Professional Documents
Culture Documents
– An in vivo study
Dissertation submitted to
BRANCH V – ORTHODONTICS
MARCH - 2010
1
CERTIFICATE
It has not been submitted (partially or fully) for the award of any other degree
or diploma.
2
Acknowledgement
3
My heartfelt thanks to my wonderful batch mates, Dr.Biju Tom,
Dr.Chintan Valia, Dr.Prabhu, Dr.Rajkumar, Dr.Preethy, Dr.Kartik Mani, and
Dr. Kaberi who were cheerfully available at all times to help me. I wish them a
successful career ahead.
I also extend my gratitude to my juniors Dr. Kavitha, Dr. Subu Thomas, Dr.
Fayaz, Dr. Ritika, Dr. Amey, Dr. Vashi, Dr. Goutham, Dr. Geetha, Dr. Ashwin,
Dr. Ayush, Dr. Sheel, Dr. Sreesan, Dr. Vinod, Dr. Saravanan, Dr. Sabitha and Dr.
Mahalaxmi for all their support and for cooperating with me to conduct this study
on their patients.
I thank Mrs. DEEPA, for helping me with the statistical analysis for the
study.
I would like to thank Sisters Lakshmi & Rathi & Mrs. Marina, Kanaka,
Azeena, Ms. Sreedevi & MR. SATHYAN for their co-operation and help during my
post-graduate course.
4
CONTENTS
1. Introduction 1
2. Review of Literature 6
4. Results 37
5. Discussion 41
6. Bibliography 56
5
Introduction
6
INTRODUCTION
Since the advent of the acid etch technique by Buonocore 10 and the
separation, improved oral hygiene and esthetics, and reduced chair time.
the number of steps for bonding procedures and minimizing the incidence
with a slurry of pumice in water with a slow speed hand piece. It is then
by washing with water and air drying with oil-free compressed air until
painted on the etched enamel, the bracket is placed on the tooth, and the
adhesive is cured.
7
Recent advances in dental bonding chemistry allow the
combination of the etchant and primer into one product called a self-etch
chair time during bonding. Questions about resultant bond strengths have
These self etching agents are 6th generation bonding agents that
2-step etching and priming, then the reduced chair time should make the
SEPs were recently reported to save 10.2 seconds per tooth, for a
total of 204 seconds (3.4 minutes) when bonding 20 teeth. The benefits of
fewer bonding steps and less chair time should be weighed against the
8
In vitro studies have shown that bond strength produced by Self
acquired organic pellicle through the use of pumice applied with a rubber
acquired pellicle.
conventional etch but disregarded the pumice prophylaxis step for all
groups. They found significantly more bond failures in the Self etching
primer group. Self etching primer has been shown to produce a weaker
9
A commonly studied SEP is Transbond Plus (3M Unitek,
bond strengths when used with Transbond XT adhesive. This system uses
2 liquids that must be mixed before use. Transbond Plus SEP contains
acid ester. Instead of rinsing the calcium away, it forms a complex with
the phosphate group that is incorporated into the network when the
enamel. First, the acid groups attached to the etching monomer are
Second, the air burst drives the solvent from the primer, increasing the
viscosity and slowing the transport of acid groups to the enamel surface.
Finally, as the primer is light cured and the monomers are polymerized,
inserted into a hand held dispenser. Upon manual compression into a light
10
impervious mixing well, enough solution is dispensed to prepare the
efficacy of the Reliance SEP with the conventionally used self etching
primers.
bracket bond failure rate of the Transbond Plus SEP with the Reliance
patients.
