
patients, which could minimize a potential source of bias.
Patients from all ethnic groups under corrective
orthodontic treatment in this age range who accepted to
participate in the study were included. Patients presenting
some cognition problem that could interfere with the
adequate completion of the questionnaire were excluded.
The main researcher (IBV) instructed and explained to
the patients how to complete the questionnaire correctly
and that the information would be confidential. The
patients who agreed to participate in the research
signed an informed consent form. The researcher
followed patient care, verifying teeth and dental
arches with failure of brackets; the presence and
severity of initial overbite, which was classified when
overbite value was higher than 3 mm; and the use of
bite plate. These data were measured with the
assessment of initial cast models of patients, performed
with the help of a millimeter ruler.
The wide range of patient’s age aimed at evaluating
the influence of age on bracket failure. Based on that,
the patients were divided regarding age, and two groups
were considered: adolescents (12 to 18 years old) and
adults (19 to 59 years old).
A questionnaire composed by five questions was
applied by the same researcher (IBV) without any
interference for each patient as follows:
1. How old are you:
2. Mark your gender: a) Male b)Female
3. Did you seek orthodontic treatment: a) By your
own initiative; b) Referred by another dentist; c)
Because of a friend or relative
4. 4-When you started treatment did you receive any
information about your diet in order to prevent
brackets failure? a) yes; b) no; c) I don’t know
5. Do you consider yourself a collaborating patient
following the instructions to avoid brackets failure?
a) yes; b) no; c) I don’t know
Another parameter assessed was the phase of
orthodontic treatment (in months) of the patient at the
moment of assessment relative to the initial date of the
corrective treatment. The patients were also instructed
to report their level of cooperation with treatment,
which was assessed by means of the visual analog scale
(VAS). This scale was defined as a 100-mm line, where
zero at the leftmost end indicated the less cooperation
level, and the opposite end, on the right, indicated the
best possible cooperation. The patients were instructed
to mark a vertical stripe between the left and right ends
of the line to indicate their scores of cooperation.
The overall bracket failure rate of the whole sample was
assessed. These data regarding bracket failure rate was
associated with patients’ age, gender, reported level of
cooperation, and the patient motivation to seek treatment.
Besides that the bracket failure were also analyzed
according to the dental arch more affected and the presence or
absence of deep overbite and the use of bite plate.
Statistical analysis Data obtained were organized in an
Excel table (Microsoft Office Excel, Redmond, WA,
USA) and were subjected to the SigmaPlot software
(SigmaPlot, San Jose, CA, USA) version 12.0. The
ShapiroWilk test was applied to verify wheter data presented
normal distribution. As they did not, the Mann-Whitney
test was used. For all statistical analyses, a 5%
significance level was adopted.
Power analysis showed that a sample size of at least 199
patients would give an 100% (α = 1.0) probability of
detecting a real difference between groups: mean 11.65 or
median 16.4 (based on the scores from VAS regarding
treatment cooperation and bracket failure) at a
statistically significant level of 5%.
From 199 patients, 40 (20%) presented failure of
brackets (Table 1). The lower arch was more affected
than the upper arch (9.5 and 7.5%, respectively).
Additionally, 3% of individuals assessed presented failure of
brackets in both arches (Table 1).
An analysis on treatment sites in educational or
private institutions found no significant difference in the
effect of bracket breakage by patients, p = 0.499. Similarly,
the presence or absence of deep overbite (p = 0.922) and
the use of bite plate (p = 0.908) were not statistically
significant (Table 2).
p = 0.097
There was also no significant difference in the
failure of brackets when considering patient gender, p =
0.097 (Table 3).
On the other hand, an analysis on whether age
(adolescent or adult) could influence bracket breakage
showed that adolescents presented more breakage than
adults, and the comparison was statistically significant,
p = 0.02 (Table 4).
Regarding cooperation, which was investigated as a
self-report of patients on the VAS score, it was found
that the group without bracket failure presented the
highest score (median 74.4) when compared to the
group with breakage (median 58.00), p ≤ 0.001 (Fig. 1).
An analysis of patient motivation (own initiative or
referred by others) found no significant difference regarding
bracket breakage, p = 0.596 (Fig. 2). However, a significant
difference was identified for the VAS (p = 0.042),
indicating that the group that sought treatment on their own
presented higher scores (median: 75.4) than the group
referred to orthodontic treatment (median 68.6).
Still regarding the VAS, it was observed that adult
patients presented higher scores (median: 82.2) than
adolescents (median 64.5), with p ≤ 0.001, showing that
adults report themselves as more cooperative with
treatment than younger individuals.
