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British Journal of Oral and Maxillofacial Surgery 49 (2011) 404408

Effect of blood contamination on shear bond strength of orthodontic brackets and disinclusion buttons
Maria Francesca Sfondrini a , Sara Gatti a , Andrea Scribante a,b,
a b

Department of Orthodontics, University of Pavia, Pavia, Italy Department of Surgical Sciences, University of Pavia, Pavia, Italy

Accepted 21 June 2010 Available online 23 July 2010

Abstract Our aim was to assess the effect of blood contamination on the shear bonding strength and sites of failure of orthodontic brackets and bondable buttons. We randomly divided 160 bovine permanent mandibular incisors into 8 groups of 20 specimens each. Both orthodontic brackets (Step brackets, Leone, Sesto Fiorentino, Italy) and bondable buttons (Flat orthodontic buttons, Leone, Sesto Fiorentino, Italy) were tested on four different enamel surfaces: dry; contamination with blood before priming; after priming; and before and after priming. Brackets and buttons were bonded to the teeth and subsequently tested using a Instron universal testing machine. Shear bonding strength and the rate of adhesive failures were recorded. Data were analysed using the analysis of variance (ANOVA), Scheff tests, and the chi-square test. Uncontaminated enamel surfaces showed the highest bonding strengths for both brackets and buttons. When they were contaminated with blood, orthodontic brackets had signicantly lower shear strengths than bondable buttons (P = 0.0001). There were signicant differences in sites of failure among the groups for the various enamel surfaces (P = 0.001). Contamination of enamel by blood during bonding lowers the strength of the bond, more so with orthodontic brackets than with bondable buttons. 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Bond strength; Blood contamination; Orthodontic brackets; Disinclusion buttons

Introduction During exposure and orthodontically assisted eruption of impacted or ectopic teeth, one option is delaying bonding until they have healed1 ; in this case the soft tissues that cover the tooth must be excised or repositioned to expose the crown, and this can result in a poor gingival margin.2,3 The only option therefore is to bond either brackets or buttons to the tooth at the time of operation.4 The presence of blood makes it difcult to place an appliance on the unerupted tooth, so buttons or brackets may have to be rebonded, which is an unpleasant procedure for both patient and clinician.1

Corresponding author at: Istituto di Discipline Odontostomatologiche S. Palazzi, P.le Golgi 2, 27100 Pavia, Italy. Tel.: +39 0382 516223; fax: +39 0382 516223. E-mail address: andrea.scribante@unipv.it (A. Scribante).

Bonding of orthodontic brackets with composite resin adhesives requires a dry eld of operation, and contamination with uid during bonding can cause premature failure.58 Even momentary contamination with saliva or blood can adversely affect the bond, as etched enamel becomes wet, most of the porosities become plugged, and penetration of resin is impaired; this results in resin tags that are not long enough and in insufcient numbers.7 Previous studies that evaluated the effect of contamination on the strength of the bond between light-cured composites showed a signicant reduction in strength.1,912 We know of no published studies that have compared the shear bonding strength of conventional orthodontic brackets with that of bondable buttons. Accordingly, our aim was to measure and compare the shear bonding strength and the adhesive remnant index (ARI) score of a conventional orthodontic bracket and button bonded on to dry enamel, and enamel contaminated with

0266-4356/$ see front matter 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2010.06.011

M.F. Sfondrini et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 404408 Table 1 Procedures for bonding the different enamel conditions. Appliance Orthodontic bracket Groups 1 2 3 4 5 6 7 8 Method of bonding Etching Etching Etching Etching Etching Etching Etching Etching Drying Drying Drying Drying Drying Drying Drying Drying Blood Blood Blood Blood Primer Primer Primer Primer Primer Primer Primer Primer Blood Blood Blood Blood Bonding Bonding Bonding Bonding Bonding Bonding Bonding Bonding

405

Light-curing Light-curing Light-curing Light-curing Light-curing Light-curing Light-curing Light-curing

Disinclusion button

blood. Our null hypothesis was that there is no signicant difference in shear bonding strength and sites of failure among the various groups.

