Questions on etching

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 The bonding of orthodontic attachments to the etched enamelThe bonding of orthodontic attachments to the etched enamel
surface of teeth is a well-established clinical procedure. There aresurface of teeth is a well-established clinical procedure. There are
at present two techniques for the placement of orthodonticat present two techniques for the placement of orthodontic
attachments.attachments.
 The first is called theThe first is called the direct techniquedirect technique in which the brackets arein which the brackets are
placed directly on the enamel surface by the operator, as wasplaced directly on the enamel surface by the operator, as was
initially described byinitially described by NewmanNewman.. The second method of bracketThe second method of bracket
placement is theplacement is the indirect techniqueindirect technique, which was first described by, which was first described by
Silverman et alSilverman et al..
 In an investigation, that examined the preference of 2000 operatorsIn an investigation, that examined the preference of 2000 operators
for either the direct or the indirect technique of bonding,for either the direct or the indirect technique of bonding, Gore lickGore lick
found that the ratio of direct to indirect as the preferred method wasfound that the ratio of direct to indirect as the preferred method was
13:113:1 ..
 In a clinical trial in which direct and indirect methods wereIn a clinical trial in which direct and indirect methods were
compared, failure rates ofcompared, failure rates of 2% for the direct method2% for the direct method andand 13% for the13% for the
indirect methodindirect method were reported.were reported.

 Apart from this difference in failure rates, the indirect techniqueApart from this difference in failure rates, the indirect technique
was inferior because of the increased time required for bracketwas inferior because of the increased time required for bracket
placement. In addition, there was excess adhesive around theplacement. In addition, there was excess adhesive around the
bracket bases, which was both difficult and time consuming tobracket bases, which was both difficult and time consuming to
remove.remove.
 BondingBonding of orthodontic attachment offers manyof orthodontic attachment offers many advantagesadvantages whenwhen
compared to conventional banding:compared to conventional banding:
 It is esthetically superior.It is esthetically superior.
 It is faster and simple.It is faster and simple.
 There is less discomfort for the patientThere is less discomfort for the patient
 Arch length is not increased by band materialArch length is not increased by band material..
 It allows more precise bracket placement.It allows more precise bracket placement.
 Bonds are more hygienic than bands.Bonds are more hygienic than bands.

 Partially erupted teeth can be controlled.Partially erupted teeth can be controlled.
 Mesiodistal enamel reduction ( proximal reduction) is possible duringMesiodistal enamel reduction ( proximal reduction) is possible during
treatment.treatment.
 Attachments may be bonded to artificial tooth surfaces (eg., amalgam,Attachments may be bonded to artificial tooth surfaces (eg., amalgam,
porcelain, gold) and to fixed bridge work.porcelain, gold) and to fixed bridge work.
 Interproximal areas are accessible for composite buildups.Interproximal areas are accessible for composite buildups.
 Caries risk under loose bands is eliminated.Caries risk under loose bands is eliminated.
 No band spaces are present to close at the end of treatment.No band spaces are present to close at the end of treatment.
 Brackets may be recycled, further reducing the cost.Brackets may be recycled, further reducing the cost.
 Lingual brackets, invisible braces, can be used when patient rejectsLingual brackets, invisible braces, can be used when patient rejects
visible orthodontic appliance.visible orthodontic appliance.

 Disadvantages of Bonding:Disadvantages of Bonding:
 A bonded bracket has a weaker attachment than a cementedA bonded bracket has a weaker attachment than a cemented
band.band.
 Some bonding adhesives are not sufficiently strong.Some bonding adhesives are not sufficiently strong.
 Better access for cleaning does not necessarily guarantee betterBetter access for cleaning does not necessarily guarantee better
oral hygiene and improved gingival condition, especially if excessoral hygiene and improved gingival condition, especially if excess
adhesive extend beyond the bracket baseadhesive extend beyond the bracket base..
 The protection against the inter proximal caries of well contouredThe protection against the inter proximal caries of well contoured
cemented band is absentcemented band is absent..

 Bonding is more complicated when lingual auxiliaries are requiredBonding is more complicated when lingual auxiliaries are required
or where headgears are attached.or where headgears are attached.
 Rebonding a loose bracket requires more preparation thanRebonding a loose bracket requires more preparation than
rebanding a loose band.rebanding a loose band.
 Rebonding is more time consuming than debanding, sinceRebonding is more time consuming than debanding, since
removal of adhesive is more difficult than removal of cement.removal of adhesive is more difficult than removal of cement.

 The steps involved areThe steps involved are
 CLEANINGCLEANING
 ENAMEL CONDITIONINGENAMEL CONDITIONING
 SEALINGSEALING
 BONDINGBONDING

CLEANINGCLEANING
 Cleaning of the teeth with pumice will remove plaque and the organicCleaning of the teeth with pumice will remove plaque and the organic
pellicle.pellicle.
 This requires rotary instruments, either a rubber cup or a polishing brush. AThis requires rotary instruments, either a rubber cup or a polishing brush. A
bristle brush cleans more effectively but care must be taken to avoidbristle brush cleans more effectively but care must be taken to avoid
traumatizing the gingival margin and initiating bleeding.traumatizing the gingival margin and initiating bleeding.
 Studies have shown enamel loss due to prophylaxisStudies have shown enamel loss due to prophylaxis.. Mark Daniel pusMark Daniel pus
et al ( AJO 1980)et al ( AJO 1980) showed that 10.7µm of enamel loss during initialshowed that 10.7µm of enamel loss during initial
prophylaxis with bristle brush was greater than the 5.0µm lost whenprophylaxis with bristle brush was greater than the 5.0µm lost when
a rubber cup as used and the difference was statistically significant.a rubber cup as used and the difference was statistically significant.
 Pumice or a prophylactic paste is often used to clean the enamel surface.Pumice or a prophylactic paste is often used to clean the enamel surface.
Either does not affect bond strengthEither does not affect bond strength..

ENAMEL CONDITIONINGENAMEL CONDITIONING
 MOISTURE CONTROLMOISTURE CONTROL::
 After the rinse, salivary control and maintenance of aAfter the rinse, salivary control and maintenance of a
completely dry working field is absolutely essential.completely dry working field is absolutely essential.
 Lip expanders and / or cheek retractorsLip expanders and / or cheek retractors
 Saliva ejectorsSaliva ejectors
 Tongue guard with bite blocksTongue guard with bite blocks
 Salivary duct obstructorsSalivary duct obstructors
 Gadgets that combine several of these (saliva ejector,Gadgets that combine several of these (saliva ejector,
tongue holder, and bite block).tongue holder, and bite block).
 Cotton or guaze rollsCotton or guaze rolls
 Antisialagogues.Antisialagogues. (Banthine)(Banthine)

ENAMEL PRETREATMENTENAMEL PRETREATMENT
 After the operative field has been isolated, the teeth to be bonded areAfter the operative field has been isolated, the teeth to be bonded are
dried.dried.
 The conditioning solution or gel (The conditioning solution or gel (usually 37% phosphoric acidusually 37% phosphoric acid ) is) is
then lightly applied over the enamel surface with a foam pellet orthen lightly applied over the enamel surface with a foam pellet or
brush for 15 to 60 sec.brush for 15 to 60 sec.
 When etching solutions are used, the surface must be kept moist byWhen etching solutions are used, the surface must be kept moist by
repeated applications. To avoid damaging delicate enamel rods, carerepeated applications. To avoid damaging delicate enamel rods, care
must be taken not to rub the liquid onto the teethmust be taken not to rub the liquid onto the teeth..
 At the end of the etching period the etchant is rinsed off the teeth withAt the end of the etching period the etchant is rinsed off the teeth with
abundant water spray.abundant water spray.
 Salivary contamination of the etched surface must not be allowed. ( IfSalivary contamination of the etched surface must not be allowed. ( If
it occurs rinse with water spray or re - etch for a few seconds; theit occurs rinse with water spray or re - etch for a few seconds; the
patient must not rinse.)patient must not rinse.) www.indiandentalacademy.comwww.indiandentalacademy.com

 Next, teeth are thoroughly dried with moisture and oil- free air sourceNext, teeth are thoroughly dried with moisture and oil- free air source
to obtain the dull frosty appearance.to obtain the dull frosty appearance.
 Teeth that do not appear dull andTeeth that do not appear dull and frosty white should befrosty white should be re- etched.re- etched.
 The effect of acid etching is to remove a small amount of the softerThe effect of acid etching is to remove a small amount of the softer
interprismatic enamel and open up pores between the enamelinterprismatic enamel and open up pores between the enamel
prisms, so the adhesive can penetrate into enamel surface.prisms, so the adhesive can penetrate into enamel surface.

 Should the etch cover the entire facial enamel or only a smallShould the etch cover the entire facial enamel or only a small
portion outside the bracket pad?portion outside the bracket pad?
Clinical experience indicates that etching the entire facialClinical experience indicates that etching the entire facial
enamel with solution is harmless at least when a fluoride mouth rinseenamel with solution is harmless at least when a fluoride mouth rinse
is used regularly.is used regularly.
 Are gels preferable to solution ?Are gels preferable to solution ?
Brannstrom et al (1982)Brannstrom et al (1982) They found one minute etching withThey found one minute etching with
an acid gel had the same effect as etching with an acid liquid for thean acid gel had the same effect as etching with an acid liquid for the
same time. Gels provide better control for restricting the etched areasame time. Gels provide better control for restricting the etched area
but may require more thorough rinsing afterward.but may require more thorough rinsing afterward.

 What is the optimal etching time?What is the optimal etching time?
 No differences in bond strength are detected between 15No differences in bond strength are detected between 15
second and 60 second etching with 37% phosphoric acid; however,second and 60 second etching with 37% phosphoric acid; however,
shorter etching times cause less enamel damage on debonding.shorter etching times cause less enamel damage on debonding.
 Acording to William A. BrantleyAcording to William A. Brantley decreasing etching time between 30decreasing etching time between 30
and 10 seconds does not affect bond strength, whereas etching for 0and 10 seconds does not affect bond strength, whereas etching for 0
or 5seconds reduces bond strength ( less than 3 MPa ) significantly.or 5seconds reduces bond strength ( less than 3 MPa ) significantly.
 Scanning electron microscopy shows that etching with 37%Scanning electron microscopy shows that etching with 37%
phosphoric acid for at least 30 seconds produces more opticalphosphoric acid for at least 30 seconds produces more optical
etching patterns than etching for 15 seconds.etching patterns than etching for 15 seconds.