11
Review of Literature
12
REVIEW OF LITERATURE
brackets.
between the deep, untouched dentin layers and the composite filling
material. This resin-dentin inter diffusion zone offers bonding sites for
13
and the maximum bond strength (10.4 MPa) was obtained at a
a primer.
primer". The 20P-30H solution was applied to "intact" dentin (i.e., non-
groups. SEM and TEM observations revealed that the 20P-30H self-
the hybrid layer was not defective, and that bonding was stable.
treated with Clearfil Liner Bond 2 and the mean shear bond strengths
were in the range of 18.1 MPa to 25.9 MPa, and they use of alternative
14
etchants resulted in the deepest etching patterns. Regardless of the
alternative etchant used, the use of the self-etching primer did not affect
dentin by shear bond test and SEM observation. Good bond strengths to
MPa). These findings suggested that good adhesion to enamel and dentin
bonding application. Clearfil Liner Bond 2/Clearfil AP-X (Group I), Etch
15
except comparison of Group I and II, and Group I and IV. The results
Rosa BT, Perdigão J.(2000)51 , determined the enamel and dentin bond
enamel.
They concluded that enamel shear bond strengths after thermal cycling of
16
smear layer was not removed but was denatured by the acid treatment; the
mineral was trapped in this gelatinous matrix and shielded from complete
reaction.
were found between the groups (p < 0.001). The mean value for groups,
GLU, KU, CLB and SE was 24 MPa. The shear bond strength recorded
Clearfil Mega Bond exhibited the mildest etching patterns, while Prompt
control group. When the self-etching adhesives were replaced with the
17
control adhesive after etching, bond strengths of NRC/Prime&Bond NT
and Prompt L-Pop were not significantly different from that of the control
group, but were significantly higher than that of Clearfil Mega Bond. The
significance is that both etching efficacy and strength of the resins are
unground enamel.
group. The adhesive remnant index scores indicated that there was
the new self-etch primer than those treated with the conventional
adhesive system.
methacrylates (Clearfil Liner Bond 2, Clearfil SE Bond, Etch & Prime 3.0
18
and Resulcin AquaPrime) compared with conventional phosphoric acid
dissolve the peripheral and central part of the enamel crystallites, while
one of four protocols: (1) a composite resin adhesive used with 40%
phosphoric acid, (2) the same composite resin used with Megabond self-
with 10% polyacrylic acid enamel conditioner, and (4) the same resin-
19
They concluded that Megabond self-etching primer treatment produced
less enamel dissolution than did etching with phosphoric acid and
enamel in vitro with the Transbond Plus Self Etching Primer. Forty-eight
extracted human teeth were obtained and randomly divided into 4 groups
of 12: (1) control group with a conventional etchant and separate primer,
(2) experimental group with the self-etching primer, left for 15 seconds
before bonding, (3) same as group 2, but with the primer left for 2
minutes before bonding, (4) same as group 2, but with the primer left for
enamel surface would not affect the enamel microtensile bond strengths
20
of self-etching adhesive materials and concluded that commercial self-
mean bonding time, mean shear bond strength and mean survival time of
etch and prime system. The SEP significantly reduced bracket bonding
time. The mean shear bond strength of the brackets bonded with the SEP
was significantly less than the conventional two-stage etch and prime
13.31) indicated that the shear bond strengths of the 4 groups were
21
drop in the shear bond strength of orthodontic brackets.
Oliveira SS, Pugach MK, Hilton JF, Watanabe LG, Marshall SJ,
and total-etch (SB) bonding systems. Results showed SBS was lower
when SB was used than when SE was used. SBS decreased with
water and saliva contamination on the shear bond strength and bond
(Transbond XT). They concluded that the self-etching primer was the
bonded with the self-etching primer under the various enamel conditions.
22
Anthony J. Ireland, Helen Knight, Martyn Sherriff, (2003) 24
brackets after using either the Transbond Plus Self- Etching Primer
result in a higher bond failure rate than conventional enamel acid etching
and priming.
with Superbond C&B. They concluded that the MMA-based resin cement
23
enamel etching with 37% phosphoric acid provided statistically
system. However, in dentin, for Clearfil Liner Bond 2V, phosphoric acid
shear bond strength of the 2-component acid etch primer was 5.9 +/- 2.7
MPa, and the mean for the 1-component system was 6.6 +/- 3.2 MPa.
They concluded that the clinician should consider the bond strength and
systems.
etchant for preparing the enamel surface and the use of Megabond saves
water-rinsing time and leads to less enamel surface loss when debonding.