Materials and methods One-hundred-and-sixty freshly extracted permanent bovine mandibular incisors were collected from a local slaughterhouse and stored in a solution of 0.1% (w/v) thymol. The criteria for the selection of teeth included intact buccal enamel with no cracks caused by extraction, and no caries. The teeth were cleaned of soft tissue and embedded in cold-curing, fast-setting acrylic (Leocryl, Leone, Sesto Fiorentino, Italy). Metal rings (15 mm in diameter) were lled with acrylic resin and allowed to cure, so encasing each specimen while allowing the buccal surface of the enamel to be exposed. Each tooth was oriented so that its labial surface was parallel to the shearing force. Teeth were randomly divided into 8 groups of 20 specimens each. Orthodontic stainless steel maxillary central incisor brackets (Step brackets, Leone, Sesto Fiorentino, Italy Code: F6122-11 base area: 14.4 mm2 ) and stainless steel orthodontic buttons (Flat orthodontic buttons, Leone, Sesto Fiorentino, Italy - Code: F2860-00 base area: 7.05 mm2 ) were used. Both brackets and buttons were tested on four different enamel surfaces: dry; contaminated with blood before priming; contaminated with blood after priming; and contaminated with blood both before and after priming. Before bonding, the labial surface of each incisor was cleaned for 10 s with a mixture of water and uoride-free pumice in a rubber polishing cup with a low-speed handpiece. The enamel surface was rinsed with water to remove pumice or debris and then dried in an oil-free air stream. Bonding procedures are shown in Table 1. Teeth were etched with 37% phosphoric acid gel (3M Unitek, Monrovia, CA, USA) for 30 s, then thoroughly washed and dried. A thin layer of primer (Ortho Solo; Ormco, Glendora, CA) was applied to the etched enamel, and then the brackets were bonded with a resin (Transbond XT, 3M Unitek, Monrovia, CA) near the centre of the facial surface of the teeth with sufcient pressure to express excess adhesive, which was removed from the margins of the bracket base with a scaler before polymerisation. To achieve reproducible conditions,

the teeth treated under conditions 2, 3, and 4 were contaminated with fresh human blood from 1 female donor; the blood was applied with a brush on to the labial surfaces until they were totally contaminated. Brackets were then light-cured with a visible light-curing unit (Ortholux XT, 3M Unitek, Monrovia, CA, USA) for 10 s on the mesial side of the bracket and for 10 s on the distal side (total cure time 20 s). After they had been bonded, all samples were stored in distilled water at room temperature for 24 h and then tested in a shear mode on a universal testing machine (Model 4301, Instron, Canton, MA, USA). Specimens were secured in the lower jaw of the machine so that the base of the bonded bracket was parallel to the direction of shear force. Specimens were stressed in an occlusogingival direction at a crosshead speed of 1 mm/min using a steel rod with a attened end attached to the crosshead of the Instron machine, as in previous studies.1315 The maximum load necessary to break the bond or to cause the bracket to fracture was recorded in Newtons (N) and then converted into MPa as a ratio of N:surface area of the bracket. After failure, the bases of the brackets and the enamel surfaces were examined by the same operator under an optical microscope (Stereomicroscope SR, Zeiss, Oberkochen, Germany) at 10 magnication. The ARI was used to assess the amount of adhesive left on the surface of the enamel.16 This scale ranges from 0 to 3: 0 indicates that there was no adhesive on the tooth in the bonded area; 1 indicates that less than half of the adhesive remained on the tooth; 2 indicates that more than half of the adhesive remained on the tooth; and 3 indicates that all the adhesive remained on the tooth. The ARI scores were used as a more complex way of distributing blame for the failure of the bond among the enamel, the adhesive, and the base of the bracket. Data were analysed with the help of Stata 7.0 software (Stata, College Station, TX, USA). Descriptive statistics, including the mean (SD) and median (range) were calculated for all groups (Fig. 1). An analysis of variance (ANOVA) test was used to calculate the signicance of differences among groups in values that indicated the strength of the bond. The Scheff test was used post hoc. The chi-square test was used to assess the signicance of differences in the ARI scores among the different groups. Probabilities of less than 0.05 were accepted as signicant.

