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| Year : 2012 | Volume
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| Issue : 2 | Page : 230-235 |
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| The effect of air abrasion on the retention of metallic brackets bonded to fluorosed enamel surface |
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S Suma1, G Anita2, BR Chandra Shekar3, Amitabh Kallury4
1 Department of Orthodontics, People’s Dental Academy, Bhanpur, Bhopal, Madhya Pradesh, India
2 Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Nalgonda District, Andhra Pradesh, India
3 Department of Public Health Dentistry, People’s Dental Academy, Bhanpur, Bhopal, Madhya Pradesh, India
4 Department of Orthodontics, People’s Dental Academy, Bhanpur, Bhopal, Madhya Pradesh, India
Click here for correspondence address and email
| Date of Submission | 04-Mar-2011 |
| Date of Decision | 01-Jun-2011 |
| Date of Acceptance | 30-Jan-2012 |
| Date of Web Publication | 3-Sep-2012 |
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 Abstract | | |
Background: Bonding brackets to fluorosed enamel remains a clinical challenge and bracket failure at the compromised enamel interface is common.
Objective: To check the effect of air abrasion on the retention of metallic brackets bonded to fluorosed enamel surface.
Materials and Methods: Sixty freshly extracted human premolar teeth having moderate to severe dental fluorosis as per Dean's criteria were collected and divided into three groups of 20 each. The groups were treated as follows: In group I, acid etching was followed by bonding with Transbond XT® ; in group II, sandblasting and acid etching was followed by bonding with Transbond XT® ; and in group III, sandblasting and acid etching was followed by bonding with Enlight LC® . An Instron™ universal testing machine was used for determining the debonding force, and from this the shear bond strength was computed. The sample with highest shear bond strength from each group was selected for the scanning electron microscopy (SEM) study. The prepared specimens were examined under a JSM-840A scanning electron microscope (JEOL Ltd, Tokyo, Japan) operated at 20 kV. Photographs were taken at progressively higher magnifications of ×50, ×100, ×500, and ×1000 to view the enamel surface and the adhesive remaining on the enamel surface after debonding. The shear bond strengths of the groups were compared using the one-way ANOVA (analysis of variance) and Tukey post hoc test. The distribution of adhesive remnant index (ARI) score was compared using the Chi-square test.
Results: The mean shear bond strength in group I was 10.36 MPa, with a standard deviation of 0.225. The corresponding values in group II and group III were 11.41±0.237 MPa and 11.39±0.201 Mpa, respectively. There was a statistically significant difference between the three groups in the mean shear bond strength values.
Conclusion: Sandblasting followed by acid etching provides significantly higher bond strength values compared to acid etching alone, irrespective of the bonding material employed. Keywords: Acid etching, adhesive remnant index, fluorosed enamel surface, sandblasting, scanning electron microscopy, shear bond strength
How to cite this article:
Suma S, Anita G, Chandra Shekar B R, Kallury A. The effect of air abrasion on the retention of metallic brackets bonded to fluorosed enamel surface. Indian J Dent Res 2012;23:230-5 |
How to cite this URL:
Suma S, Anita G, Chandra Shekar B R, Kallury A. The effect of air abrasion on the retention of metallic brackets bonded to fluorosed enamel surface. Indian J Dent Res [serial online] 2012 [cited 2023 Mar 22];23:230-5. Available from: https://www.ijdr.in/text.asp?2012/23/2/230/100432 |
Bonding of orthodontic attachments to enamel has been in use for over 50 years. Few aspects of orthodontics have received as much attention as the bonding of orthodontic brackets to the enamel surface of the teeth. The advent of this system brought about a radical change in the concept of orthodontic attachment procedure. [1] The development of the acid-etch technique by Buonocore (1955) led to the direct bonding of orthodontic brackets with composite resin. This development further led to improvements in orthodontic treatment, with greater comfort to the patient, elimination of pretreatment separation, decrease in gingival irritation, easier maintenance of oral hygiene, improved esthetics, and reduced chairside time. [2],[3]
Zachrisson and Buyukyimaz [4] found that the technique of sandblasting improved retention and increased bond strength to gold, porcelain, and amalgam. The success of the sandblasting technique currently used in orthodontics, as well as in other areas of dentistry, suggests that sandblasting the enamel directly is a feasible technique for preparing teeth before bonding and for increasing bond strength. [5]
Bonding brackets to fluorosed enamel remains a clinical challenge because of frequent bracket failure at the compromised enamel interface. [6] Fluorosis manifests itself as defects in subsurface enamel, with white to brown discoloration and the presence of pits and irregular white opaque lines, striations, or cloudy areas, which exacerbate the problem of bonding to the enamel. Bracket failure occurs as it is difficult to etch the outer enamel surface of fluorosed teeth, which is hypermineralized and acid resistant. Some scanning electron microscope (SEM) studies have confirmed the difficulty of bonding. This may be attributed to the inability to effectively etch fluorosed enamel with 37% phosphoric acid, which results in a decreased amount of enamel irregularity and thus prevents effective bonding. [6] Restorative dentists have also found bonding of veneers and laminates to fluorosed teeth to be problematic.