 Wei Nan Wang et al (1991)Wei Nan Wang et al (1991) study on tensile strengths of anstudy on tensile strengths of an
orthodontic resin cement were compared for 15, 30, 60, 90,120orthodontic resin cement were compared for 15, 30, 60, 90,120
seconds etching times, with 37% phosphoric acid solution on theseconds etching times, with 37% phosphoric acid solution on the
enamel surface of young permanent teeth .enamel surface of young permanent teeth .
 The results of tensile bond strength for 15, 30,60,90The results of tensile bond strength for 15, 30,60,90
seconds etching times were not statistically different . Resultsseconds etching times were not statistically different . Results
showed that to achieve good retention, to decrease enamel loss, andshowed that to achieve good retention, to decrease enamel loss, and
to reduce moisture contamination in the clinic as well as to saveto reduce moisture contamination in the clinic as well as to save
chair side time a 15-seconds etching time was suggested.chair side time a 15-seconds etching time was suggested.

 Is etching time is different for young and old teeth?Is etching time is different for young and old teeth?
 K J. Nordenvall et al (AJO 1980)K J. Nordenvall et al (AJO 1980) did a comparison between thedid a comparison between the
effects of 15 and 60 seconds of etching with a 37 percent phosphoriceffects of 15 and 60 seconds of etching with a 37 percent phosphoric
acid solution on enamel surfaces of deciduous and young and oldacid solution on enamel surfaces of deciduous and young and old
permanent teeth.permanent teeth.
 For deciduous teethFor deciduous teeth, no difference was found in effect between the, no difference was found in effect between the
etching periods.etching periods.
 For young permanent teethFor young permanent teeth, 15 seconds of etching created more, 15 seconds of etching created more
retentive conditions than 60 seconds.retentive conditions than 60 seconds.
 For old permanent teethFor old permanent teeth, the reverse was found. The most retentive, the reverse was found. The most retentive
conditions were found for the deciduous teeth, regardless of etchingconditions were found for the deciduous teeth, regardless of etching
time.time.

 Concentration of AcidConcentration of Acid ??
 Etching with 10% or 37% phosphoric acid produces the highest bondEtching with 10% or 37% phosphoric acid produces the highest bond
strengths (28 MPa ) to enamel. No differences in bond strengths arestrengths (28 MPa ) to enamel. No differences in bond strengths are
observed when enamel is etched with phosphoric acid ranging inobserved when enamel is etched with phosphoric acid ranging in
concentration from 2% to 37%. One study reported that 2%concentration from 2% to 37%. One study reported that 2%
phosphoric acid etchant was adequate for bonding, whereas anotherphosphoric acid etchant was adequate for bonding, whereas another
recommended 10 – 30% phosphoric acid.recommended 10 – 30% phosphoric acid.
 Wolfgang Carstensen (AJO 1995)Wolfgang Carstensen (AJO 1995).. Compared three acidCompared three acid
concentration (37%, 2% and 5%) was used for 30 seconds to bondconcentration (37%, 2% and 5%) was used for 30 seconds to bond
the brackets. The results showed that 37% phosphoric acid had athe brackets. The results showed that 37% phosphoric acid had a
higher bond strength.higher bond strength.
The amount of adhesive left on the teeth after debondingThe amount of adhesive left on the teeth after debonding
was smaller for 2% acid than 37% and 5%, and it was concluded thatwas smaller for 2% acid than 37% and 5%, and it was concluded that
2% phosphoric acid solution is appropriate for bonding of brackets2% phosphoric acid solution is appropriate for bonding of brackets
and the reduced etching could be favorable in preventing enameland the reduced etching could be favorable in preventing enamel
damage during the treatment and at the time of debonding.damage during the treatment and at the time of debonding.

 Wasundhara(AJO)Wasundhara(AJO) made an invitro study to detect the etch patternmade an invitro study to detect the etch pattern
and compare the shear bond strength by using 37% and 5%and compare the shear bond strength by using 37% and 5%
phosphoric acid and it was observed that there was no significantphosphoric acid and it was observed that there was no significant
difference in shear bond strength, but 5% phosphoric acid produceddifference in shear bond strength, but 5% phosphoric acid produced
a minimal enamel loss.a minimal enamel loss.
 What is preferred procedure for deciduous teeth?What is preferred procedure for deciduous teeth?
 Acording toAcording to ZachrissonZachrisson recommended procedure for conditioningrecommended procedure for conditioning
deciduous teeth is to sand blast with 50 μm aluminum oxide for 3deciduous teeth is to sand blast with 50 μm aluminum oxide for 3
seconds to remove some outermost aprismatic enamel and thenseconds to remove some outermost aprismatic enamel and then
etch for 30 seconds with Ultra-Etch 35% phosphoric acid gel.etch for 30 seconds with Ultra-Etch 35% phosphoric acid gel.

 Is prolonged etching necessary when teeth are pretreated withIs prolonged etching necessary when teeth are pretreated with
fluoride?fluoride?
M. Brannstrom et al(1982 AJO)M. Brannstrom et al(1982 AJO) suggested that extra etchingsuggested that extra etching
time is not necessary when teeth have been pretreated with fluoride.time is not necessary when teeth have been pretreated with fluoride.
When in doubt, check that the enamel looks uniformly dull and frostyWhen in doubt, check that the enamel looks uniformly dull and frosty
white after etch. If it does, surface retention is adequate for bonding.white after etch. If it does, surface retention is adequate for bonding.
Will incorporation of fluorides in the etching solution will decrease theWill incorporation of fluorides in the etching solution will decrease the
bond strength?bond strength?
Fluoridated phosphoric acid solutions and gels provide anFluoridated phosphoric acid solutions and gels provide an
etching effect similar to nonflouridated ones and give adequate bondetching effect similar to nonflouridated ones and give adequate bond
strength in direct bonding procedures.strength in direct bonding procedures.

 F.Garcia etal (AJO 1991)F.Garcia etal (AJO 1991) compared the enamel morphology andcompared the enamel morphology and
shear bond strength of orthodontic bonded to enamel etched withshear bond strength of orthodontic bonded to enamel etched with
fluoridated or a non fluoridated phosphoric acid gel. The resultfluoridated or a non fluoridated phosphoric acid gel. The result
showed that overall morphologic etching effect was similar in bothshowed that overall morphologic etching effect was similar in both
groups.groups.
 J .B Thornton etalJ .B Thornton etal found thatfound that addition of fluoride to the phosphoricaddition of fluoride to the phosphoric
acid solution reduce the decalcification adjacent to bonded brackets.acid solution reduce the decalcification adjacent to bonded brackets.

 Is etching permissible on teeth with internal white spots?Is etching permissible on teeth with internal white spots?
 Caution should be exercised when etching over acquired andCaution should be exercised when etching over acquired and
developmental demineralizations. It is best to avoid it. If this isdevelopmental demineralizations. It is best to avoid it. If this is
impossible, a short etching time, the application of sealent, and theimpossible, a short etching time, the application of sealent, and the
use of direct bonding with extra attention to not having areas ofuse of direct bonding with extra attention to not having areas of
adhesive deficiency are important.adhesive deficiency are important.
 The presence of voids, together with poor hygiene, can lead toThe presence of voids, together with poor hygiene, can lead to
metal corrosion and staining of underlying developmental whitemetal corrosion and staining of underlying developmental white
spots.spots.

 How much enamel is removed by etching and how deep are theHow much enamel is removed by etching and how deep are the
histological alterations?histological alterations?
Are they reversible? Is etching is harmful?Are they reversible? Is etching is harmful?
A routine etching removes 3 to 10 μm of surfaceA routine etching removes 3 to 10 μm of surface
enamel.enamel.
Mark Daniel et al (AJO 1980)Mark Daniel et al (AJO 1980) found that a 90 second etchfound that a 90 second etch
with phosphoric acid resulted in mean loss of 6.9µm with nowith phosphoric acid resulted in mean loss of 6.9µm with no
significant difference between liquid and gel.significant difference between liquid and gel.
Deeper localized dissolutions will generally causeDeeper localized dissolutions will generally cause
penetration to a depth of about 100µm or more.penetration to a depth of about 100µm or more.
..

 Although laboratory studies indicate that the enamel alterations areAlthough laboratory studies indicate that the enamel alterations are
largely reversible ( though not completely ) it can be stated that thelargely reversible ( though not completely ) it can be stated that the
overall effect of applying etchant to healthy enamel is notoverall effect of applying etchant to healthy enamel is not
detrimental.detrimental.
 This is augmented by the fact that normally enamel is 1000This is augmented by the fact that normally enamel is 1000
to 2000 µm thick, abrasive wear of facial enamel is normal andto 2000 µm thick, abrasive wear of facial enamel is normal and
proceeds at a rate of up to 2 µm per year on facial surface are selfproceeds at a rate of up to 2 µm per year on facial surface are self
cleaning and not prone to caries.cleaning and not prone to caries.

Possible iatrogenic effects of acid etching ofPossible iatrogenic effects of acid etching of
enamelenamel
 Fracture and cracking of enamel upon debondingFracture and cracking of enamel upon debonding
 Increased surface porosity – possible staining.Increased surface porosity – possible staining.
 Loss of acquired fluoride in outer 10Loss of acquired fluoride in outer 10µµm of enamelm of enamel
surface.surface.
 Loss of enamel during etching.Loss of enamel during etching.
 Resin tags retained in enamel – possibleResin tags retained in enamel – possible
discoloration of resin.discoloration of resin.
 Rougher surface if over-etched.Rougher surface if over-etched.