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Fig. 1. Mean (SD) shear bond strengths (MPa) of the two appliances under the four different testing conditions (1 = no contamination; 2 = blood contamination before priming; 3 = blood contamination after priming; 4 = blood contamination before and after priming).

Results Descriptive statistics for the strength of the shear bond (MPa) of the different brackets are shown in Table 2. The ANOVA indicated that there were signicant differences among the various groups ((P = 0.0001), see Table 2). Post hoc testing showed that groups 1 and 5 (brackets and buttons on to dry enamel) had the highest shear bonding strength (P < 0.001) and there was no signicant difference between them (P = 0.313). Groups 6, 7, and 8 (disinclusion button on to contaminated enamel) had lower bonding strengths (P < 0.001), and showed no signicant difference among them (P = 0.236). Groups 2, 3, and 4 (orthodontic bracket on to contaminated enamel) had the lowest bonding strengths and no signicant difference among them (P = 0.265). The results of ARI scores are shown in Table 3. There were more ARI scores of 2 for the uncontaminated enamel groups (1 and 5) (P = 0.018), but there was no signicant difference between them (P = 0.171). Groups 2, 3, and 4 had more ARI scores of 0 and there were no signicant differences among them (P = 0.104). Groups 6, 7, and 8 had more ARI scores of 1 and there were no signicant differences among the groups (P = 0.0001).

Discussion The null hypothesis of the study has been rejected. Conventional brackets and buttons bonded on to dry enamel had signicantly higher shear bonding strength than other groups and there were no signicant differences among them. Appliances bonded on to contaminated enamel had signicantly lower shear strengths, which is in agreement with previous investigations that evaluated shear bonding strength of orthodontic brackets bonded on to enamel contaminated with blood using conventional,912 self-etching,15 and hydrophilic primers.17 Blood seems to be a physical barrier that impedes the mechanical retention of the adhesive to the etched tooth. To our knowledge there are no published studies that have evaluated the bonding strength of bondable buttons on to dry or contaminated enamel. When we tested them on contaminated enamel, bondable buttons had signicantly higher shear strengths than conventional brackets. Contamination of the surface of the enamel can occur at different critical times in the bonding procedure: after the surface of the tooth has been etched, after the primer has been applied, and after both procedures.15 In this study we found no signicant differences, either for bondable buttons

Table 2 Descriptive statistics (MPa) of shear bond strengths of the 8 groups tested (n = 20 in each group). Bracket = orthodontic bracket; button = disinclusion button. Groups 1 and 5 did not differ signicantly from each other; neither did groups 24, or 68. Appliance Orthodontic Bracket Group 1 2 3 4 5 6 7 8 Contamination Dry Before priming After priming Before and after Dry Before priming After priming Before and after Mean 12.65 1.29 2.28 1.75 12.27 5.74 6.35 5.63 SD 3.96 1.05 1.69 1.38 0.85 2.37 2.45 2.84 Min 5.00 0.21 0.18 0.13 10.49 2.36 1.56 0.42 Median 11.53 0.90 2.00 1.16 12.34 5.97 5.18 6.65 Max 21.46 4.21 6.49 6.10 13.54 10.70 13.06 18.43