Many parts of India are endemic for fluorosis. Nalgonda district of Andhra Pradesh is one such area, where the concentration of fluoride in the drinking water ranges from 1.5-5 ppm in some regions [7],[8],[9],[10] to as high as 31.3 ppm in others. [11] Orthodontists practicing in endemic fluorosis belts are constantly faced with the problem of achieving optimal bond strength and durable bonding, which ultimately has to be overcome in order to obtain favorable end results in their patients.
The literature on the efficiency of bonding to fluorosed enamel with acid etching alone and in combination with air abrasion in India is very limited. Hence, the present study makes an attempt to evaluate the effect of air abrasion on the retention of metallic orthodontic brackets bonded to fluorosed enamel surface and also to compare shear bond strength with the use of different types of bonding materials.
| Materials and Methods | |  |
Selection of teeth
Sixty freshly extracted human premolar teeth were selected for the study from patients undergoing orthodontic extractions in the department of Oral and Maxillofacial Surgery, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda district; all patients had moderate to severe dental fluorosis as per Dean's criteria (WHO, 1997) [12] for assessing the severity of dental fluorosis. The selected teeth had intact buccal and lingual surfaces, without any cracks or chipping that might have occurred during extraction. Teeth having cracks, evidence of dental caries, or a Dean's fluorosis index score of less than 3 (0 = normal, 0.5 = questionable fluorosis, 1 = very mild fluorosis, 2 = mild fluorosis) were not included in the sample. The teeth were thoroughly cleaned under running water to remove any soft tissue debris or blood and were stored immediately in distilled water at room temperature.
Preparation of sample specimens
Mounting of specimens and color coding of groups
The selected teeth were mounted using cold-cure acrylic resin in uniform-sized metal rings of 1.5-inch diameter. The teeth were mounted in such a way that the buccal surfaces of the teeth were parallel to the direction of force application during the process of testing the shear bond force, or perpendicular to the central axis of the metal ring. The apical one-third of the root surface was covered with acrylic to enhance retention of the teeth. The mounted teeth were checked by a dental surveyor for parallelism. The mounted specimens were divided into three groups of 20 samples each and these groups were color coded. The teeth in each of these groups were numbered for easy identification and data recording. Coloring and tooth numbering for all the specimens was done on the outer surface of the metallic ring.
Bonding of brackets to the sample teeth
Two different types adhesives [Transbond XT® (3M Unitek, USA) and Enlight LC® (Ormco, Italy)], an intraoral sandblaster MicroEtcher TM ERC (Danville Materials, San Ramon, CA), and sixty premolar brackets (0.022-inch PEA Roth brackets, Gemini series, 3M Unitek) with a base surface area of 9.806 mm 2 were used for bonding the brackets.
- Group I: Acid etching followed by bonding with Transbond XT® (blue): The buccal surfaces of the premolar teeth in this group were acid etched with 37% phosphoric acid for 15 seconds, thoroughly rinsed with water using a three-way syringe for 30 seconds, and then dried with compressed air for 20 seconds. On the prepared enamel surface, a thin coating of the primer was first applied with a brush. Then Transbond XT® light-cure adhesive was put on the bracket base and the bracket was firmly pushed on to the enamel surface with sufficient pressure to express out the excess adhesive. Care was taken to remove the excess adhesive around the brackets with a probe.
- Group II: Sandblasting and acid etching followed by bonding with Transbond XT® (green): The buccal surfaces of the specimens in this group were subjected to sandblasting followed by acid etching. The sandblasting was done with 50-μm aluminium oxide, using the intraoral sandblaster (MicroEtcher TM ERC; Danville Materials, San Ramon, CA). The sandblasting was done for 5 seconds, at 80 psi, and with nozzle distance of 10 mm and angulation of 45°. After sandblasting, the teeth surfaces were cleaned with compressed air to remove the sandblasting powder. This was followed by acid etching with 37% phosphoric acid gel for 60 seconds, after which the teeth were thoroughly rinsed with water for 30 seconds using a three-way syringe and then dried with compressed air. On the prepared enamel surface, the bracket was bonded using Transbond XT® light-cure adhesive as described earlier.