24
In addition, saliva contamination does not affect the bond strength, and
repeat treatment with the self-etching primer is not necessary after saliva
contamination.
mean clinical chair-side time required for bracket bonding and the mean
concluded that the mean bracket bonding time with the SEP per patient
was significantly shorter than that of the two-stage bonding system (P <
0.001). The difference between the overall bond failure rate and the mean
bond failure rate per patient for the two bonding systems was not
that the application of fluoride varnish does not affect the bond strength
25
of orthodontic brackets to enamel with conventional or self-etching
primer systems.
lowest mean shear-peel bond strength values were noted at the 30-day
L-Pop and the resin orthodontic adhesive system Transbond XT. Their
of SEPs has a lesser influence on the reduction of the shear bond strength
failure rate of 2 SEPs (Transbond Plus Self Etching Primer and One Step
26
and 8.10% for One-Step. Although significantly more failures were found
assessed the long-term in vivo failure rate of tubes bonded to first and
were all significantly lower (P < .05) than that of the control group
(Prompt L-Pop, 1.72 +/- 0.13 MPa; Clearfil SE Bond, 1.75 +/- 0.19 MPa;
FL Bond, 1.71 +/- 0.22 MPa; One-Up Bond F, 1.77 +/- 0.14 MPa;
control, 10.5 +/- 0.86 MPa) but not different from one another (P > .05).
produced bond strength values much lower than the control and that
27
bonding in terms of the shear bond strength achieved after thermal
They concluded that the SEP was more conservative and produced a
acid system.
Sunil Hirani and Martyn Sherriff (2006)23 compared the shear bond
or 37 per cent phosphoric acid as the conditioner. They found the shear
( P < 0.05) than their initial SBS and the locus of bond failure altered
28
a conventional acid-etched technique with control adhesive (Transbond).
between the clinical bond failure rates for brackets bonded using a self-
per cent phosphoric acid and primer method, and that the bond failure
29
Julio Pedra e Cal-Neto; Felipe Carvalho; Rhita Cristina C. Almeida;
primer/adhesive was 5.9 +/- 2.7 Mpa and the mean for the one-step
system was 3.1 +/- 1.7 MPa. The results showed that the shear bond
conditioning with phosphoric acid and Prompt L-Pop (PLP) on the shear
30
the shear bond strength of CG to dentin but did not affect DAP. The
different from PBNT (Prime & Bond NT) or CPNE (Compobond NE).
bonding systems; Transbond Plus SEP (3M Unitek) and Ideal 1 SEP
Ideal 1 SEP bonding system had 3 times as many bracket failures as the
Transbond Plus SEP bonding system; and that clinicians should consider
the many associated costs of bracket failures (chair time, material costs)
time of placement on the teeth, even with light and heavy saliva
contamination.
31
Ascensio´n Vicente; Luis Alberto Bravo (2007)64 tested the hypothesis
that there were no significant differences in the shear bond strength or the
found that there was no significant difference in the bond strength of the
times of 5, 15, 30, and 60 minutes and 24 hours. Highest SBS was
obtained with a debond time of 24 hours for the CM group (16.82 MPa)
and the SEP group (19.11 MPa) They concluded that adequate SBS was
obtained with self-etching primer during the first 60 minutes (5, 15, 30
and 60 minutes) when compared with the conventional method and that it
bond strengths (SBSs) of a self etching primer (SEP) after 0, 2000, and
32
SEP (Transbond Plus) was applied. In the control group, SBSs did not
cycles. However, in group SEP, SBSs decreased with 2000 and 5000
primer [conventional method (CM)]. The chair time required for bonding
was also evaluated. The failure rates were 0.6 per cent for both bonding
procedures. The failure and survival rates did not show significant
failure rate and a lower survival rate than incisor and canine brackets.
This finding indicates that SEP can be effectively used for bonding of
SEP per tooth was significantly shorter than with the CM.