Button

M.F. Sfondrini et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 404408 Table 3 Distribution of adhesive remnant index (ARI) scores (%). Groups 1 2 3 4 5 6 7 8 Contamination Orthodontic bracket: dry environment Orthodontic bracket: blood before priming Orthodontic bracket: blood after priming Orthodontic bracket: blood before and after priming Disinclusion button: dry environment Disinclusion button: blood before priming Disinclusion button: blood after priming Disinclusion button: blood before and after priming ARI = 0 0 12 (60) 13 (65) 14 (70) 0 6 (30) 3 (15) 6 (30) ARI = 1 0 5 (25) 5 (25) 6 (30) 1 (5) 12 (60) 14 (70) 11 (55) ARI = 2 16 (80) 3 (15) 1 (5) 0 14 (70) 2 (10) 2 (10) 3 (15)

407

ARI = 3 4 (20) 0 1 (5) 0 5 (25) 0 1 (5) 0

or for conventional orthodontic brackets, under the different conditions of contamination. We found no signicant differences for either bondable buttons or orthodontic brackets among the three degrees of contamination. The time at which the blood contamination occurred during bonding, therefore, had no signicant inuence on the strength of the bond. These results agree with those previously reported in other investigations using conventional brackets bonded with different adhesive systems on blood-moistened enamel surfaces.15,17 When shear strength is evaluated in dry rather than contaminated conditions, adhesive forces decrease less when buttons are used than when brackets are used. A possible explanation could be the smaller dimensions of the area of the bonding pad of buttons that could allow a better t to the enamel surface. We used permanent lower incisor teeth. Previous studies have shown that bovine and human enamel are similar in their physical properties, composition, and bonding strengths.18,19 Bovine enamel has been reported to be a reliable substitute for human enamel in bonding studies.1820 Bovine mandibular incisors were therefore used in the present study because they were readily available and inexpensive, and have a close morphological similarity to human enamel. Reynolds and von Fraunhofer21 suggested that a minimum bond strength of 68 MPa was adequate for most clinical orthodontic needs, because these strengths can withstand masticatory and orthodontic forces. In this study, the bonding strengths of both bondable buttons and conventional brackets bonded on to dry enamel surfaces were above these limits. A wide range of values was reported for uncontaminated specimens of brackets, probably as a result of possible imperfection in bonding procedures or in application of the load. Nevertheless these ndings are in accordance with those reported by other authors who tested the same adhesive system in dry conditions.22 When appliances were tested on blood-contaminated enamel, the minimum bonding requirement was not achieved using orthodontic brackets, independently of the time of contamination. This is in agreement with previous investigations that evaluated the shear bonding strength of conventional orthodontic brackets bonded on to enamel contaminated with blood.15,17,23 Using bondable buttons, bonding strengths were closer to the minimum adequate clinical values,21 sug-

gesting that the clinician would prefer them to orthodontic brackets when bonding in critical conditions on to contaminated enamel. A possible explanation could be the different design of the appliance, or the different retention of the mesh pad, or both. We recorded ARI scores. Uncontaminated enamel groups had more ARI scores of 2. After contamination with blood, conventional brackets had more ARI scores of 0, whereas bondable buttons showed more ARI scores of 1. This is in agreement with previous investigations that evaluated ARI scores of orthodontic brackets bonded on to enamel contaminated with blood,15,17 which all showed lower scores for groups contaminated with blood.1,15,17,23 To date we know of no studies that have evaluated ARI scores of bondable buttons. Testing two products (brackets and buttons) from a single manufacturer could be a limitation of the present investigation. Further studies are therefore needed to support or contradict the results of this research.

Acknowledgements The authors wish to thank Leone and 3M/Unitek and Ormco for providing the materials tested in this study.