Patient motivation represents an important factor for
orthodontic treatment success, and it is directly
associated with patient cooperation regarding care and hygiene
instructions provided by the orthodontist. A high level
of motivation may decrease brackets failure, a common
problem observed in the orthodontic practice that may
causes great treatment delays [
2, 10, 13, 15–17
]. Robb et
al. (1998)  reported that treatment duration changes
up to 46% are related to bracket failure. Literature
showed that an increase of 0.3 to 0.6 times in treatment
duration could be attributed to each bracket failure
Understanding the type of patients who mostly present
bracket breakage and the most prevalent arches and tooth
could help the orthodontist to prevent this situation.
Therefore, this research included an extensive sample of
199 individuals, which allowed observing the profile of
patients who presented more failures during orthodontic
treatment, as well as the most affected teeth.
It was found that 20% of patients from the sample
presented some bracket breakage at the moment of
assessment (Table 1). The literature shows a great variation in
the prevalence of failure—from 3.5 to 23%—due to the
different variables that may be considered [
When assessing distribution per arch (Table 1), we
found a higher bracket failure rate in the lower arch (9.
5%), and this result agrees with previous studies [
1, 5, 9,
]. The challenge in maintaining the lower arch dry
during bracket bonding, the higher initial crowding, and
the occlusal interference may be the causes of greater
1, 17, 20
Overall, considering the areas and teeth more
susceptible to breakage and failure, the professional may
perform carefully the bonding procedure in these areas,
preventing contamination with saliva and placing the
bracket without occlusion interference.
In order to verify the level of patient cooperation
regarding the instructions received, the VAS was used. A
simple method that is easily understood and applicable
by evaluators [
]. It was observed that the group of
patients that presented bracket breakage (Fig. 1) showed
a lower VAS score (median 58.0) than the group without
breakage (median 74.4). These data are in accordance
with the literature, which states that the number of
brackets lost during treatment is inversely related to
patient cooperation [
Motivation becomes an important factor for great
treatment outcomes. This characteristic may be
observed even before therapy, when the individual decides
to initiate treatment. This motivation may be described
as either external, resulting from the pressure from
friends or family members, or internal, resulting from a
personal desire. This definition is important considering
that it is suggested that patients internally motivated are
more cooperative [
In this research, when assessing patient motivation, we
found that the group that sought treatment on their
own presented higher VAS scores than the group that
was referred by others (Fig. 2). This result could justify
the fact that adult patients present lower breakage rate,
because normally they seek treatment on their own,
while adolescents do it by the indication of parents or
other professionals [
In addition, some authors have observed a reduction
in bracket failure and improvement in treatment
efficiency when interventions with the purpose to improve
patient compliance during orthodontic treatment have
been implemented [
Considering the age group, it was observed that adult
patients presented higher level of cooperation (median
82.2) than adolescents (median 64.5). A study performed
in 2009 reported a correlation between patient
motivation and level of cooperation during orthodontic
treatment, and the most motivated patients were the ones
that better followed the instructions provided by the
]. Accordingly, it was reported that 52%
of adolescent patients do not follow the treatment
instructions provided by the professional [
The aforementioned results could justify the fact that
adult patients presented a lower breakage rate (12.3%)
than adolescents (25.4%) (Table 4). These values agree
with several studies that observed that the incidence of
failure of brackets seems to decrease with age and that
the level of cooperation of adults is higher,
counterbalancing even the greatest mechanical difficulties in their
tooth movements [
1, 13, 16, 17, 25, 27, 28
A limitation of our study comprises the evaluation in
one time point, although the distribution of patients at
various stages of orthodontic treatment could provide an
overview of device breakages. In a future study, a long
period of evaluation should be performed in order to
confirm these findings.
Based on the information above, identifying patients
who need to be more motivated along the treatment is a
task professionals should not neglect. Spending some
time encouraging and motivating patients to increase
their level of cooperation with treatment is as important
as a good treatment plan and execution.
Adult patients, individuals who sought treatment on
their own and those that considered themselves more
cooperative presented lower rate of brackets failure.
Thus, means of motivating patients, especially
adolescents, should be implemented to increase their
cooperation and optimize the orthodontic treatment.
VAS: Visual analog scale
IVB, VML, MAC, and JFSJ contributed to the concepts. IVB, VML, and MAC
helped in the design. VML contributed to the definition of intellectual
content. IVB, VML, VML, MAC, and ACCFC carried out the literature search.
IVB, VML, and VML helped in the data acquisition. MAC, JFSJ, and ACCFC
participated in the data analysis. JFSJ and ACCFC helped in the statistical
analysis. IVB, VML, VML, and ACCFC prepared the manuscript. VML, VML, and
ACCFC edited the manuscript. VML, MAC, and ACCFC reviewed the
manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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