Should other means than acid etching beShould other means than acid etching be
preferred?preferred?
 AIR ABRASIONAIR ABRASION
 Air Abrasion, also referred to asAir Abrasion, also referred to as micro-etchingmicro-etching, is a technique in, is a technique in
which particles ofwhich particles of aluminum oxidealuminum oxide are propelled against theare propelled against the
surface of enamel by high air pressure, causing abrasion of thesurface of enamel by high air pressure, causing abrasion of the
surface.surface.
 Some manufactures of commercial units have suggested that airSome manufactures of commercial units have suggested that air
abrasion could eliminate acid etching; however, bond strengths toabrasion could eliminate acid etching; however, bond strengths to
air-abraded enamel are only aboutair-abraded enamel are only about 50%50% of those to acid-etchedof those to acid-etched
enamel.enamel.
 Air abrasion of metal brackets or bands is an effective techniqueAir abrasion of metal brackets or bands is an effective technique
for improving bond strength.for improving bond strength.
 It could be an alternative to pumicing the teeth before etching.It could be an alternative to pumicing the teeth before etching.www.indiandentalacademy.comwww.indiandentalacademy.com

 Karenet al (AJO 1997Karenet al (AJO 1997)) compared the use of acompared the use of a
sandblasting and current techniques. Four methods ofsandblasting and current techniques. Four methods of
enamel preparation before orthodontic bonding that areenamel preparation before orthodontic bonding that are
currently in use were investigated.currently in use were investigated.
 Group A – Only sand blastingGroup A – Only sand blasting
 Group B – Sand blasted and etchedGroup B – Sand blasted and etched
 Group C – Surfaces buffed with bur and acid etchedGroup C – Surfaces buffed with bur and acid etched
 Group D – pumiced and etched.Group D – pumiced and etched.
 Result showed no statistical difference in surfaceResult showed no statistical difference in surface
roughness and no difference in bond strength.roughness and no difference in bond strength.

CRYSTAL-GROWING SOLUTIONSCRYSTAL-GROWING SOLUTIONS
 Crystal bonding involves application to enamel of aCrystal bonding involves application to enamel of a poly (acrylic acid)poly (acrylic acid)
solutionsolution containing sulfate ions, which causes growth of calcium sulfatecontaining sulfate ions, which causes growth of calcium sulfate
dihydrate crystals on the enamel surface. These crystals in turn retain thedihydrate crystals on the enamel surface. These crystals in turn retain the
adhesive.adhesive.
 Potential advantages of crystal bonding include easier debonding, lessPotential advantages of crystal bonding include easier debonding, less
residual adhesive left on the tooth and less damage to enamel.residual adhesive left on the tooth and less damage to enamel.
 Since crystal bonding produces bond strengths ofSince crystal bonding produces bond strengths of 60 – 80%60 – 80% of the bondof the bond
strength obtained with acid etching, it is not yet considered a practicalstrength obtained with acid etching, it is not yet considered a practical
technique.technique.
 Maijer R, Smith Dc ( J Biomed Mater 1979):Maijer R, Smith Dc ( J Biomed Mater 1979): Found that crystal growingFound that crystal growing
solutions provided retention similar to those after etching with phosphoricsolutions provided retention similar to those after etching with phosphoric
acid with less risk of enamel damage at debonding.acid with less risk of enamel damage at debonding.

LASER ETCHINGLASER ETCHING
 The application of laser energy to an enamel surface causes localized meltingThe application of laser energy to an enamel surface causes localized melting
and ablation.and ablation.
 MECHANISMMECHANISM
- Removal of enamel (etching) results primarily from the micro-explosion- Removal of enamel (etching) results primarily from the micro-explosion
of entrapped water in the enamel.of entrapped water in the enamel.
- In addition, there may be some melting of the hydroxyapatite crystals.- In addition, there may be some melting of the hydroxyapatite crystals.
Laser etching of enamel by aLaser etching of enamel by a neodymium-yttrium-aluminumneodymium-yttrium-aluminum garnetgarnet
(Nd:YAG) laser typically produced lower bond strengths than does acid(Nd:YAG) laser typically produced lower bond strengths than does acid
etching.etching.
Satisfactory in vitro bond strengths were obtained in one study only when theSatisfactory in vitro bond strengths were obtained in one study only when the
Nd: YAG laser was used for 12 seconds at maximum power (3 W).Nd: YAG laser was used for 12 seconds at maximum power (3 W).
Studies ofStudies of CO2 laser (pulsed mode)CO2 laser (pulsed mode) etching of enamel have shown thatetching of enamel have shown that
bond strengths of 10 Mpa can be obtained reliably.bond strengths of 10 Mpa can be obtained reliably.
The thermal effects of laser etching on the enamel substructure requireThe thermal effects of laser etching on the enamel substructure require
further research.further research. www.indiandentalacademy.comwww.indiandentalacademy.com

BLEACHINGBLEACHING
 Teeth recently bleached have been observed to have significantlyTeeth recently bleached have been observed to have significantly
lower bond strengths to resin composites. The bleach produceslower bond strengths to resin composites. The bleach produces
oxygen, which inhibits free radical polymerization of resin composites.oxygen, which inhibits free radical polymerization of resin composites.
 Research has shown that orthodontic brackets can be placed afterResearch has shown that orthodontic brackets can be placed after
use ofuse of carbamide peroxidecarbamide peroxide bleaching with no adverse effect on bondbleaching with no adverse effect on bond
strength.strength.

SEALINGSEALING
 After the teeth are completely dry and frosty white, a thin layer ofAfter the teeth are completely dry and frosty white, a thin layer of
sealant may be painted over the entire etched enamel surface.sealant may be painted over the entire etched enamel surface.
 Sealent is best applied with a small foam pellet or brush with aSealent is best applied with a small foam pellet or brush with a
single gingivoincisal stroke on each tooth.single gingivoincisal stroke on each tooth.
 The sealant coating should be thin and even, because excessThe sealant coating should be thin and even, because excess
sealant may induce bracket drift and unnatural enamel topographysealant may induce bracket drift and unnatural enamel topography
when polymerized.when polymerized.
 Bracket placement should be started immediately after all etchedBracket placement should be started immediately after all etched
surfaces are coated with sealant.surfaces are coated with sealant.

 Research has been devoted in the acid etch procedure. The findingsResearch has been devoted in the acid etch procedure. The findings
are divergent.are divergent.
 Some investigators conclude that an intermediate resin isSome investigators conclude that an intermediate resin is
necessary to achieve proper bond strength.necessary to achieve proper bond strength.
 Some indicate that it is necessary to improve resistance toSome indicate that it is necessary to improve resistance to
micro leakage.micro leakage.
 Others feel it is necessary for both reasons.Others feel it is necessary for both reasons.
 Still others do not think that the intermediate resin is necessary atStill others do not think that the intermediate resin is necessary at
all.all.

 Wang and Tang (AJO 1991)Wang and Tang (AJO 1991) studiedstudied bond strengths with andbond strengths with and
without sealants in orthodontic bonding.without sealants in orthodontic bonding.
The results indicated no statistical differencesThe results indicated no statistical differences
between the tensile bond strengths of the two evaluated groups .between the tensile bond strengths of the two evaluated groups .
This study therefore indicated that, use of the sealant in theThis study therefore indicated that, use of the sealant in the
two – paste orthodontic bonding system for enhanced strengthtwo – paste orthodontic bonding system for enhanced strength
is unnecessary . However, the use of a sealant offer extrais unnecessary . However, the use of a sealant offer extra
protection to the enamel during debonding procedures.protection to the enamel during debonding procedures.

 BONDINGBONDING
 Immediately after all teeth to be bonded have been painted withImmediately after all teeth to be bonded have been painted with
sealant, the operator should proceed with the actual bonding of thesealant, the operator should proceed with the actual bonding of the
attachments.attachments.
 The recommended bracket bonding procedure consist of the followingThe recommended bracket bonding procedure consist of the following
stepssteps
 1.TRANSFER1.TRANSFER
 2.POSITIONING2.POSITIONING
 3.FITTING3.FITTING
 4.REMOVAL OF EXCESS4.REMOVAL OF EXCESS

 TRANSFER:TRANSFER:
 The bracket is gripped with a pair of cotton pliers or a reverse action plierThe bracket is gripped with a pair of cotton pliers or a reverse action plier
(bracket holding forceps) and the mixed adhesive is applied to the back of the(bracket holding forceps) and the mixed adhesive is applied to the back of the
bonding base.bonding base.
 The bracket is immediately placed on the tooth close to its correct position.The bracket is immediately placed on the tooth close to its correct position.
 POSITIONING:POSITIONING:
 A placement scaler, such as the RM 349 or one with parallel edges is used toA placement scaler, such as the RM 349 or one with parallel edges is used to
position the brackets mesiodistally and incisogingivilly and angulate themposition the brackets mesiodistally and incisogingivilly and angulate them
accurately.accurately.
 The placement scaler with parallel edges allows visualization of the bracketThe placement scaler with parallel edges allows visualization of the bracket
slot relative to the incisal edge and long axis of the teeth, with the scalerslot relative to the incisal edge and long axis of the teeth, with the scaler
seated in slot.seated in slot.
 Proper vertical positioning may enhanced by different measuring devices orProper vertical positioning may enhanced by different measuring devices or
height guides on the brackets themselves. A mouth mirror will aid inheight guides on the brackets themselves. A mouth mirror will aid in
horizontal positioning, particularly on rotated premolars.horizontal positioning, particularly on rotated premolars.

 FITTINGFITTING
 The scaler is turned and with one – point contact with the bracket it isThe scaler is turned and with one – point contact with the bracket it is
pushed firmly toward the tooth surface. The tight fit will result in good bondpushed firmly toward the tooth surface. The tight fit will result in good bond
strength, little material to remove on debonding and reduced slide whenstrength, little material to remove on debonding and reduced slide when
excess material extrudes peripherally.excess material extrudes peripherally.
 It is important that the scaler be removed once the bracket is in correctIt is important that the scaler be removed once the bracket is in correct
position and no attempts should be made to hold the bracket in place withposition and no attempts should be made to hold the bracket in place with
instrument. Even slight movement may disturb the setting of the adhesive.instrument. Even slight movement may disturb the setting of the adhesive.
 REMOVAL OF EXCESSREMOVAL OF EXCESS
A slight bit of excess adhesive is essential to minimize the possibilityA slight bit of excess adhesive is essential to minimize the possibility
of voids.of voids.
 Excess must be removed with the scaler before the adhesive has set or itExcess must be removed with the scaler before the adhesive has set or it
must be removed with bur after setting.must be removed with bur after setting.
 To avoid disturbing the bracket position during setting, remove the excessTo avoid disturbing the bracket position during setting, remove the excess
after the adhesive has set, for this purpose careful use of tapered tungstenafter the adhesive has set, for this purpose careful use of tapered tungsten
carbide bur.carbide bur.

