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The European Journal of Orthodontics Advance Access originally published online on January 20, 2006
The European Journal of Orthodontics 2006 28(2):173-178; doi:10.1093/ejo/cji089
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© The Author 2006. Published by Oxford University Press on behalf of the European Orthodontics Society. All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org.

Self-etching primer and a non-rinse conditioner versus phosphoric acid: alternative methods for bonding brackets

Ascensión Vicente*, Luis A. Bravo* and Martín Romero**

Units of * Orthodontics and ** Pediatric Dentistry, Dental Clinic, University of Murcia, Spain

Address for correspondence Dr A. Vicente, Unit of Orthodontics, Dental Clinic, University of Murcia, Hospital Morales Meseguer, 2a planta, C/Marqués de los Vélez, s/n, 30008 Murcia, Spain, E-mail: ascenvi{at}um.es


   Summary
Top
 Summary
Introduction
 Materials and methods
 Results
 Discussion
 Conclusion
 References
 
The objective of this study was to evaluate the effectiveness of a self-etching primer, Transbond Plus Self Etching Primer (TSEP, 3M Unitek), and a non-rinse conditioner (NRC, Dentsply DeTrey) for bonding brackets, compared with the acid-etch technique. The brackets were bonded to extracted premolars using Transbond XT (3M Unitek). One of the following three conditioning protocols were used: (1) 37 per cent phosphoric acid (n = 25), (2) TSEP (n = 25), and (3) NRC (n = 15). Shear bond strength (SBS) was measured with a universal testing machine. The adhesive remaining after debonding was determined using image analysis equipment. Scanning electron microscope (SEM) observations were also carried out on 12 premolars to observe the enamel surfaces.

No significant differences were observed in SBS between the three groups (P = 0.56). TSEP and NRC left significantly less adhesive on the tooth than the traditional acid-etch technique (P = 0.004 and P = 0.000, respectively). NRC left significantly less adhesive than TSEP (P = 0.001). SEM observations showed that NRC produced a less aggressive etch pattern than TSEP, and that the etching effect of TSEP approximated that of phosphoric acid.


   Introduction
Top
 Summary
 Introduction
Materials and methods
 Results
 Discussion
 Conclusion
 References
 
Phosphoric acid and its derivatives were used for treating metallic surfaces in order to adhere paints, resins, etc. Based on this fact, Buonocore (1955)Go found an increase in the adhesion of acrylic materials used at that time when the enamel surface had been previously treated with an 85 per cent phosphoric acid solution for 30 seconds. This procedure resulted in one of the most important advances in dentistry, improving the nature of resin–enamel bonds and generating new clinical applications such as pit and fissure sealants, resin restorations, adhesion of orthodontic brackets, bridges, etc. (Hasshimoto et al., 2003Go)

It is estimated that the enamel surface lost during etching prior to the bonding of brackets is between 10 and 30 µm. On the other hand, removal of adhesive remnants on the enamel surface after debonding results in a reduction of enamel of approximately 55.6 µm (Bishara et al., 2000Go). One of the main research objectives in orthodontics concerning adhesion, is to improve the bonding procedure by minimizing the loss of enamel during the bonding and debonding of brackets without compromising the bond strength (Bishara et al., 2001aGo).

The effects of reducing the acid concentration (Wang et al., 1994Go; Bhad and Hazarey, 1995Go; Cartensen, 1995Go) and the time of application (Sheen et al., 1993Go; Osorio et al., 1999Go; Gardner and Hobson, 2001Go) have been investigated, as well the use of alternative acids (Urabe et al., 1999Go; Çehreli and Altay, 2000Go; Gardner and Hobson, 2001Go). Alternative methods to acid etching have also been proposed, such as air abrasion (Reisner et al., 1997Go; Canay et al., 2000Go; Van Waveren Hogerverst et al., 2000Go) or laser etching (Von Fraunhofer et al., 1993Go).

Alternatives to acid etching have recently been introduced in orthodontics in an attempt to reduce enamel loss and simplify bonding procedures. These methods include the use of self-etching primers and non-rinse conditioners (NRCs).

As the name suggests, an NRC etches the enamel without the need for rinsing. The literature concerning its use in orthodontics is limited. Çehreli and Altay (2000)Go observed that its application produced a smooth yet ‘adequately rough’ enamel surface for bonding. However, Bishara et al. (2001a)Go reported unacceptable bond strengths when combining an NRC with a compomer.