References
1. Hobson RS, Ledvinka J, Meechan JG. The effect of moisture and blood contamination on bond strength of a new orthodontic bonding material. Am J Orthod Dentofacial Orthop 2001;120:547. 2. Wisth PJ, Nordenval K, Boe OE. Periodontal status of orthodontically treated impacted maxillary canines. Angle Orthod 1976;46:6976. 3. Kohavi D, Becker A, Zilberman Y. Surgical exposure, orthodontic movement, and nal tooth position as factors in periodontal breakdown of treated palatally impacted canines. Am J Orthod 1984;85:727. 4. Reddy L, Marker VA, Ellis III E. Bond strength for orthodontic brackets contaminated by blood: composite versus resin-modied glass ionomer cements. J Oral Maxillofac Surg 2003;61:20613. 5. Zachrisson BJ. A posttreatment evaluation of direct bonding in orthodontics. Am J Orthod 1977;71:17389. 6. Gwinnett AJ. Bonding of restorative resins to enamel. Int Dent J 1988;38:916. 7. Hormati AA, Fuller JL, Denehy GE. Effects of contamination and mechanical disturbance on the quality of acid-etched enamel. J Am Dent Assoc 1980;100:348.

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M.F. Sfondrini et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 404408 16. rtun J, Bergland S. Clinical trials with crystal growth conditioning as an alternative to acid-etch enamel pretreatment. Am J Orthod 1984;85:33340. 17. Cacciafesta V, Sfondrini MF, Scribante A, De Angelis M, Klersy C. Effects of blood contamination on the shear bond strengths of conventional and hydrophilic primers. Am J Orthod Dentofacial Orthop 2004;126:20712. 18. Nakamichi I, Iwaku M, Fusayama T. Bovine teeth as possible substitutes in the adhesion test. J Dent Res 1983;62:107681. 19. Oesterle LJ, Shellhart WC, Belanger GK. The use of bovine enamel in bonding studies. Am J Orthod Dentofacial Orthop 1998;114: 5149. 20. Barkmeier WW, Erickson RL. Shear bond strength of composite to enamel and dentin using Scotchbond Multi-Purpose. Am J Dent 1994;7:1759. 21. Reynolds IR, von Fraunhofer JA. Direct bonding of orthodontic brackets: a comparative study of adhesives. Br J Orthod 1976;3: 1436. 22. Northrup RG, Berzins DW, Bradley TG, Schukit W. Shear bond strength comparison between two orthodontic adhesives and self-ligating and conventional brackets. Angle Orthod 2007;77:7016. 23. Oztoprak MO, Isik F, Sayinsu K, Arun T, Aydemir B. Effect of blood and saliva contamination on shear bond strength of brackets bonded with 4 adhesives. Am J Orthod Dentofacial Orthop 2007;131: 23842.

8. Silverstone LM, Hicks MJ, Featherstone MJ. Oral uid contamination of etched enamel surfaces: an SEM study. J Am Dent Assoc 1985;110:32932. 9. Xie J, Powers JM, McGuckin RS. In vitro bond strength of two adhesives to enamel and dentin under normal and contaminated conditions. Dent Mater 1993;9:2959. 10. Sayinsu K, Isik F, Sezen S, Aydemir B. Light curing the primer-benecial when working in problem areas? Angle Orthod 2006;76:3103. 11. Faltermeier A, Behr M, Rosentritt M, Reicheneder C, Mssig D. An in vitro comparative assessment of different enamel contaminants during bracket bonding. Eur J Orthod 2007;29:55963. 12. Sayinsu K, Isik F, Sezen S, Aydemir B. Effect of blood and saliva contamination on bond strength of brackets bonded with a protective liquid polish and a light-cured adhesive. Am J Orthod Dentofacial Orthop 2007;131:3914. 13. Jobalia SB, Valente RM, de Rijk WG, BeGole EA, Evans CA. Bond strength of visible light-cured glass ionomer orthodontic cement. Am J Orthod Dentofacial Orthop 1997;112:2058. 14. Millett DT, Cattanach D, McFadzean R, Pattison J, McColl J. Laboratory evaluation of a compomer and a resin-modied glass ionomer cement for orthodontic bonding. Angle Orthod 1999;69:5864. 15. Sfondrini MF, Cacciafesta V, Scribante A, De Angelis M, Klersy C. Effect of blood contamination on shear bond strength of brackets bonded with conventional and self-etching primers. Am J Orthod Dentofacial Orthop 2004;125:35760.