Orthodontic light curing sourcesOrthodontic light curing sources
 Halogen light curing unitsHalogen light curing units
 Plasma Arc curing unitsPlasma Arc curing units
 LED (light emitting diodes) curing unitsLED (light emitting diodes) curing units

Halogen light curing unitsHalogen light curing units
 DrawbacksDrawbacks
 Halogen bulbs have a limitedHalogen bulbs have a limited
effective lifetime of approximatelyeffective lifetime of approximately
40 – 100 hrs.40 – 100 hrs.
 High temperatures cause a gradualHigh temperatures cause a gradual
degradation of the halogen bulb,degradation of the halogen bulb,
reflector and filter, reducing thereflector and filter, reducing the
intensity of the light output & thusintensity of the light output & thus
the units effectiveness is reduced.the units effectiveness is reduced.
 Clinical implicationClinical implication
 With an aging light – curing unit,With an aging light – curing unit,
adhesives will be less well curedadhesives will be less well cured
and risk of bond failure.and risk of bond failure.
 Replace the filter & halogen bulb onReplace the filter & halogen bulb on
a regular basis.a regular basis.

Plasma Arc curing unitsPlasma Arc curing units
AdavantagesAdavantages
 Overall time reduction – 2 minOverall time reduction – 2 min
for whole arch.for whole arch.
 Immediate bond strengthImmediate bond strength
appears to be very high.appears to be very high.
 No enamel damage onNo enamel damage on
debonding.debonding.
 Rebonding bracket- easy.Rebonding bracket- easy.
DisadvantagesDisadvantages
 Light emitted from plasma arcLight emitted from plasma arc
device is so powerful that bothdevice is so powerful that both
the operator & assistant shouldthe operator & assistant should
wear protective glasses.wear protective glasses.
 Additional cost of curing light.Additional cost of curing light.

LED (Light emitting diodes)LED (Light emitting diodes)
 Are semiconducting materials thatAre semiconducting materials that
transform current into light of atransform current into light of a
specific wavelength.specific wavelength.
 First suggested byFirst suggested by
Mills (Br. Dent J 1995)Mills (Br. Dent J 1995)
First report byFirst report by
Fujibayashi et al (Dent. JapFujibayashi et al (Dent. Jap
1998)1998)

ADVANTAGESADVANTAGES
 Much smaller & lighter than conventional bulbs.Much smaller & lighter than conventional bulbs.
 Offer high shock resistance, as there is no filament to be damaged andOffer high shock resistance, as there is no filament to be damaged and
their relatively low power consumption makes them suitable fortheir relatively low power consumption makes them suitable for
portable use in cordless devices.portable use in cordless devices.
 LEDs have lifetimes of more thanLEDs have lifetimes of more than 10,000 hours10,000 hours and experienceand experience
little degradation of light output over this time –little degradation of light output over this time – a distincta distinct
advantage over halogen bulbs.advantage over halogen bulbs.
 Require no filters to produce blue light. The spectral output of theseRequire no filters to produce blue light. The spectral output of these
LEDs falls mainly within the absorption spectrum of theLEDs falls mainly within the absorption spectrum of the
camphoroquinone photoinitiatior of most dental composites.camphoroquinone photoinitiatior of most dental composites.
 Depth of cure – significantly greater than halogen lightDepth of cure – significantly greater than halogen light

 Lay Man et al 2004Lay Man et al 2004
Bracket failure rateBracket failure rate
 Halogen light –Halogen light – 4.8%4.8%
 LED unit –LED unit – 1.9%1.9%
 More the number of LEDs significantly higher shear bond strength.More the number of LEDs significantly higher shear bond strength.
 Generally Shear bond strength greater than 8 MPa, even with 10Generally Shear bond strength greater than 8 MPa, even with 10
second cure.second cure.
 Effects on PulpEffects on Pulp
 Halogen lights were found to produce a greater pulpal temp rise –Halogen lights were found to produce a greater pulpal temp rise –
with longer curing cycles increasing iatrogenic pulpal damage risk.with longer curing cycles increasing iatrogenic pulpal damage risk.
 LEDs, lesser pulpal wall heating & had shorter cooling times – mayLEDs, lesser pulpal wall heating & had shorter cooling times – may
be related to their narrow energy spectrum.be related to their narrow energy spectrum.

In Indirect bonding, brackets are attached to the teeth on the patients models,In Indirect bonding, brackets are attached to the teeth on the patients models,
transferred to the mouth with some sort of tray on to which the bracketstransferred to the mouth with some sort of tray on to which the brackets
become incorporated, and then bonded simultaneously.become incorporated, and then bonded simultaneously.
 Several techniques for indirect bonding are available. Most are based on theSeveral techniques for indirect bonding are available. Most are based on the
procedures described byprocedures described by Silverman and Cohen ( JCO 1976)Silverman and Cohen ( JCO 1976)..
 H. Stuart ( Jco 2003 )H. Stuart ( Jco 2003 ) suggested most indirect bonding techniques aresuggested most indirect bonding techniques are
successful in accurately placing brackets but can be expensive, complexsuccessful in accurately placing brackets but can be expensive, complex
and time – consuming. So he introduced a simplified method that hasand time – consuming. So he introduced a simplified method that has
reduced lab cost and chair time.reduced lab cost and chair time.

 Mark the long axis of eachMark the long axis of each
tooth to be bonded with atooth to be bonded with a
sharp pencil, beginning at thesharp pencil, beginning at the
midpoint of the incisal crownmidpoint of the incisal crown
and extending to the gingivaland extending to the gingival
margin.margin.
 Paint the casts with a liquid foilPaint the casts with a liquid foil
separating medium.separating medium. www.indiandentalacademy.comwww.indiandentalacademy.com

 Paint a thin layer of unfilled light –Paint a thin layer of unfilled light –
cured resin on each bracket padcured resin on each bracket pad
followed by a thin layer of microfilledfollowed by a thin layer of microfilled
resin paste. Place each bracket in itsresin paste. Place each bracket in its
correct position and press thecorrect position and press the
bracket firmly against the toothbracket firmly against the tooth
surface and remove any excess.surface and remove any excess.
 The adhesive is cured.The adhesive is cured.

Inject polyvinyl siloxaneInject polyvinyl siloxane
impression material over theimpression material over the
brackets, occlusal andbrackets, occlusal and
lingual tooth surfaces.lingual tooth surfaces.
Sculpt the material to aSculpt the material to a
smooth contour with finger.smooth contour with finger.
 The transfer tray trimmedThe transfer tray trimmed
with scissor after removalwith scissor after removal
from the cast.from the cast.

Etch and prepare the entire dentition asEtch and prepare the entire dentition as
usual. Dry and apply a layer ofusual. Dry and apply a layer of
Orthosolo.Orthosolo.
 Wipe the composite pad surfacesWipe the composite pad surfaces
in the transfer tray with absolutein the transfer tray with absolute
alcohol to ensure that noalcohol to ensure that no
separating medium remain. A thinseparating medium remain. A thin
layer of Orthosolo is then applied.,layer of Orthosolo is then applied.,
 Followed by a very thin layer ofFollowed by a very thin layer of
Enlight LV (microfilled resin) isEnlight LV (microfilled resin) is
applied. The Orthosolo brushapplied. The Orthosolo brush
should be reused to spread theshould be reused to spread the
adhesive paste thinly over theadhesive paste thinly over the
entire surface of each bracket padentire surface of each bracket pad
and thus prevent voids duringand thus prevent voids during
seating or polymerization.seating or polymerization.

 Seat the indirect transferr traySeat the indirect transferr tray
firmly over the prepared teeth..firmly over the prepared teeth..
Bracket bonded with 10 –Bracket bonded with 10 –
second exposure fromsecond exposure from
occlusal.occlusal.
 The transfer tray removedThe transfer tray removed
immediately after each sectionimmediately after each section
is bonded.is bonded.
 Remove any excess flash ifRemove any excess flash if
there.there.

 According toAccording to Hickham and Rossouw (Jco 1993)Hickham and Rossouw (Jco 1993)
An indirect bonding system must satisfy the followingAn indirect bonding system must satisfy the following
criteria to be successful:criteria to be successful:
 Positions brackets accurately on all teeth.Positions brackets accurately on all teeth.
 Ensures adequate bracket adherence by avoidingEnsures adequate bracket adherence by avoiding
moisture contaminationmoisture contamination

 Reduces patient discomfort and duration of the bondingReduces patient discomfort and duration of the bonding
procedure.procedure.
 Reduces laboratory expense and doctor chair time.Reduces laboratory expense and doctor chair time.
 Ensures sufficient integrity of transfer trays to holdEnsures sufficient integrity of transfer trays to hold
brackets securely in place while the adhesivebrackets securely in place while the adhesive
polymerizes.polymerizes.
 Reduces stress for the clinical staff.Reduces stress for the clinical staff.

 The scope of orthodontics has expanded over the past two decades toThe scope of orthodontics has expanded over the past two decades to
include more adult patients, and it is expected that many of theseinclude more adult patients, and it is expected that many of these
people will have restorations placed on their teeth. Although bandingpeople will have restorations placed on their teeth. Although banding
is always an alternative for the teeth that have restorations, bonding isis always an alternative for the teeth that have restorations, bonding is
desirable in aesthetic areas.desirable in aesthetic areas.
 BONDING TO CERAMICSBONDING TO CERAMICS
 Acid etchingAcid etching with phosphoric acid iswith phosphoric acid is ineffectiveineffective..
 Alternative surface preparation techniques have been found toAlternative surface preparation techniques have been found to
satisfactory results which includes;satisfactory results which includes;
- Mechanical roughening with stones and diamonds- Mechanical roughening with stones and diamonds
- Sandblasting- Sandblasting
- Chemical roughening with hydrofluoric acid- Chemical roughening with hydrofluoric acid
- Combination of sand blasting and chemical roughening with- Combination of sand blasting and chemical roughening with
hydrofluoric acid and chemical coupling with the use of silaneshydrofluoric acid and chemical coupling with the use of silanes..www.indiandentalacademy.comwww.indiandentalacademy.com

 Roughening the porcelain surface with diamonds or stonesRoughening the porcelain surface with diamonds or stones (never(never
with carbide burs) increases the bond strength, but does not providewith carbide burs) increases the bond strength, but does not provide
sufficient retention for the whole period of the orthodontic treatment.sufficient retention for the whole period of the orthodontic treatment.
 Micro-etching of the ceramic surfaceMicro-etching of the ceramic surface. Small intraoral sandblaster. Small intraoral sandblaster
with a contrangle nozzle have been used. They usewith a contrangle nozzle have been used. They use 5050 µµmm oror
coarser aluminum oxide (A12O3)coarser aluminum oxide (A12O3) powder connected to apowder connected to a
compressed – air source in the operatory. An alternative powdercompressed – air source in the operatory. An alternative powder
that could be used in cases where patients have an allergic reactionthat could be used in cases where patients have an allergic reaction
to aluminum oxide isto aluminum oxide is silicon carbidesilicon carbide..
 Application ofApplication of silanesilane to the ceramic surface has been used toto the ceramic surface has been used to
promote the adhesion of resin composites. For example,promote the adhesion of resin composites. For example, y-y-
methacryloxy-propyltrimethoxysilanemethacryloxy-propyltrimethoxysilane is a coupling agent thatis a coupling agent that
provides reactive sites for inorganic and organic components.provides reactive sites for inorganic and organic components.