Self-etching primers combine etching and priming simultaneously; thus simplifying application. There is controversy concerning the use of self-etching primers to etch enamel. Some investigations show that they provide bond strengths comparable with those obtained with the acid-etch technique (Arnold et al., 2002Go; Cacciafesta et al., 2003Go; Dorminey et al., 2003Go) whilst others have observed significantly lower bond strengths (Bishara et al. 2001bGo, 2002Go; Yamada et al., 2002Go; Zeppieri et al., 2003Go).

The objective of this study was to evaluate the bonding effectiveness of a self-etching primer, Transbond Plus Self Etching Primer (TSEP, 3M Unitek Dental Products, Monrovia, California, USA), and an NRC (Dentsply DeTrey, Konstanz, Germany) in comparison with the traditional acid-etch technique. Scanning electron microscope (SEM) observations were also carried out to observe the enamel surfaces treated with each product.


   Materials and methods
Top
 Summary
 Introduction
 Materials and methods
Results
 Discussion
 Conclusion
 References
 

Teeth

Seventy-seven sound human maxillary premolars were used. These had been extracted for reasons unrelated to the objectives of this study and with the informed consent of the patients. The project was approved by the Murcia University Bio-ethical Commission.

The teeth were washed in water to remove any traces of blood and then placed in 0.1 per cent Timol solution. They were then stored in distilled water which was changed periodically to avoid deterioration. In no case was a tooth stored for more than 1 month after extraction.

For shear bond strength (SBS) testing, 65 premolars were used. The teeth were set in a 4 cm long copper cylinder with an internal diameter of 3 cm and their roots set in type IV plaster.

For SEM observations, 12 premolars were used.


Brackets

Sixty-five metal maxillary premolar brackets were used (Victory Series, 3M Unitek). The base area of each bracket was calculated (mean = 9.79 mm2) using image analysis equipment and MIP 4 software (Microm Image Processing Software, Digital Image Systems, Barcelona, Spain).


Bonding procedure

The maxillary premolars were divided into three groups and the brackets were bonded buccally. The manufacturers' instructions were followed throughout the study.

For all groups the buccal surfaces were polished with a rubber cup and a glycerine-free polishing paste (Détartrine, Septodont, Saint-Maur, France).

Group I (n = 25): Acid + Transbond XT primer + Transbond XT paste (3M Unitek). The teeth were etched with 37 per cent o-phosphoric acid gel (Total Etch, Ivoclar, Vivadent. Schaan, Liechtenstein) for 30 seconds, and then thoroughly washed and air dried. A layer of Transbond XT primer was applied to the tooth and Transbond XT paste applied to the base of the bracket which was then placed on the tooth with firm pressure. Excess adhesive was removed from around the base of the bracket and the adhesive was then light-cured, positioning the light guide of an Ortholux XT lamp (3M Unitek) on each interproximal side for 10 seconds.

Group II (n = 25): TSEP + Transbond XT paste. The enamel was treated with TSEP, which was gently rubbed onto the enamel for 3 seconds. A moisture-free air source was used to deliver a gentle burst of air to the enamel and the bracket bonded with Transbond XT paste as in group I.

Group III (n = 15): NRC + Transbond XT primer + Transbond XT paste. NRC was gently brushed onto the enamel leaving it undisturbed for 20 seconds. A moisture-free air source was used to deliver a gentle burst of air to the enamel and the bracket bonded with Transbond XT (primer and paste) as in group I.


Storage of test specimens

The specimens were immersed in distilled water at a temperature of 37°C for 24 hours (International Organization for Standardization, 1994Go).


Bond strength test

SBS was measured with a universal test machine (Autograph AGS-1KND, Shimadzu, Japan) with a 1 kN load cell connected to a metal rod with one end angled at 30 degrees. The crosshead speed was 1 mm/minute (International Organization for Standardization, 1994Go).

The teeth were set at the base of the machine so that the sharp end of the rod contacted the area between the base and the wings of the bracket, exerting a force parallel to the tooth surface in an occluso-gingival direction (Figure 1).


Figure 1
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  		Figure 1  Shear bond strength test.

 
The force required to debond each bracket was registered in newtons (N), and converted into megapascals (MPa) as a ratio of N to the surface area of the bracket (MPa = N/mm2).


Adhesive Remnant Index

The percentage of the surface of the bracket base covered by adhesive was determined using image analysis equipment (Sony dxc 151-ap video camera, connected to an Olympus SZ11 microscope (Digital Image Systems) and MIP 4 software (Digital Image Systems).

