Rajiv Gandhi University of Health Sciences, Bengaluru,

Karnataka.

MDS ORTHODONTICS & DENTOFACIAL ORTHOPEDICS

Synopsis for Registration of Dissertation.

M. R. Ambedkar Dental College & Hospital

#1/36, Cline Road, Cooke Town,

Bengaluru, Karnataka- 560005.

 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BENGALURU.

ANNEXURE II

SYNOPSIS FOR REGISTRATION OF DISSERTATION

Dr. MODI DRIMAL NILESHKUMAR

1 NAME OF THE CANDIDATE
Department Of Orthodontics & Dentofacial Orthopedics
AND ADDRESS
M. R. Ambedkar Dental College & Hospital
#1/36, Cline Road ,Cooke Town
Bengaluru-560005.

M. R. AMBEDKAR DENTAL COLLEGE &

2 NAME OF INSTITUTION HOSPITAL
#1/36, Cline Road ,Cooke Town
Bengaluru-560005.

COURSE OF STUDY AND M.D.S Orthodontics and Dentofacial Orthopedics

3 SUBJECT

4 DATE OF ADMISSION 27/05/2016

5 TITLE OF THE TOPIC:

ENAMEL DEPROTEINIZATION AND ITS EFFECT ON ETCH PATTERN

AND SHEAR BOND STRENGTH – An In vitro study

6 BRIEF RESUME OF WORK:
6.1 INTRODUCTION:
Esthetics is the main reason for which patients seek orthodontic treatment. The introduction of
fixed appliances has several advantages such as shorter treatment time, precise finishing and
more controlled tooth movement.In orthodontic practice, obtaining a reliable adhesive bond
between brackets and enamel is essential for efficient orthodontic treatment. As the bond
between enamel and bracket is highly dependent on the enamel surface alterations, removal of
excess proteins may provide an advantage in the bonding of the bracket. .(1)

Various methods are available for removal of excess proteins, Deproteinization is one such
process. Deproteinization is a process of elimination of organic substances from the enamel
surface before acid etching. It increases the resistance to orthodontic debonding by providing
better adhesion and better acid etching pattern on enamel. According to De-Deus et al. Sodium
hypochlorite (NaOCl) eliminates the organic matter present on the enamel surface by
dissolving it. By eliminating the organic substances from the enamel surface before etching
(deproteinization), orthodontic bond strength can theoretically be increased. .(2)

Enamel demineralization is a significant risk associated with orthodontic treatment when oral
hygiene is poor. Prevention of demineralization during orthodontic treatment is one of the
greatest challenges faced by clinicians despite modern advances in caries prevention.The
development of white spot lesions (WSLs) is attributed to prolonged plaque accumulation
around the brackets. (3)

Fluoride application can be used to promote remineralization after debonding. Fluoride-

releasing resin-modified glass ionomer cements (RMGIs) might routinely be used to bond
brackets, instead of composite resins. Reducing the incidence of white spot lesions, a major
current iatrogenic effect of orthodontic treatment, is a worthy cause which might be achieved
due to the fluoride-releasing properties of RMGIs. .(4)

This study is designed to compare and evaluate the effect of Deproteinization on shear bond
strength of orthodontic brackets in vitro using two different fluoridated adhesives.

REVIEW OF LITERATURE:
6.2
6.3 AIMS AND OBJECTIVES:

The main aim of the study is to evaluate the effect of enamel deproteinization on shear bond
strength and etch pattern.

The objectives of this study are to :