This silane contains silanol groups that can bond with silanols on theThis silane contains silanol groups that can bond with silanols on the
ceramic surface, forming a siloxane (Si-O-Si) bond. Additionally, thisceramic surface, forming a siloxane (Si-O-Si) bond. Additionally, this
silane contains methacrylate groups that can form covalent bondssilane contains methacrylate groups that can form covalent bonds
with the polymer matrix of the resin composite.with the polymer matrix of the resin composite.
 Etching of the ceramic surface with hydrofluoric acid (HF)Etching of the ceramic surface with hydrofluoric acid (HF) waswas
introduced in the early 1980s for bonding porcelain laminateintroduced in the early 1980s for bonding porcelain laminate
veneers.. A commonly used hydrofluoric acid product has aveneers.. A commonly used hydrofluoric acid product has a
concentration ofconcentration of 9.6% in gel form9.6% in gel form and is placed on the ceramic forand is placed on the ceramic for
two to four minutes. Other available commercial products usetwo to four minutes. Other available commercial products use 4%4%
acidulated phosphate fluoride containing 1.43% hydrofluoric acidacidulated phosphate fluoride containing 1.43% hydrofluoric acid inin
gel form for two minutes. Acid etching of ceramic surface isgel form for two minutes. Acid etching of ceramic surface is
recommended when maximum bond strength is required.recommended when maximum bond strength is required.

 The protocol for optimal bonding to ceramic surfaces is asThe protocol for optimal bonding to ceramic surfaces is as
follows:follows:
 (1)(1) The glaze is first removed by sandblasting, using 50The glaze is first removed by sandblasting, using 50 µµm Al2O3 form Al2O3 for
two to four seconds.two to four seconds.
 (2)(2) The ceramic surface is then etched for two minutes, using 9.6%The ceramic surface is then etched for two minutes, using 9.6%
hydrofluoric acid in gel form.hydrofluoric acid in gel form.
 (3)(3) Subsequently, two to three coatings of a silane coupling agent areSubsequently, two to three coatings of a silane coupling agent are
applied to the etched surface, followed by drying.applied to the etched surface, followed by drying.
 (4)(4) Two layers of unfilled resin are then applied to form a thin coating.Two layers of unfilled resin are then applied to form a thin coating.
 (5)(5) Finally, the bracket is bonded to the prepared ceramic surface,Finally, the bracket is bonded to the prepared ceramic surface,
using a highly filled Bis-GMA resin .using a highly filled Bis-GMA resin .

 BONDING TO CASTING ALLOYSBONDING TO CASTING ALLOYS
Proper surface preparation and special adhesives areProper surface preparation and special adhesives are
required for acceptable bonding to casting alloys. Althoughrequired for acceptable bonding to casting alloys. Although
roughening the alloy surface with a stone increases the bondroughening the alloy surface with a stone increases the bond
strength to brackets, intraoral sandblasters provide better results.strength to brackets, intraoral sandblasters provide better results.
In recent years, adhesives that chemically bond to metalIn recent years, adhesives that chemically bond to metal
surfaces have been developed. The commercial productssurfaces have been developed. The commercial products Super-Super-
Bond C&BBond C&B (Sun Medical, Kyoto, Japan) and(Sun Medical, Kyoto, Japan) and C&B MetabondC&B Metabond
(Parkell, Farmingdale, NY, USA) combine(Parkell, Farmingdale, NY, USA) combine 4-META4-META (4-(4-
methacryloxyethyltrimethyl anhydride) withmethacryloxyethyltrimethyl anhydride) with tributylborane monomertributylborane monomer
andand a polymer powder.a polymer powder.

It is believed that 4-META forms aIt is believed that 4-META forms a hydrogen bond with hydroxylhydrogen bond with hydroxyl
groupsgroups found on the prepared surface of the metal.found on the prepared surface of the metal.
In vitro studies have shown that brackets bonded to sandblastedIn vitro studies have shown that brackets bonded to sandblasted
gold alloys using these 4-META adhesives attain the bond strengthgold alloys using these 4-META adhesives attain the bond strength
values to acid-etched enamel. It has been found that thesevalues to acid-etched enamel. It has been found that these
adhesives bond better to base metal alloys than to gold alloys.adhesives bond better to base metal alloys than to gold alloys.
.Panavia EX.Panavia EX andand PanaviaPanavia 2121(J. Morita USA, Tustin, CA, USA).(J. Morita USA, Tustin, CA, USA).
BONDING TO AMALGAMBONDING TO AMALGAM
Sandblasting the surface of the amalgam restoration, followed bySandblasting the surface of the amalgam restoration, followed by
use of the adhesives,use of the adhesives, 4-=META4-=META,, 10MDP10MDP(10-methacryloyloxydecyl(10-methacryloyloxydecyl
dihydrogenphosphate)dihydrogenphosphate) // Bis-GMABis-GMA, and, and intermediate resinsintermediate resins,,
improves bonding to dental amalgam. However, the bond strengthimproves bonding to dental amalgam. However, the bond strength
achieved is at best about half that for resin composite to etchedachieved is at best about half that for resin composite to etched
enamel.enamel.

 Sandblasting the dental amalgam surface produces significantlySandblasting the dental amalgam surface produces significantly
better bonding than that achieved with a polished dental amalgambetter bonding than that achieved with a polished dental amalgam
surface.surface.
 However, when compared to roughening with a diamond bur,However, when compared to roughening with a diamond bur,
sandblasting of dental amalgam surfaces did not produce bettersandblasting of dental amalgam surfaces did not produce better
bonding.bonding.
 BONDING TO RESIN COMPOSITESBONDING TO RESIN COMPOSITES
 As the resin composite restoration ages in the mouth, lessAs the resin composite restoration ages in the mouth, less
unreacted methacrylate groupsunreacted methacrylate groups remain on the surface for cross-remain on the surface for cross-
linking with the bonding resin. Additionally, the exposed fillerlinking with the bonding resin. Additionally, the exposed filler
particles are freed (“plucked out”) from the silane-coupling agent. Toparticles are freed (“plucked out”) from the silane-coupling agent. To
achieve acceptable bonding to these restoration surfaces, theachieve acceptable bonding to these restoration surfaces, the
uppermost resin composite layer has to be removed with a diamonduppermost resin composite layer has to be removed with a diamond
or carbide bur.or carbide bur.

 Then the surface is acid-etched withThen the surface is acid-etched with 37% phosphoric acid37% phosphoric acid.. SilanationSilanation
follows before application of an unfilled resin and bonding. Thefollows before application of an unfilled resin and bonding. The
reported bond strengths to resin laminates are aboutreported bond strengths to resin laminates are about 60-85%60-85% of theof the
bond strengths to etched enamel, and this level of bond strength hasbond strengths to etched enamel, and this level of bond strength has
been judged adequate to provide clinically acceptable retention.been judged adequate to provide clinically acceptable retention.
 BONDING TO ACRYLIC RESINSBONDING TO ACRYLIC RESINS
 If Polymethyl methacrylate (PMMA) has been used, the surfaceIf Polymethyl methacrylate (PMMA) has been used, the surface
of the provisional restoration has to be firstof the provisional restoration has to be first wetted with methylwetted with methyl
methacrylatemethacrylate for three minutesfor three minutes. The brackets can then be bonded. The brackets can then be bonded
using a bonding agent (e.g., unfilled resin) and resin composite.using a bonding agent (e.g., unfilled resin) and resin composite.
Alternatively, the bracket can be attached using PMMA with theAlternatively, the bracket can be attached using PMMA with the
brush-bead technique, or it can be embedded in the PMMAbrush-bead technique, or it can be embedded in the PMMA
provisional restoration.provisional restoration.

 Divided into two categories depending upon site of failuresDivided into two categories depending upon site of failures
 1.1. Adhesive – enamel bond failuresAdhesive – enamel bond failures
 2. Adhesive – bracket bond failures2. Adhesive – bracket bond failures
Possible causes of Adhesive – enamel Bond failuresPossible causes of Adhesive – enamel Bond failures
1. Contamination of etched enamel by saliva, moisture or oil from1. Contamination of etched enamel by saliva, moisture or oil from
water line.water line.
2. Insufficient rinsing of etchant from tooth before bonding.2. Insufficient rinsing of etchant from tooth before bonding.
3. Inadequate drying of enamel surface precludes penetration of3. Inadequate drying of enamel surface precludes penetration of
resin.resin.
4. Over – etching demineralizes enamel, reduces depth of resin4. Over – etching demineralizes enamel, reduces depth of resin
tags penetration, and removes excessive amounts of enamel.tags penetration, and removes excessive amounts of enamel.
5. Faulty bonding materials, materials with expired date.5. Faulty bonding materials, materials with expired date.

Possible Causes of Adhesive – bracket bond failuresPossible Causes of Adhesive – bracket bond failures
 Excessive force exerted on bracket from occlusion or excessiveExcessive force exerted on bracket from occlusion or excessive
from appliance.from appliance.
 Movement of bracket during initial setting of adhesive.Movement of bracket during initial setting of adhesive.
 Contaminated bracket mesh (oil from hands, glove powder orContaminated bracket mesh (oil from hands, glove powder or
rebonded bracket).rebonded bracket).
 Adhesive not buttered into base firmly.Adhesive not buttered into base firmly.
 Activator not placed on bracket in paste primer system.Activator not placed on bracket in paste primer system.
 Inadequate cure of light cured resin composite.Inadequate cure of light cured resin composite.