The estimation of the error of the method of the adhesive remnant quantification, obtained with the image analysis equipment was carried out as follows: the adhesive remaining on 25 brackets was measured with the image analysis equipment twice with a period of 6 months between the measurements. The results of the two measurements were compared with a t-test for two dependent samples. No significant differences were found (P < 0.05).

The percentage of the area with adhesive remaining on the tooth after debonding was obtained by subtracting the area of adhesive covering the bracket base from 100 per cent. Each tooth was then assigned an Adhesive Remnant Index (ARI) value according to the following criteria (Årtun and Bergland, 1984Go):

0 = No adhesive left on the tooth.
1 = Less than half of the adhesive left on the tooth.
2 = More than half of the adhesive left on the tooth.
3 = All the adhesive left on the tooth.
Possible enamel fractures were also registered macroscopically.


Statistical analysis

The Kolmogorov–Smirnov normality test, the Shapiro–Wilk normality test, and Levene's variance homogeneity test were applied to the bond strength data. As the data did not show a normal distribution, significant differences were evaluated using the Kruskal–Wallis test (P < 0.05).

Bond strength data were analysed with Kaplan–Meier survival analysis using the Breslow statistic (P < 0.05).

ARI values were analysed with Pearson's chi-square test. An analysis of corrected residuals was also carried out to detect particular associations for the different groups and ARI scores. Both statistical tests were repeated grouping the cases in categories with scores 0 and 1 or scores 2 and 3, with the aim of avoiding categories showing an expected frequency lower than 5. A significance level of P < 0.05 was set for both Pearson's chi-square test and the analysis of corrected residuals (residual > 2 implies P < 0.05).

The Kolmogorov–Smirnov, the Shapiro–Wilk test, and Levene's homogeneity test of variances were applied to the data for percentage of area of adhesive remaining on tooth. As there was neither homogeneity of variance nor a normal distribution, they were analysed using the Kruskal–Wallis test. To determine those groups which were significantly different, the Mann–Whitney test for two independent samples was used. In order to avoid an accumulation of errors due to multiple comparisons (to compare the three groups two by two, three comparisons were made) a Bonferroni correction was carried out. The significance level (P < 0.05) was modified by dividing by the number of comparisons made, and therefore P < 0.017 was considered significant.


SEM observation

SEM was used to observe the effect of conditioning with phosphoric acid, NRC, and TSEP on the buccal enamel surface. Twelve premolars were divided into three groups. The crowns were sectioned from the roots with a diamond disc at the cementolabial enamel junction, and each crown was cut longitudinally in a mesiodistal direction. Group 1: the enamel was polished with a rubber cup and polishing paste, etched with 37 per cent o-phosphoric acid gel for 30 seconds, followed by rinsing and drying. Group 2: the enamel was polished with a rubber cup and polishing paste, treated with TSEP and rinsed with acetone for 10 seconds to remove the self-etching primer (Kanemura et al., 1999Go). Group 3: the enamel was polished with a rubber cup and polishing paste, and NRC was applied to the enamel leaving it undisturbed for 20 seconds. A moisture-free air source was used to deliver a gentle burst of air to the enamel.

All specimens were cleaned in distilled water with ultrasonic agitation for 30 minutes and gently air dried. They were then fixed to SEM stubs, coated with gold and examined under a 6100 SEM (Joel Limited, Tokyo, Japan) operating at 15 kV. Representative images for the different surface treatments were captured digitally and stored in computer files.


   Results
Top
 Summary
 Introduction
 Materials and methods
 Results
Discussion
 Conclusion
 References
 
The results for bond strength are shown in Table 1. The Kruskal–Wallis test did not show significant differences (P = 0.56) between the groups (Table 1), nor did the Kaplan–Meier survival analysis detect significant differences in bond strength for the different groups (P = 0.53; Figure 2).


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  		Table 1 Shear bond strengths (MPa).

 

Figure 2
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  		Figure 2  Probability of failure of the different groups at particular shear stress values. P = 0.53.

 
Pearson's chi-square test showed significant differences (P < 0.05) for the ARI. The analysis of corrected residuals demonstrated that while the acid etching group was significantly associated (residue = 3.3) with ARI 2, NRC was associated with ARI 1 (residue = 3.6). TSEP was not significantly associated with any particular ARI (Table 2).


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  		Table 2 Adhesive Remnant Index (ARI).

 
Both tests were repeated grouping the values obtained for scores 0 and 1, and scores 2 and 3. Significant differences (P < 0.05) were also obtained when the chi-square test was applied, and a significant association was found for the acid etching group (residue = 3.3) in the ‘2 + 3’ category, and for NRC in the ‘0 + 1’ category (residue = 3.5). TSEP showed no significant associations (Table 3).