- Group III: Sandblasting and acid etching followed by bonding with Enlight LC® (white): The buccal enamel surfaces of the specimens in this group were first sandblasted with 50-μm aluminium oxide and then etched with 37% phosphoric acid as described previously. On the prepared enamel surface, the bonding of bracket was done using Enlight LC® light-cure adhesive, following the same procedure detailed earlier.
Measurement of shear bond strength
An Instron™ universal testing machine (Model number 4467) was used for determining the bond strength in all the three groups. For shear testing, the prepared metal ring was fixed to the metal framework with a central circular opening of 1.5 inches diameter, which in turn was secured in the lower jaw with the long axis of the tooth and the bracket base parallel to the direction of the shear force applied. A loop was made using 23-gauge stainless steel wire, and the ends of the wire were gripped in another metal framework with a hook (to secure the stainless steel wire), which in turn was fixed to the upper jaw. The specimens were stressed in an occlusogingival direction with a uniform crosshead speed. The maximum force necessary to debond or initiate bracket fracture was noted in Newtons. The shear bond strength in mega Pascals (MPa) was computed as a ratio of force in Newtons to the surface area of the bracket (9.806 mm 2 ).
Data recording
A data collection sheet was used to record the information on shear bond strengths for all the teeth in each of the three color-coded groups. The evaluator testing the shear bond strength was blinded regarding the group allocation of the teeth.
Scanning electron microscopy (SEM) and adhesive remnant index (ARI)
The tooth with the highest shear bond strength from each group was selected, for the SEM study. The crowns were sectioned from roots with a carborundum disc using water spray at the labial cementoenamel junction. Each crown was sectioned vertically in the labiolingual direction. The sections of the teeth were cleaned with water and dried with compressed air. All specimens were mounted on carbon stubs and prepared for SEM study by sputtering with gold/palladium in a high-vacuum evaporator (JFC 1100E ion sputtering device, JEOL Ltd., Tokyo, Japan) for 6 minutes. They were examined in a JSM-840A SEM (JEOL Ltd, Tokyo, Japan) operated at 20 kV. Photographs were taken at progressively higher magnifications of ×50, ×100, ×500 and ×1000 to view the enamel surface and the adhesive remaining on the enamel surface after debonding. The amount of adhesive remaining on the tooth surface was scored using the criteria of adhesive remnant index, [13] as follows:
0. No adhesive remaining on the tooth surface
1. Less than half of the enamel bonding site covered with adhesive
2. More than half of the enamel bonding site covered with adhesive
3. The enamel bonding site entirely covered with adhesive
Statistical analysis
The Kolmogorov-Smirnov Z test was performed to check the normality for shear bond strength and ARI scores. One-way analysis of variance (ANOVA) was used to test the difference in shear bond strength between different groups. Whenever, ANOVA yielded significant result, the pair-wise comparison was done using the Tukey post hoc test. The distribution of ARI scores in different groups was analyzed using the chi-square test. Statistical significance was fixed at P=.05.
| Results | | |
The test distribution was found to be normal, with P values .003 and .001, respectively, for shear bond strength and ARI scores (Kolmogorov-Smirnov Z test).
Mean shear bond strength
The highest mean shear bond strength on debonding was found in group II (sandblasting and acid etching followed by bonding with Transbond XT® ), where the mean value was 11.41±0.237 MPa (SD); this was followed by group III (sandblasting and acid etching followed by bonding with Enlight LC® ), with mean shear bond strength of 11.39±0.201 MPa. Group I (acid etching followed by bonding with Transbond XT® ) had the lowest mean shear bond strength on debonding (10.36±0.225 MPa). The differences were statistically significant (P<.0001, [Table 1]). The post hoc Tukey HSD test done for pair-wise comparison between the three groups revealed a statistically significant difference in the mean shear bond strength between group I and group II as well as between group I and group III (P<.001). There was no statistically significant difference in the mean shear bond strength between group II and group III [Table 2]. | Table 2: Pair-wise comparison of mean shear bond strength in the three groups
Click here to view |
Comparison of adhesive remnant index scores between three groups
In group I, 20% of the samples had ARI score of 0 (adhesive mode of bond failure) and 80% of the samples had ARI scores between 1 and 2 (adhesive-cohesive mode of bond failure). None of the samples in group I had ARI score of 3 (cohesive mode of bond failure). In group II, 75% of the samples had ARI scores between 1 and 2 (adhesive-cohesive mode of bond failure) and 25% of the samples had an ARI score of 3 (cohesive mode of bond failure). In group III, 75% of the samples had ARI scores between 1 and 2 (adhesive-cohesive mode of bond failure) and the remaining 25% of the samples had an ARI score of 3 (cohesive mode of bond failure). None of the samples in group II and group III had an ARI score of 0 (adhesive mode of bond failure). The difference in the distribution of the ARI scores between the three groups was statistically significant (P<.0001) [Table 3]. | Table 3: Distribution of adhesive remnant index (ARI) score among the three groups
Click here to view |
Scanning electron microscopy (SEM)
The sample selected from group I for the SEM study had an ARI score of 1, indicating that on debonding less than half of the enamel bonding site was covered with adhesive. The samples selected from group II and group III for the SEM study had an ARI score of 3, meaning that on debonding the enamel bonding site was entirely covered with adhesive. The SEM pictures of the three test samples from different groups viewed at magnifications of ×50, ×100, ×500, and ×1000 are shown in [Figure 1].