 To determine whether deproteinization of human dental enamel surfaces, with 5.25%
sodium hypochlorite (NaOCl) before etching, increases orthodontic bracket shear bond
strength (SBS) of 2 adhesive systems: Flouridated Adhesive(Rely.A.Bond) and a
RMGIC (RelyX TM 200, 3M ESPE)
 To identify the topographical features of the enamel surface deproteinized with 5.25%
NaOCl and etched with phosphoric acid compared to phosphoric acid alone.
 To compare the results achieved in enamel conditioning surface as well as the quality
of etch pattern with different time interval(30 seconds and 60 seconds) of 5.25%
NaOCl.
7
7.1 MATERIALS AND METHOD:
SOURCE OF DATA:
In this study, it is proposed to obtain 70 human maxillary first premolars, extracted from
patients undergoing orthodontic treatment after taking their consent, at the Department of
Orthodontics and Dentofacial Orthopedics, M. R. Ambedkar Dental College and Hospital,
Bangalore.
Exclusion criteria:
 Decayed teeth
 Fluorosed teeth
 Attrited teeth
 Restored teeth
 Hypoplastic teeth
Material used for the study:
 70 human maxillary first premolars with no visible enamel defects.
 Ultrasonic Dental scaler (EMS)
 Normal Saline solution
 Non –fluoridated pumice (Safeplus)
 Rubber Cup (Dentmark, India)
 37% Orthophosphoric acid (Prime Dental Products, India)
 5.25% Sodium Hypochlorite
 Acrylic (Pink, DPI-RR Cold Cure, Dentsply)
 Primer (Rely A Bond kit primer)
 Resin Modified GIC (RelyX TM 200, 3M ESPE)
 Flouridated Adhesive (Rely.A.Bond)
 LED curing light (3M Elipar 2500)
 Premolar bondable pre-adjusted edgewise stainless steel brackets of 0.022 inch slot
(Unitek, 3M, Gemini series).
 Applicator
 Universal testing machine (Instron instrument).
 Scanning electron microscope
 Stereomicroscope (SZ-40; Lawrence and Mayo)
7.2
A
METHODOLOGY
The study will be divided into two parts: First part will be to study the etch pattern and second
part will be to evaluate the effect of deproteinization on shear bond strength.
To study the etch pattern ,10 human maxillary first premolars with no visible enamel defects,
extracted during routine orthodontic treatment will be collected after taking consent from the
patients. Any soft tissue, calculus and/or bone remaining on the teeth will be removed with an
ultrasonic dental scaler.
Teeth will be stored in saline solution at 37°C. Each tooth will be polished with pumice and
rinsed with distilled water for 10 seconds
The samples will be divided into 2 groups

Group I
37% H3PO4 (15 seconds)

Group II 5.25% NaOCl (60 seconds) + 37% H3PO4 (15 seconds)

In group I, the enamel surface of each tooth will be cleaned with a nonfluoridated prophylaxis
paste and rubber prophylactic cups for 10 seconds, will be rinsed, dried and etched with 37%
ortho-phosphoric acid (Prime Dental Products, India) for 15 seconds, rinsed with water for 15
seconds and then will be dried with oil-free air for 10 seconds until a frosty white appearance
is obtained.
In group II , the enamel surfaces of the premolars will be cleaned with a nonfluoridated
prophylaxis paste and rubber prophylactic cups for 10 seconds,will be rinsed, dried and
deproteinized with 5.25% NaOCl for 60 seconds using a micro-brush, followed by rinsing,
drying and acid etching with 37% phosphoric acid for 15 seconds. Subsequently, the acid will
be rinsed off, the enamel will be dried.
All samples will be coated with gold electrodepositing, using a sputtering effacoater and
prepared for surface Scanning Electron Microscope (SEM) analysis.The samples will be
subjected to SEM analysis and 5 microphotographs of each sample will be obtained at 500X
magnification and evaluated for the quality of etching pattern of the enamel
B

Other part of the study will be to evaluate the effect of deproteinization on shear bond strength,
60 human maxillary first premolars with no visible enamel defects extracted during routine
orthodontic treatment will be collected after taking consent from the patients. Any soft tissue,
calculus and/or bone remaining on the teeth are to be removed with an ultrasonic dental scaler.
Teeth will be stored in saline solution at 37°C. Each tooth will be polished with pumice and
rinsed with distilled water for 10 seconds
The samples will be divided into 3 groups, and 2 subgroups from each group. 10 samples in
each division.