33
in reducing bond failures. A split-mouth design was used; in each patient,
group. A total of 508 teeth were bonded with SEP (Transbond Plus; 3M
Unitek) and monitored for 3 months for bond failures. Thirty-five failures
(6.9%) were recorded, with 6 (2.4%) in the pumice group and 29 (11.4%)
bond failure rate was demonstrated with Transbond Plus SEP after
need for pumice prophylaxis when using SEP for orthodontic bonding.
or 72 hours of acidic challenge with Ten Cate solution (pH 4.46), the
rhodomine B dye to evaluate les ions, lesion depths, area of lesions, and
34
incidence of lesion was 50% in the sealant group and 100% in both the
SEP and the control group. The lesion in the sealant group was present
only when the sealant integrity was broken. These results suggest that
demineralization.
concluded that using a SEP might save chair time and improve cost-
35
effectiveness, but it provides less resistance to enamel decalcification
shear bond strength (SBS) of orthodontic brackets bonded with the same
randomly divided into 7 groups (20 per group). In group I (control), the
enamel was etched with 37% phosphoric acid. In the other groups, it was
group II, Transbond Plus SEP (3M Unitek); group III, AdheSE (Ivoclar
Vivadent AG); group IV, Primers A and B (Shofu, Kyoto, Japan); group
(3M Unitek), and the teeth were then stored, tested, and statistically
analyzed. The adhesive remnant index (ARI) was also recorded. The
results showed that Group I had a significantly higher SBS value than the
among groups II, V, VI, and VII. The values for groups I, II, and VI were
36
III and the value for group IV was significantly lower than the values for
groups I, II, V, VI, and VII. Significant differences were found in the ARI
scores. This study concluded that the SBS values of all groups might be
SEPs. However, since the SEPs used in groups III and IV significantly
in 24 patients with the SEPs. The observation period was 12 months. One
week after bonding and at every third recall, the plaque index and a visual
rating of the enamel adjacent to the bracket were assessed at the lateral
incisors and the first premolars. Over the investigation time, 26 failures
were recorded. Five occurred with the brackets bonded with Transbond
Plus, and the rest with Clearfil Protect Bond (P = 0.002). This study
concluded that the failure rate with Clearfil Protect Bond was
37
Julio Pedra e Cal-Neto, Catia Abdo Quintao, Marco Antonio de
They were randomly assigned to either the TBXT or the SEP group. A
patient sex were compared with the log-rank test. The failure rates of the
sex were analyzed, only tooth location was significant. Posterior brackets
were more likely to fail than anterior brackets (P = 0.013). The study
concluded that both systems had low bond failure rates and are adequate
38
etching Primer; and at how each responded when contaminated with
either saliva or water. They found that in five of the six groups that
compared the primers, Reliance SEP had the highest bond strengths.
However, for two of the groups, the measurements were not significantly
In all six groups, GAC Ideal 1 had the lowest bond strengths. They
39
Materials and Methods
40
MATERIALS AND METHODS
The materials and methodology used in this study are described below.
MATERIALS
2. Brackets:
3. Adhesive:
TM
Transbond XT (Composite resin), a light-cured composite paste was
TM
3M Ortholux XT curing light, visible light range – 400 to 500 nm,
41
5. Other materials and armamentarium used were:
pumice.
Suction unit.
METHODOLOGY
subject.
42
All teeth were pumiced and rinsed, and extra care was taken to
remove any calculus. A split – mouth design was used. For each patient
the SEPs were used in alternating quadrants so that they were distributed
equally on the left and right sides. The SEPs were applied according to
SEP (3M Unitek) on the maxillary right and the mandibular left
quadrants; and the Reliance SEP on the maxillary left and mandibular
with the Reliance SEP on the maxillary right and mandibular left
quadrants and the Transbond Plus SEP on the maxillary left and
mandibular right quadrants. This totaled to 320 teeth being bonded; out of
which 160 teeth were bonded with the Transbond Plus SEP and the other
permanent molars.