| Discussion | | |
Bonding brackets to fluorosed teeth remains a clinical challenge because of frequent bracket failure at the compromised enamel interface. The bonding of brackets to fluorosed enamel surface challenges orthodontists even more than bonding them to gold, amalgam, and porcelain. [14] Studies have demonstrated the uncertainties in predicting how a fluorosed tooth will be etched. [15],[16] Clinicians have therefore frequently relied on micro-mechanical etching of fluorosed teeth to obtain a roughened surface. It has been suggested that microabrasion of fluorosed enamel with concomitant acid etching improves bond strength. [14],[17],[18],[19],[20] Acid etching results in modifications of the organic matter and decalcification of the inorganic component of enamel. Acid etching is a form of microetching, whereas sandblasting can be regarded as a form of macroetching. Chung et al.[21] used sandblasting to remove unfavorable oxide and contaminants, and the resulting increased surface roughness proved convenient for bonding; this was noted in other studies as well. [22],[23],[24],[25],[26] Studies from India determining the shear bond strengths on fluorosed enamel following different methods of enamel preparations are scanty. The present study makes an attempt to determine the effect of air abrasion on retention of metallic brackets on fluorosed enamel.
Our study revealed higher shear bond strength in groups II and III, where the enamel preparation was done with sandblasting followed by acid etching, as compared to group I, where enamel preparation was done with acid etching alone. The study found no statistically significant difference in shear bond strength between group II and group III, both of which used the same method of enamel preparation but two different adhesive systems for bonding the brackets. This confirms the fact that the combination of sandblasting with acid etching provides greater shear bond strength than acid etching alone, regardless of the adhesive system used.
Karen et al.[27] compared four methods of enamel preparations before orthodontic bonding. In their study, in group A, the surfaces were sandblasted with 50-μm aluminium oxide at 65-70 psi for 2-3 seconds; acid etching was not done. In group B, the surfaces were sandblasted with 50-μm aluminium oxide at 65-70 psi for 2-3 seconds and then acid etched for 30 seconds. In group C, the surfaces were buffed with a 1172 fluted bur at slow speed and then acid etched for 30 seconds. In group D, the surfaces were pumiced for 10 seconds, followed by acid etching for 30 seconds. Sandblasting without acid etching produced lower bond strengths than sandblasting followed by acid etching. The greatest debonding force was achieved by sandblasting before acid etching. The results of our study were in agreement with the findings of this study.
Borsatto et al.[28] compared the shear bond strength of enamel surface treated with air abrasion or acid etching, or a combination of both acid etching and air abrasion. In group I, the enamel was conditioned with 37% phosphoric acid gel for 15 seconds. In group II, the enamel surfaces were treated with an air-abrasive system, using 27.5-μm aluminium oxide particles at 60 psi air pressure for 10 seconds at a distance of 2 mm. In group III, the enamel surfaces were treated with a combination of aluminium oxide jet and 37% phosphoric acid gel. Bonding was carried out by using a hybrid light-activated resin (Z-100™, 9CX, 3M) cured for 40 seconds. Air abrasion with aluminium oxide combined with acid etching provided the highest shear bond strength value, which was similar to that found in group II and group III in our study.