Avoid bond failures….Avoid bond failures….
 Increases treatment timeIncreases treatment time
 Additional cost in materialsAdditional cost in materials
 Unexpected additional visits by patients.Unexpected additional visits by patients.

 Bonded brackets that become loose during treatment consumeBonded brackets that become loose during treatment consume
much chair time, are poor publicity for the office, and are amuch chair time, are poor publicity for the office, and are a
nuisance to the orthodontist..nuisance to the orthodontist..
 The best way to avoid loose brackets is to adhere strictly to theThe best way to avoid loose brackets is to adhere strictly to the
rules for good bonding technique.rules for good bonding technique.
 The loose bracket is removed from the archwire. Any adhesiveThe loose bracket is removed from the archwire. Any adhesive
remaining on the tooth surface is removed with TC bur. Theremaining on the tooth surface is removed with TC bur. The
adhesive remaining on the loose bracket is treated byadhesive remaining on the loose bracket is treated by
sandblasting.sandblasting.

 Until all visible material is removed from the base. The tooth isUntil all visible material is removed from the base. The tooth is
then etched with Ultraetch 35% phosphoric acid gel for 15 to 30then etched with Ultraetch 35% phosphoric acid gel for 15 to 30
seconds. On inspection, the enamel surface may not be uniformlyseconds. On inspection, the enamel surface may not be uniformly
frosty because areas are likely still retaining resin. The phosphoricfrosty because areas are likely still retaining resin. The phosphoric
acid will re-etch any exposed enamel and remove the pellicle onacid will re-etch any exposed enamel and remove the pellicle on
any exposed resin.any exposed resin.
 Sonis AL (AJO 1996)Sonis AL (AJO 1996) found out that the bond strength offound out that the bond strength of
sandblasted rebonded brackets is comparable to the success ratesandblasted rebonded brackets is comparable to the success rate
of new brackets.of new brackets.

RECYCLINGRECYCLING
 Several methods of recycling debonded attachments for repeatSeveral methods of recycling debonded attachments for repeat
use, either by commercial companies or by duplicated procedureuse, either by commercial companies or by duplicated procedure
in the office, are available.in the office, are available.
 The main goal of the recycling process is to remove the adhesiveThe main goal of the recycling process is to remove the adhesive
from the bracket completely without damaging or weakening thefrom the bracket completely without damaging or weakening the
delicate bracket backing or distorting the dimensions of the bracketdelicate bracket backing or distorting the dimensions of the bracket
slot.slot.
 Commercial processes employ heatCommercial processes employ heat ( about 450º C ),( about 450º C ), to burn offto burn off
resin, followed by eloctropolishing to remove the oxide buildupresin, followed by eloctropolishing to remove the oxide buildup
(e.g. Esmadent)(e.g. Esmadent) or they use solvent stripping combined with highor they use solvent stripping combined with high
frequency vibrations and only flash electropolishing (e.g.,frequency vibrations and only flash electropolishing (e.g., Ortho –Ortho –
Cycle).Cycle).
 The electropolishing is needed for removal of any tarnish or oxideThe electropolishing is needed for removal of any tarnish or oxide
formed during the elimination of the adhesive from the cloggedformed during the elimination of the adhesive from the clogged
pad.pad.

 Buchman ( AJO 1980)Buchman ( AJO 1980)
The methods of 3 recycling companies (Esmadent, OrhoThe methods of 3 recycling companies (Esmadent, Orho
cycle & Ortho Bonding ) and the flame method are examined for theircycle & Ortho Bonding ) and the flame method are examined for their
effects on bracket base torque, slot width & mechanical properties.effects on bracket base torque, slot width & mechanical properties.
Changes in slot width & base torque angle showed no statisticallyChanges in slot width & base torque angle showed no statistically
differencedifference..
- Recycling of used ceramic brackets- Recycling of used ceramic brackets by heating or resilanatingby heating or resilanating
appears to produce an acceptable bond strength.appears to produce an acceptable bond strength.

Recycling of ceramic bracketsRecycling of ceramic brackets
 Kenneth and Djeng (Jco 1990),Kenneth and Djeng (Jco 1990),
composite resin remaining on the bracket base is removedcomposite resin remaining on the bracket base is removed
by holding the bracket with a pair of tweezers and heating it in a miniby holding the bracket with a pair of tweezers and heating it in a mini
torch until it turns cherry red .torch until it turns cherry red .
On cooling, the residual composite resin will turn chalky whiteOn cooling, the residual composite resin will turn chalky white
and flaky. It can easily be removed by gently tapping the bracket onand flaky. It can easily be removed by gently tapping the bracket on
a table top or by lightly scraping the base with a wax knife thisa table top or by lightly scraping the base with a wax knife this
produces a clean surface.produces a clean surface.
 The bracket is allowed to cool for 5 minutes until it reaches roomThe bracket is allowed to cool for 5 minutes until it reaches room
temperatures.temperatures.
 It is dried with compressed air to remove any possible residue. It isIt is dried with compressed air to remove any possible residue. It is
rinsed in 100% isopropyl alcohol at pure acetone and allowed to airrinsed in 100% isopropyl alcohol at pure acetone and allowed to air
dry.dry.

Apply phosphoric acid etchant with a cotton pellet and leave itApply phosphoric acid etchant with a cotton pellet and leave it
on the base for 60 to 90 seconds. Do not rinse of the acid because iton the base for 60 to 90 seconds. Do not rinse of the acid because it
is used to hydrolyze the hydrogen atom and hydroxyl groups in theis used to hydrolyze the hydrogen atom and hydroxyl groups in the
silica surface. Apply the primer over the acid and leave it on thesilica surface. Apply the primer over the acid and leave it on the
surface for one minute before rinsing and drying thoroughly.surface for one minute before rinsing and drying thoroughly.
After 10 minutes of air drying the primed brackets can beAfter 10 minutes of air drying the primed brackets can be
bonded to the etched enamel surface with a chemically “or” lightbonded to the etched enamel surface with a chemically “or” light
cured composite resin.cured composite resin.

 The objectives of debonding are to remove the attachment and allThe objectives of debonding are to remove the attachment and all
the adhesive resin from the tooth and restore the surface as closelythe adhesive resin from the tooth and restore the surface as closely
as possible to its pretreatment condition without inducing iatrogenicas possible to its pretreatment condition without inducing iatrogenic
damage.damage.
 To obtain these objectives, a correct technique is of fundamentalTo obtain these objectives, a correct technique is of fundamental
importance.importance.
 Debonding may be unnecessarily time consuming and damaging toDebonding may be unnecessarily time consuming and damaging to
the enamel if performed with improper technique or in a carelessthe enamel if performed with improper technique or in a careless
mannermanner..

 Debonding is discussed as follows:Debonding is discussed as follows:
•• Clinical procedureClinical procedure
•• Influence of different debonding instruments on surface enamelInfluence of different debonding instruments on surface enamel
•• Amount of enamel lost in debondingAmount of enamel lost in debonding
•• Enamel tearoutsEnamel tearouts
•• Enamel cracksEnamel cracks
•• Adhesive remanant wearAdhesive remanant wear
•• Reversal of decalcificationsReversal of decalcifications

CLINICAL PROCEDURESCLINICAL PROCEDURES
 Bracket removalBracket removal
 Removal of residual adhesivesRemoval of residual adhesives

BracketBracket RRemovalemoval
DEBONDING STEEL BRACKETSDEBONDING STEEL BRACKETS
 Several different procedures for debracketing with pliers areSeveral different procedures for debracketing with pliers are
available.available.
 An original method was to place the tips of a twin-beaked pliersAn original method was to place the tips of a twin-beaked pliers
against the mesial and distal edges of the bonding base and cutagainst the mesial and distal edges of the bonding base and cut
the brackets off between the tooth and the base.the brackets off between the tooth and the base.
 A gentler technique is to squeeze the bracket wingsA gentler technique is to squeeze the bracket wings
mesiodistaly and lift the bracket off with a peel force. This ismesiodistaly and lift the bracket off with a peel force. This is
particularly useful on brittle, mobile, or endodontically treatedparticularly useful on brittle, mobile, or endodontically treated
teeth.teeth.

The recommended techniqueThe recommended technique
 Here brackets are ligated, the brackets are gripped one by one withHere brackets are ligated, the brackets are gripped one by one with
an 095 Orthopli bracket removing plier and lifted outwardly at a 45˚an 095 Orthopli bracket removing plier and lifted outwardly at a 45˚
angle.angle.
 The indentation in the pliers fits into the gingival tie-wings for aThe indentation in the pliers fits into the gingival tie-wings for a
secure grip. This is a quick and gentle technique that leaves thesecure grip. This is a quick and gentle technique that leaves the
brackets intact and fit for recycling, if so desired.brackets intact and fit for recycling, if so desired.
 The bond breaks in that adhesive bracket interface, and the patternThe bond breaks in that adhesive bracket interface, and the pattern
of the mesh – backing is visible on the adhesive remaining on theof the mesh – backing is visible on the adhesive remaining on the
teeth. A peel force, as in peeling an orange, creates peripheralteeth. A peel force, as in peeling an orange, creates peripheral
stress concentrations that cause bonded metal brackets to fail at lowstress concentrations that cause bonded metal brackets to fail at low
force values.force values.

 REMOVING BONDED BEGG BRACKETREMOVING BONDED BEGG BRACKET
 James nJames n, here the walls of the vertical slot are squeezed together., here the walls of the vertical slot are squeezed together.
This action causes the base of the bracket to peel away from theThis action causes the base of the bracket to peel away from the
bonding material, lifting the edges of the base and breaking thebonding material, lifting the edges of the base and breaking the
adhesive bond. The bracket and base then can be peeled off theadhesive bond. The bracket and base then can be peeled off the
tooth and any adhesive remaining on the tooth surface can be gentlytooth and any adhesive remaining on the tooth surface can be gently
sanded and polished.sanded and polished.
 A plier with a sturdy tip should be used for this technique, to avoidA plier with a sturdy tip should be used for this technique, to avoid
breakage. The technique works best on minibased (3 – mm width)breakage. The technique works best on minibased (3 – mm width)
brackets. If the base is wider or curved then ‘base – squeezing” isbrackets. If the base is wider or curved then ‘base – squeezing” is
very effective.very effective.