43
Patients requiring extraction for orthodontic treatment; provided
Recording of failed brackets involved only first time failures, and the
study was conducted till the leveling and aligning stage of treatment was
completed.
44
ARMAMENTARIUM USED IN THE STUDY
45
TRANSBOND PLUS S.E.P.
RELIANCE S.E.P.
46
Results
47
RESULTS
Group A and Group B, of ten patients each. All patients had a pumice
brackets were bonded using the Transbond Plus Self Etching Primer and
This totaled to 160 brackets bonded with the Transbond Plus SEP and
STATISTICAL TEST:
bracket bond failure rate, between the two groups, with a 5% level of
48
Table 1
No. OF
PRODUCT BRACKET FAILURE
P - VALUE
BOND PERCENTAGE
FAILURES
4.5
4
3.5
3
2.5
Transbond Plus
2
Reliance S.E.P.
1.5
1
0.5
0
Group A Group B
49
Bar Diagram showing bracket bond failures in the anterior and posterior
segments of the arch:
3.5
2.5
2
Transbond Plus
1.5
Reliance S.E.P.
1
0.5
0
Anteriors Posteriors
Out of the seven bracket bond failures recorded, three bond failures
occurred in the anterior segment and four bond failures occurred in the
posterior segment.
50
CONSORT DIAGRAM FOR THE STUDY
51
Discussion
52
DISCUSSION
and dentin has developed a niche in nearly all areas of dentistry, includ-
with 85% phosphoric acid for 30 seconds, Buonocore opened the door to
acid etchant, followed by a priming agent, and then adhesive resin. One of
53
the potential disadvantages of etching with phosphoric acid is that the
attempt to control the depth of enamel etching and excessive enamel loss
to phosphoric acid. The use of maleic acid, poly acrylic acid has been
pattern17, for most current clinical phosphoric acid application 37% acid
concentration is used.
orthodontic attachment via its bonding agent. Since the depth of enamel
procedure by minimizing enamel loss and reducing chair time while still
54
and priming can be successfully used to bond orthodontic brackets to
enamel.
combination of the etchant and primer into one product called a Self
the 1990’s SEP was introduced as a means of reducing chair time during
bonding. Questions about resultant bond strength have been studied both
with Self etching primer was lower than those bonded with a
conventional etch.
55
failures can occur if the etchant is left on too long, which yields weak
It has been reported that most bond failures occur within the first 3
bracket failure rates of 50 and 82 per cent, respectively, during the first 6
period of treatment,
56
The purpose of this study was to compare the bracket bond failure
rate with two commercially available Self Etching Primers during the
Bond failure rates obtained by in-vitro studies might not mirror the
real world of clinical practice. Most studies are conducted in vitro and use
found that in-vitro bond strengths had no correlation with clinical bond
failure rates.
(eg, torque, shear, tensile) and might be subjected to more than 1 type
should be used when inferences are made from in-vitro bonding studies.
Keeping this aspect in mind, it was the aim of this in – vivo study
to compare the bracket bond failure rate and thereby the clinic al
57
Failure rates were compared between anterior and posterior teeth.
possible explanations for this are given – difficult clinical access and
this study were in contrast to these other studies in that there was a failure
rate of 0.9% for anterior and 1.25% for posterior teeth; however, this was
of brackets bonded with SEP and conventional acid etching also found no
significance in the bracket bond failure rates in the anterior and posterior
segments.
bonding with self etching primer, and concluded that there was a
significant increase in the bond failure rate of brackets bonded with SEP
The light curing kit used in this study is the Ortholux™ XT Curing
58
unit, which uses a halogen lamp to generate a white light which is then
filtered so that only blue light in the 400 to 500 nanometer range is
emitted from the tip. Each bracket bonded in this study was cured for a
total time of 25 seconds each, curing the labial, occlusal, gingival, mesial
Reliance SEP
random number generator is seeded with the time of the day, so it works
non randomly. Then the assignment of each subject is swapped with the
SEP (3M Unitek) on the maxillary right and the mandibular left
quadrants; and the Reliance SEP on the maxillary left and mandibular
right quadrants.