Canay et al.[5] compared the conventional acid-etch technique with an air-abrasion surface preparation technique. In their study, the teeth were randomly divided into four groups: (1) acid etching with 37% phosphoric acid for 15 seconds, followed by rinsing with water and drying with oil-free air; (2) sandblasting with 50-μm aluminium oxide using a microetcher, followed by cleaning with compressed air; (3) polishing with pumice, followed by acid etching with 37% phosphoric acid for 15 seconds, rinsing with water, and drying with oil-free air; and (4) sandblasting with 50-μm aluminium oxide using a microetcher, followed by acid etching with 37% phosphoric acid for 15 seconds. All groups had stainless steel brackets bonded to the buccal surface of each tooth with no-mix adhesive. The lowest bracket strength was seen when sandblasting alone was done. Sandblasting followed by acid etching produced significantly higher bond strength values compared to the other three groups. The pattern of bond failure indicated that all specimens that were only sandblasted debonded totally at the tooth/resin interface. In the sandblasting-only group, there was 100% adhesive remaining at the base of the bracket suggesting a lower mean bond strength. This study showed that sandblasting should be followed by acid etching to produce enamel surfaces with adequate bond strength. Sandblasting alone results in a significantly low bond strength and the technique should not be advocated for clinical use as an enamel conditioner. The bond strength in group 4 of this study was comparable with the bond strengths noted in group II and group III of our study, where we employed the same method of enamel preparation.
| Summary and Conclusion | | |
The present study attempted to find out the effect of air abrasion on the retention of bonded metallic orthodontic brackets on fluorosed enamel surface. The highest mean shear bond strength on debonding was found in group II (sandblasting and acid etching followed by bonding with Transbond XT® ); this was followed by group III (sandblasting and acid etching followed by bonding with Enlight LC® ). Group I (acid etching followed by bonding with Transbond XT® ) had the lowest mean shear bond strength on debonding. In group I, 20% of the samples had an adhesive mode of bond failure and 80% of the samples had an adhesive-cohesive mode of bond failure. In group II, 75% of the samples had an adhesive-cohesive mode of bond failure and 25% of the samples had a cohesive mode of bond failure. In group III, 75% of the samples had an adhesive-cohesive mode of bond failure and the remaining 25% of the samples had a cohesive mode of bond failure.
We can conclude that the combination of sandblasting followed by acid etching produces higher bond strengths on fluorosed enamel surfaces than acid etching alone, irrespective of the adhesive system used. However, this was an in vitro study, and although all possible efforts have been made to simulate the clinical situation, in vitro studies can at best be used to rank performance and give an indication of likely clinical performance. Further in vivo studies are required to validate the conclusions of the present study. While conducting in vivo studies, the tooth surface preparation with sandblasting should be done with proper care. The instrument should be held at a distance of around 4-5 mm from the tooth surface and at an angulation of 60° for anterior smooth surfaces, 80° for posterior smooth surfaces, and 90° for occlusal surfaces. A constant circular motion, with an exposure time of 30-60 seconds should be used. [29] The operator should consider the use of a mask and protective eyewear as the use of the devise generates an aerosol. Protective eyewear should be provided to the patient as well. Any contact lenses should be removed during the procedure. The patient's lip should be lubricated to offer greater comfort during the procedure as sodium bicarbonate employed in sandblasting has a desiccating effect. The operator should be aware of any contraindications on the basis of patient's health history. Though the documented health risks are few, sandblasting should be avoided in patients with respiratory diseases, hypokalemia, chronic diarrhea, renal insufficiency, and patients on long-term steroid therapy or those taking medications that may alter electrolyte balance. Finally, the procedure should be employed with due operating care to avoid unwarranted tissue injury. [29]
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Correspondence Address:
S Suma
Department of Orthodontics, People’s Dental Academy, Bhanpur, Bhopal, Madhya Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.100432
[Figure 1]
[Table 1], [Table 2], [Table 3] |
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| Moshabab A Asiry, Ibrahim AlShahrani, Khalid Abdelaziz, Al Jowharah A Al AlShikh, Wala AlGhamdi, Hajer A Mansour | | The Journal of Contemporary Dental Practice. 2018; 19(7): 762 | | [Pubmed] | [DOI] | | | 11 |
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Surface and interfacial analysis of sandblasted and acid-etched enamel for bonding orthodontic adhesives |
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| Raphael Patcas,Spiros Zinelis,George Eliades,Theodore Eliades | | American Journal of Orthodontics and Dentofacial Orthopedics. 2015; 147(4): S64 | | [Pubmed] | [DOI] | | | 14 |
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Factors Affecting the Shear Bond Strength of Orthodontic Brackets – a Review of In Vitro Studies |
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Effect of lingual enamel sandblasting with aluminum oxide of different particle sizes in combination with phosphoric acid etching on indirect bonding of lingual brackets |
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Shear bond strength of orthodontic brackets to fluorosed enamel |
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