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  		Table 3 Adhesive Remnant Index (ARI) values grouped into categories.

 
The percentage of tooth area occupied by adhesive remnants is shown in Table 4. Kruskal–Wallis test detected significant differences. The Mann–Whitney testing for two independent samples showed that these differences were between the acid etch group and NRC (P = 0.000), the acid etch group and TSEP (P = 0.004), and TSEP and NRC (P = 0.001).


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  		Table 4 Percentage of tooth area occupied by adhesive.

 
Figure 3 shows the SEM observations. Treatment with NRC resulted in fine surface roughening and pitted enamel surfaces. The enamel treated with phosphoric acid showed a rougher surface, and an overall increase in microporosity was evident. The enamel treated with TSEP produced a porous surface, with the etching effect approximating that with use of phosphoric acid.


Figure 3
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  		Figure 3  Scanning electron micrographs of enamel after the application of (a) non-rinse conditioner, (b) 37 per cent phosphoric acid for 30 seconds, and (c) Transbond Plus Self Etching Primer.

 

   Discussion
Top
 Summary
 Introduction
 Materials and methods
 Results
 Discussion
Conclusion
 References
 
The results showed no significant differences in bond strength between the three groups and are in agreement with some in vitro investigations, which demonstrated comparable bond strengths when using TSEP and phosphoric acid as the conditioners (Arnold et al., 2002Go; Cacciafesta et al., 2003Go; Dorminey et al., 2003Go; Larmour and Stirrups, 2003Go). However, Zeppieri et al. (2003)Go observed that TSEP resulted in a significantly lower bond strength than the acid-etch technique. Conversely, Buyukyilmaz et al. (2003)Go found that the use of TSEP provided significantly greater bond strength than etching the enamel with phosphoric acid. Ireland et al. (2003)Go, in an in vivo study, stated that the percentage of bracket failure was greater using TSEP than the acid-etch technique.

Studies concerning the use of NRC for bonding brackets are limited. Bishara et al. (2001a)Go reported unacceptable bond strengths when using NRC together with a compomer. In an investigation on ground enamel, Sunico et al. (2002)Go observed no significant differences between etching the enamel with 36 per cent phosphoric acid for 30 seconds and using a NRC to adhere a composite resin.

Significant differences were observed in the ARI between the three groups. TSEP and NRC left significantly less adhesive on the tooth than the traditional acid-etch technique, and NRC left significantly less adhesive than TSEP. This is clinically advantageous as adhesive removal implies loss of enamel (Bishara et al., 2000Go) and less chairside time is required when removing adhesive.

These results are in agreement with others showing that TSEP left less adhesive on the tooth than when the acid-etching technique was used (Cacciafesta et al., 2003Go; Larmour and Stirrups, 2003Go). However, other investigators have found that TSEP left adhesive on the tooth that did not differ from that remaining when the enamel was conditioned with phosphoric acid (Buyukyilmaz et al., 2003Go; Zeppieri et al., 2003Go).

SEM observations showed that NRC produced a modest etch pattern when compared with TSEP, and that the etching effect of TSEP approximated that of phosphoric acid. These results agree with those of Pashley and Tay (2001)Go who observed that NRC produced a less aggressive etch pattern than a self-etching primer used in restorative dentistry, and furthermore that the etching effect of this self-etching primer was similar to the effect of phosphoric acid. NRC produced a less aggressive etch pattern than phosphoric acid and TSEP. Despite this, the etch pattern was sufficiently retentive for orthodontic bonding; its bond strength was comparable with TSEP and phosphoric acid.


   Conclusion
Top
 Summary
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusion
References
 
Both TSEP and NRC are adequate for bonding. However, caution must be exercised when extrapolating laboratory results to the clinical situation as there is a complex relationship between in vitro bond strength mean values and adhesive failures in vivo (Pickett et al., 2001Go). Therefore, in vivo research must follow in vitro investigations.


   References
Top
 Summary
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusion
 References
 

    Arnold R W, Combe E C, Warford Jr J H 2002 Bonding of stainless steel brackets to enamel with a new self-etching primer. American Journal of Orthodontics and Dentofacial Orthopedics 122: 274–276[CrossRef][Web of Science][Medline]

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    Bhad W A, Hazarey P V 1995 Scanning electron microscopic study and shear bond strength measurements with 5% and 37% phosphoric acid. American Journal of Orthodontics and Dentofacial Orthopedics 108: 410–414[CrossRef][Web of Science][Medline]

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