DEBONDING CERAMIC BRACKETSDEBONDING CERAMIC BRACKETS
- First generation ceramic brackets depended onFirst generation ceramic brackets depended on silane coatingsilane coating toto
ensure adhesion. The silane coupling led to excessively high bondensure adhesion. The silane coupling led to excessively high bond
strengths and a resultant damage to the enamel at the time ofstrengths and a resultant damage to the enamel at the time of
debonding.debonding.
This problem has been solved in second generation byThis problem has been solved in second generation by
incorporating aincorporating a polycarbonate base or base can be sprayed withpolycarbonate base or base can be sprayed with
atomized glassatomized glass. This ensured that at the time of debonding the failure. This ensured that at the time of debonding the failure
occurred at the bracket adhesive interphase.occurred at the bracket adhesive interphase.
 Ceramic brackets will not flex when squeezed with debonding pliers.Ceramic brackets will not flex when squeezed with debonding pliers.
The preferred mechanical debonding is to lift the brackets off withThe preferred mechanical debonding is to lift the brackets off with
peripheral force application, much the same as for steel brackets.peripheral force application, much the same as for steel brackets.

 Several tie-wings may still fracture, which in practice requiresSeveral tie-wings may still fracture, which in practice requires
grinding away the rest of the bracket. Cutting the brackets off withgrinding away the rest of the bracket. Cutting the brackets off with
gradual pressure from the tips of twin-beaked pliers orientedgradual pressure from the tips of twin-beaked pliers oriented
mesiodistally close to the bracket-adhesive interface is notmesiodistally close to the bracket-adhesive interface is not
recommended because it might introduce horizontal enamel cracks.recommended because it might introduce horizontal enamel cracks.
 Vukovich ME etal (AJO 1991)Vukovich ME etal (AJO 1991) Low – speed grinding of ceramicLow – speed grinding of ceramic
brackets with no watercoolant cause permanent damage or necrosisbrackets with no watercoolant cause permanent damage or necrosis
of dental pulps. Therefore water cooling of the grinding sites isof dental pulps. Therefore water cooling of the grinding sites is
necessary.necessary.
 Bishara SE etal (AJO1997)Bishara SE etal (AJO1997) More recent ceramic brackets have aMore recent ceramic brackets have a
mechanical lock base and a vertical slot, which will split the bracketmechanical lock base and a vertical slot, which will split the bracket
by squeezing. Seperation is at the bracket adhesive interface, withby squeezing. Seperation is at the bracket adhesive interface, with
little risk of enamel fracture.little risk of enamel fracture.

THERMAL DEBONDINGTHERMAL DEBONDING
 Norman R. GorbackNorman R. Gorback suggested that removal of ceramic brackets cansuggested that removal of ceramic brackets can
be painful and harmful for the patient, and difficult to remove by thebe painful and harmful for the patient, and difficult to remove by the
orthodontist. The use of heat makes bracket removal efficient andorthodontist. The use of heat makes bracket removal efficient and
painless, although extreme care is required to avoid touching the teethpainless, although extreme care is required to avoid touching the teeth
with a heated instrument.with a heated instrument.
Procedure:Procedure:
 Tips of the utility plier are heated in the micro torch for ten seconds.Tips of the utility plier are heated in the micro torch for ten seconds.
 The bracket is gripped with the heated plier.The bracket is gripped with the heated plier.
 A light rotational force is applied after ten seconds.A light rotational force is applied after ten seconds.
 If the bracket does not snap off easily the procedure is repeated afterIf the bracket does not snap off easily the procedure is repeated after
heating the plier for 15 seconds.heating the plier for 15 seconds.

LASER DEBONDINGLASER DEBONDING
 Since the early 1990s, laser have been used experimentally forSince the early 1990s, laser have been used experimentally for
debonding ceramic brackets.debonding ceramic brackets.
 Mechanism of laser debondingMechanism of laser debonding (Tocchio et al AJO 1993 )(Tocchio et al AJO 1993 )
Laser energy can degrade the adhesive resin by three methods :Laser energy can degrade the adhesive resin by three methods :
1.1. Thermal softeningThermal softening
2.2. Thermal ablationThermal ablation
3.3. PhotoablationPhotoablation
 Thermal softeningThermal softening occurs when the laser heats the bonding agentoccurs when the laser heats the bonding agent
until it softens. Clinically, this results in the bracket’s surrendering tountil it softens. Clinically, this results in the bracket’s surrendering to
gravity and sliding off the tooth surfacegravity and sliding off the tooth surface..

 Thermal ablationThermal ablation occurs when heating is fast enough to raise theoccurs when heating is fast enough to raise the
temperature of the resin into its vaporization range.temperature of the resin into its vaporization range.
 PhotoablationPhotoablation It occurs when very high – energy laser light interactsIt occurs when very high – energy laser light interacts
with the adhesive material.with the adhesive material.
Time span for debonding with lasersTime span for debonding with lasers
 The super CO2 laser products have high energy pulses over aThe super CO2 laser products have high energy pulses over a
short time. The normal CO2 laser is made of continuos waves withshort time. The normal CO2 laser is made of continuos waves with
millisecond – duration pulses.millisecond – duration pulses.
 Obata et al (Eur J 1999)Obata et al (Eur J 1999) reported that the super – pulse CO2 laserreported that the super – pulse CO2 laser
took less time for debonding than did the normal – pulse laser (lesstook less time for debonding than did the normal – pulse laser (less
than 4 seconds).than 4 seconds).

 Effects on the pulpEffects on the pulp
When laser radiation is applied to a ceramic bracket, energy is absorbedWhen laser radiation is applied to a ceramic bracket, energy is absorbed
and converted into heat. This heat is then free to propagate by conductionand converted into heat. This heat is then free to propagate by conduction
to the base of the bracket to soften the adhesive. There is also potential forto the base of the bracket to soften the adhesive. There is also potential for
this heat to propagate to the tooth structure and eventually lead to pulpthis heat to propagate to the tooth structure and eventually lead to pulp
damage.damage.
 Ma et al ( AJO 1997)Ma et al ( AJO 1997) showed that there is a linear relationship betweenshowed that there is a linear relationship between
lasing time and an increase in intrapulpal temperature. A mean intrapulpallasing time and an increase in intrapulpal temperature. A mean intrapulpal
temperature increase oftemperature increase of
0.91º C0.91º C afterafter 11 second of lasingsecond of lasing
1.74º C1.74º C afterafter 22 secondsseconds
2.67ºC2.67ºC afterafter 33 secondsseconds
 Obata (1995)Obata (1995) reported that there was less increase in pulp cavityreported that there was less increase in pulp cavity
temperature compared with bracket surface temperature. Furthermore,temperature compared with bracket surface temperature. Furthermore,
lased and nonlased tooth pulps showed no histological difference.lased and nonlased tooth pulps showed no histological difference.

 Time lag between lasing and debondingTime lag between lasing and debonding
 Abdul – kader and Ibrahim(1999)Abdul – kader and Ibrahim(1999) reported that significantlyreported that significantly
higher force was required for debonding ceramic brackets when 1higher force was required for debonding ceramic brackets when 1
minute elapsed after laser exposure compared with debondingminute elapsed after laser exposure compared with debonding
immediately after laser exposure.immediately after laser exposure.
Therefore, debonding ceramic brackets one by oneTherefore, debonding ceramic brackets one by one
immediately after exposure, before the adhesive resin materialimmediately after exposure, before the adhesive resin material
resolidifies, requires less debonding force.resolidifies, requires less debonding force.

According to comprehensive review done on Laser debonding ofAccording to comprehensive review done on Laser debonding of
ceramic brackets byceramic brackets by Ezz Azzeh and Paul J. Feldon (AJO 2003Ezz Azzeh and Paul J. Feldon (AJO 2003))
they concluded that:they concluded that:
 The time spent to debond ceramic brackets is less when usingThe time spent to debond ceramic brackets is less when using
lasers.lasers.
 Debonding forces are significantly reduced with lasers.Debonding forces are significantly reduced with lasers.
 The risk of enamel damage and bracket fracture is significantlyThe risk of enamel damage and bracket fracture is significantly
reduced with lasers.reduced with lasers.
 The CO2 super – pulse laser is superior to normal pulse CO2 andThe CO2 super – pulse laser is superior to normal pulse CO2 and
YAG lasers.YAG lasers.

 The use of monocrystalline brackets is suggested overThe use of monocrystalline brackets is suggested over
polycrystalline brackets.polycrystalline brackets.
 Ceramic brackets should be irradiated and debonded one by oneCeramic brackets should be irradiated and debonded one by one
immediately after laser exposure.immediately after laser exposure.
 The risk of pulpal damage is significantly reduced if the following areThe risk of pulpal damage is significantly reduced if the following are
used:used:
 Super – pulse CO2 laser at 2 W for less than 4 seconds.Super – pulse CO2 laser at 2 W for less than 4 seconds.
 CO2 laser for 3 seconds at 3 W.CO2 laser for 3 seconds at 3 W.
 CO2 laser ( normal pulse ) at 18 W for 2 seconds.CO2 laser ( normal pulse ) at 18 W for 2 seconds.

REMOVAL OF RESIDUAL ADHESIVEREMOVAL OF RESIDUAL ADHESIVE
 Because of the color similarity between present adhesives andBecause of the color similarity between present adhesives and
enamel, complete removal of all remaining adhesive is not easilyenamel, complete removal of all remaining adhesive is not easily
achieved.achieved.
 Many patients may be left with incomplete resin removal, which isMany patients may be left with incomplete resin removal, which is
not acceptable.not acceptable.
 Abrasive wear of present bonding resins is limited and remnantsAbrasive wear of present bonding resins is limited and remnants
are likely to become unesthetically discolored with time.are likely to become unesthetically discolored with time.

 The removal of excess adhesive may be accomplished byThe removal of excess adhesive may be accomplished by
1. Scraping with a very sharp band or bond-removing pliers or with1. Scraping with a very sharp band or bond-removing pliers or with
scaler.scaler.
2. Using a suitable bur and contra –angle.2. Using a suitable bur and contra –angle.
Although the first method is fast and frequently successful onAlthough the first method is fast and frequently successful on
curved teeth it is less useful on flat anterior teeth. Also, a risk exists ofcurved teeth it is less useful on flat anterior teeth. Also, a risk exists of
creating significant scratch marks.creating significant scratch marks.
The preferred alternative is to use a suitable dome tapered TC bur inThe preferred alternative is to use a suitable dome tapered TC bur in
a contra-angle handpiece. Clinical experience and laboratory studiesa contra-angle handpiece. Clinical experience and laboratory studies
indicate that approximately 30,000 rpm is optimal for rapid adhesiveindicate that approximately 30,000 rpm is optimal for rapid adhesive
removal without enamel damage.removal without enamel damage.