59
Group B consisted of the remaining ten patients bonded with the
Reliance SEP on the maxillary right and mandibular left quadrants and
the Transbond Plus SEP on the maxillary left and mandibular right
quadrants.
This totaled to 320 teeth being bonded; out of which 160 teeth
were bonded with the Transbond Plus SEP and the other 160 teeth with
well, single-patient use foil pack with an advanced delivery system. The
For activation, the thumb and index finger are used to squeeze the
black reservoir and empty the contents of the first compartment into the
back into the black reservoir, the package is carefully kept folded at the
interface of the black and white reservoir. Using controlled pressure, the
applicator tip is then churned and swirled inside the purple reservoir for 5
60
applicator tip. The applicator tip is then removed. It must be moist and
calcium from the enamel and removes it from the hydroxylapatite. Rather
than being rinsed away, the calcium forms a complex with the phosphate
group and is incorporated into the network when the primer polymerizes.
there is less evaporation and thus a more stable viscosity and wetting
capability. The applicator tip is dipped again into the reservoir to saturate
it, before rubbing it onto the next tooth. When all the teeth in the
particular quadrant are primed, an oil and moisture-free air source is used
to deliver a gentle burst of air onto each tooth, to dry the primer into a
thin film. The gentle burst of air is directed away from the gingiva, so as
to avoid any gingival irritation that may occur with the primer fluid
excessive adhesive using a scaler, the brackets were light cured using the
61
Asgari et al5 recently evaluated Transbond Plus Self etching
primer versus a traditional acid etch sequence in vivo and found that
those brackets bonded with Self etching primer had a significantly lower
disregarded the pumice prophylaxis step for all groups. They found a
before beginning the bonding process with Self etching primer. This
pellicle27.
enamel and the adhesive. As a result, it was thought that a deeper etching
pattern would provide a greater surface area for bonding and, thus,
62
greater bonding strengths 39. However, in a test of 3 SEPs on unground
systems; Transbond Plus SEP (3M Unitek) and Ideal 1 SEP (GAC
Transbond Plus SEP bonding system; and that clinicians should consider
the many associated costs of bracket failures (chair time, material costs)
3:1 ratio, into a light impervious mixing well. The first liquid contains
63
phosphate and Polyethlene glycol dimethacrylate. Once the liquids are
dispensed into the mixing well, they are mixed well using an applicator
brush and the remaining liquid is covered in the mixing well to protect it
from light. The manufacturers claim that the mixed solution of the self
etching primer can be usable for upto six hours if covered in the mixing
enamel surface for 10 seconds in a circular motion. Once all the teeth in
each tooth, away from the gingival, so as to dry the primer into a thin
film. This step is followed with bracket bonding and light curing
Transbond Plus SEP. The Reliance SEP is intended for use only with
when contaminated with either saliva or water. The in-vitro study used
240 bovine incisor teeth and divided them into 4 groups of 60 each. In
64
five of the six groups that compared the primers, Reliance SEP had the
Ideal 1 had the lowest bond strengths. They concluded that both
phosphoric acid.
bracket bond failure rates with the Reliance Self Etching Primer when
compared with the Transbond Plus Self Etching Primer. Out of the total
Plus SEP had 5 bracket bond failures, while the Reliance SEP had 2
65
Summary & Conclusion
66
SUMMARY AND CONCLUSION
two Self Etching Primers, the Transbond Plus S.E.P. and the newly
The results of the statistical tests showed that the Reliance S.E.P.
Based on the statistical results derived from this study, the following
in this study.
solution can be stored for upto six hours in light impervious mixing wells,
bracket bond failures between the anterior and posterior segments of the
arch.
The Self- etching primer that has been introduced to overcome the
laborious process of etching and priming will definitely reduce the chair
67
side time and the ill effects of acid etching. By reducing the number of
steps during bonding, the clinicians are able to save time as well as
reduce the potential for error and contamination during the bonding
procedure.
68
Bibliography
69
BIBLIOGRAPHY
70
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