Light painting movements of the bur should be used so as not toLight painting movements of the bur should be used so as not to
scratch the enamel. Water cooling should not be employed when thescratch the enamel. Water cooling should not be employed when the
last remnants are removed because water lessens the contrast withlast remnants are removed because water lessens the contrast with
enamel.enamel.
When all adhesive has been removed, the tooth surface mayWhen all adhesive has been removed, the tooth surface may
be polished with pumice.be polished with pumice.

INFLUENCE ON ENAMEL BY DIFFERENTINFLUENCE ON ENAMEL BY DIFFERENT
DEBONDING INSTRUMENTSDEBONDING INSTRUMENTS
Zachrisson and ArtunZachrisson and Artun were able to compare different instrumentswere able to compare different instruments
commonly used in debonding procedures and rank their degreescommonly used in debonding procedures and rank their degrees
of surface marring on young permanent teeth.of surface marring on young permanent teeth.
 The study demonstrated thatThe study demonstrated that
1.1. diamond instruments were unacceptable; even finediamond instruments were unacceptable; even fine
diamond burs produced coarse scratches and gave a deeplydiamond burs produced coarse scratches and gave a deeply
rough appearance.rough appearance.
2.2. medium sandpaper disks and a green rubber wheelmedium sandpaper disks and a green rubber wheel
produced similar scratches that could not be polished awayproduced similar scratches that could not be polished away

 3.3. fine sandpaper disks produced several marked and some evenfine sandpaper disks produced several marked and some even
deeper scratches and a surface appearance largely resembling thatdeeper scratches and a surface appearance largely resembling that
of adult teeth.of adult teeth.
 4.4. plain cut and spiral fluted TC burs operated at about 25,000 rpmplain cut and spiral fluted TC burs operated at about 25,000 rpm
were the only instruments that provided the satisfactory surfacewere the only instruments that provided the satisfactory surface
appearance.appearance.
 5.5.none of the instruments tested left the virgin tooth surface with itsnone of the instruments tested left the virgin tooth surface with its
perikymata intact.perikymata intact.
The clinical implication of the study is that TC burs producedThe clinical implication of the study is that TC burs produced
the finest scratch pattern with the least enamel loss and are superiorthe finest scratch pattern with the least enamel loss and are superior
in their ability to reach difficult areas-pits, fissures,, and along thein their ability to reach difficult areas-pits, fissures,, and along the
gingival margingingival margin

AMOUNT OF ENAMEL LOST INAMOUNT OF ENAMEL LOST IN
DEBONDINGDEBONDING
 10 to 25 μm.10 to 25 μm.
 Pus and Way(AJO 1980)Pus and Way(AJO 1980) found a high-speed bur and green rubberfound a high-speed bur and green rubber
wheel removes approximately 20μm and a low-speed TC burwheel removes approximately 20μm and a low-speed TC bur
removes around 10μm of enamel.removes around 10μm of enamel.
 Van Waes etal(1997)Van Waes etal(1997) recently confirmed observations of a morerecently confirmed observations of a more
limited loss of enamel when TC burs are used cautiously. Theylimited loss of enamel when TC burs are used cautiously. They
found an average enamel loss of only 7.4 μm and concluded thatfound an average enamel loss of only 7.4 μm and concluded that
minimal enamel damage is associated with careful use of a TC burminimal enamel damage is associated with careful use of a TC bur
for removal of residual composite.for removal of residual composite.

ENAMEL TEAROUTSENAMEL TEAROUTS
 Redd TB(Jco1991)Redd TB(Jco1991) suggestedsuggested localized enamel tearoutslocalized enamel tearouts
have been reported to occur associated with bonding andhave been reported to occur associated with bonding and
debonding both metal and ceramic brackets.debonding both metal and ceramic brackets.
They may be related to the type of filler particles in theThey may be related to the type of filler particles in the
adhesive resin used for bonding and to the location of bondadhesive resin used for bonding and to the location of bond
breakage.breakage.
When comparisons were made between tooth surfaceWhen comparisons were made between tooth surface
appearances after debonding metal brackets attached with eitherappearances after debonding metal brackets attached with either
macrofilled (10 to 30μm) or microfilled (0.2 to 0.3μm) adhesives, amacrofilled (10 to 30μm) or microfilled (0.2 to 0.3μm) adhesives, a
difference occurred when the resin was scrapped off with pliers.difference occurred when the resin was scrapped off with pliers.

On debonding the small fillers reinforce theOn debonding the small fillers reinforce the
adhesive tags. The macrofillers, on the other hand, create a moreadhesive tags. The macrofillers, on the other hand, create a more
natural breakup-point in the enamel-adhesive interface. Similarly,natural breakup-point in the enamel-adhesive interface. Similarly,
with unfilled resins there is no natural breakpoint.with unfilled resins there is no natural breakpoint.
 The clinical implications isThe clinical implications is
1.1. To use brackets that have mechanical retention andTo use brackets that have mechanical retention and
debonding instruments and techniques that primarily leave all or thedebonding instruments and techniques that primarily leave all or the
majority of composite on the tooth.majority of composite on the tooth.
2.2. To avoid scraping away adhesive remnants with handTo avoid scraping away adhesive remnants with hand
instrument.instrument.

ENAMEL CRACKSENAMEL CRACKS
 Zachrisson BU et al (AJO 1980)Zachrisson BU et al (AJO 1980) The prevalance of cracks, theirThe prevalance of cracks, their
distribution per tooth, their location on the tooth surface and the typedistribution per tooth, their location on the tooth surface and the type
were described;were described;
1. Vertical cracks are common, but great individual variation.1. Vertical cracks are common, but great individual variation.
2. Few horizontal and oblique cracks are observed normally.2. Few horizontal and oblique cracks are observed normally.
3. No significant difference exists between the three groups with3. No significant difference exists between the three groups with
regard to prevalance and location of cracks.regard to prevalance and location of cracks.
4. The most notable cracks are on the maxillary central incisors and4. The most notable cracks are on the maxillary central incisors and
canines.canines.

 The clinical implication of these findingsThe clinical implication of these findings
1.1. observes several distinct enamel cracks on the patientsobserves several distinct enamel cracks on the patients
teeth after debonding, particularly on teeth other than maxillaryteeth after debonding, particularly on teeth other than maxillary
canines and central incisorscanines and central incisors
22. detects cracks in horizontal direction, this is an indication. detects cracks in horizontal direction, this is an indication
that the bonding or debonding technique used may needthat the bonding or debonding technique used may need
improvement.improvement.
With ceramic brackets, the risk for creating enamel cracks isWith ceramic brackets, the risk for creating enamel cracks is
greater than for metal brackets. The lack of ductility may generategreater than for metal brackets. The lack of ductility may generate
stress build-up in the adhesive-enamel interface that may producestress build-up in the adhesive-enamel interface that may produce
enamel cracks at debonding.enamel cracks at debonding.

ADHESIVE REMNANT WEARADHESIVE REMNANT WEAR
 Adhesive has been found on the tooth surface, even after attemptsAdhesive has been found on the tooth surface, even after attempts
to remove it with mechanical instruments.to remove it with mechanical instruments.
 Because of color resemblance to the teeth, particularly when wet,Because of color resemblance to the teeth, particularly when wet,
residual adhesive may easily remain undetected.residual adhesive may easily remain undetected.
 Brobakken and Zachrisson (AJO 1981)Brobakken and Zachrisson (AJO 1981)
Abrasive wear depends on the size, type and amount ofAbrasive wear depends on the size, type and amount of
reinforcing fillers in the adhesive. At the time of debonding, varyingreinforcing fillers in the adhesive. At the time of debonding, varying
amounts of adhesive were purposely left on the teeth assumed to beamounts of adhesive were purposely left on the teeth assumed to be
the most exposed to tooth brushing forces. Only thin films of residualthe most exposed to tooth brushing forces. Only thin films of residual
adhesive showed any reduction in size.adhesive showed any reduction in size.

 Gwinnett and Ceen (AJO 1978)Gwinnett and Ceen (AJO 1978) reported that small remanants ofreported that small remanants of
unfilled sealant did not predispose to plaque accumulation and didunfilled sealant did not predispose to plaque accumulation and did
begin to wear away with time. However, this finding can notbegin to wear away with time. However, this finding can not
automatically be transferred to different types of filled adhesives,automatically be transferred to different types of filled adhesives,
some of which have much greater wear resistance and accumulatesome of which have much greater wear resistance and accumulate
plaque more readily.plaque more readily.
 Brobakken and Zachrissons( AJO 1981)Brobakken and Zachrissons( AJO 1981) findings showed thatfindings showed that
residual filled adhesive will quickly disappear by itself afterresidual filled adhesive will quickly disappear by itself after
debonding; it appears irresponsible to leave large accumulations ofdebonding; it appears irresponsible to leave large accumulations of
adhesive.adhesive.

REVERSAL OF DECALCIFICATIONREVERSAL OF DECALCIFICATION
 White spots or areas of demineralization are carious lesions ofWhite spots or areas of demineralization are carious lesions of
varying extent.varying extent.
 The general conclusion was that individual teeth, banded or bonded,The general conclusion was that individual teeth, banded or bonded,
may exhibit significantly more white spot formation than untreatedmay exhibit significantly more white spot formation than untreated
control teeth.control teeth.
 In a multibonded techniqueIn a multibonded technique Gorelick et al (AJO 1982)Gorelick et al (AJO 1982) found thatfound that
50% of the patients experienced an increase in whitespots. The50% of the patients experienced an increase in whitespots. The
highest incidence was in the maxillary incisors, particularly thehighest incidence was in the maxillary incisors, particularly the
laterals. This obvious degree of iatrogenic damage suggests thelaterals. This obvious degree of iatrogenic damage suggests the
need for preventive programs using fluoride associated with fixedneed for preventive programs using fluoride associated with fixed
appliance orthodontic treatment.appliance orthodontic treatment.

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