37% H3PO4 + Resin modified GIC (RelyX TM

Subgroup 1a 200, 3M ESPE)
Group 1
Control group

37% H3PO4 + Flouridated adhesive

Subgroup 1b
(Rely.A.Bond)

Subgroup 2a 5.25% NaOCl for 30 sec + 37% H3PO4 + Resin

Group 2
modified GIC(RelyX TM 200, 3M ESPE)
Deproteinization
with 5.25%
NaOCl for 30 5.25% NaOCl for 30 sec + 37% H3PO4 +
Subgroup 2b
seconds Flouridated adhesive(Rely.A.Bond)

Group 3 5.25% NaOCl for 60 sec + 37% H3PO4 + Resin

Subgroup 3a
Deproteinization modified GIC(RelyX TM 200, 3M ESPE)
with 5.25%
NaOCl for 60
seconds Subgroup 3b 5.25% NaOCl for 60 sec + 37% H3PO4 +
Flouridated adhesive(Rely.A.Bond)

In group 1, the enamel surface of each tooth will be cleaned with a nonfluoridated prophylaxis
 paste and rubber prophylactic cups for 10 seconds, will be rinsed, dried and etched with 37%
ortho-phosphoric acid (Prime Dental Products, India) for 15 seconds, rinsed with water for 15
seconds and then dried with oil-free air for 10 seconds until a frosty white appearance is
obtained. Subsequently, the acid will be rinsed off, the enamel will be dried, a thin layer of
primer will be applied with a micro-brush, and light cured for 20 seconds.

In group 1a, Resin modified GIC will be placed on the bracket mesh covering the entire base of
the bracket, without bubbles or voids, and the bracket will then applied to the tooth using
sufficient force to produce a “flash” of excess adhesive around the bracket to ensure a uniform
thickness of adhesive.
In group 1b, Flouridated adhesive will be used to bond the bracket on to the tooth structure.

In group 2a, the enamel surfaces of the premolars will be cleaned with a nonfluoridated
prophylaxis paste and rubber prophylactic cups for 10 seconds, will be rinsed, dried and
deproteinized with 5.25% NaOCl for 30 seconds using a micro-brush, followed by rinsing,
drying and acid etching with 37% phosphoric acid for 15 seconds. Subsequently, the acid will
be rinsed off, the enamel will be dried, a thin layer of primer will be applied with a micro-
brush, and light cured for 20 seconds. The Resin modified GIC will then be placed on the
bracket for bonding whereas in 2b, Flouridated adhesive will be used for bonding

In group 3a, the enamel surfaces of the premolars will be cleaned with a nonfluoridated
prophylaxis paste and rubber prophylactic cups for 10 seconds, will be rinsed, dried and
deproteinized with 5.25% NaOCl for 30 seconds using a micro-brush, followed by rinsing,
drying and acid etching with 37% phosphoric acid for 15 seconds. Subsequently, the acid will
be rinsed off, the enamel will be dried, a thin layer of primer will be applied with a micro-
brush, and light cured for 20 seconds. The Resin modified GIC will then be placed on the
bracket for bonding whereas in 3b, Flouridated adhesive will be used for bonding.

Each tooth will be vertically mounted on self-cured acrylic blocks so that the crown is exposed
and the specimens will be ready for debonding.
7.3

DEBONDING PROCEDURE:
The embedded specimens would be secured in a jig attached to the base plate of a universal
 testing machine (Instron instrument).
A chisel-edge plunger will be mounted in the movable crosshead of the testing machine and
positioned so that the leading edge would be aimed at enamel-adhesive interface. A crosshead
speed of 1 mm/min will be used and the maximum load necessary to debond the bracket is to
be recorded.
The force required to remove the brackets will be measured in Newtons (N) and SBS
(2MPa = 1 N/mm sq.) will be calculated by dividing the force values by the bracket base area.

7.4

FRACTURE ANALYSIS: After debonding procedure, the remnant adhesive on the enamel
surface are to be assessed under a stereomicroscope (SZ-40; Lawrence and Mayo) at 20X
magnification and the Modified Adhesive Remnant Index (ARI) (12) will be quantified.

 Score 0 = no adhesive left on bracket

 Score 1 = less than 25% of adhesive left on bracket
 Score 2 = 25% of adhesive left on bracket
 Score 3 = 50% of adhesive left on bracket
 Score 4 = 75% of adhesive left on bracket
 Score 5 = 100% of adhesive left on bracket.

7.5

STATISTICAL ANALYSIS
 The SBS values will be tested with one-way analysis of variance ANOVA, and when the
results found are significant, multiple comparisons will be assessed with Weibull analysis,
Tukey’s Honestly Significant Difference test.

The Chi square will be used to determine significant differences in the ARI scores among the
groups.
7.6 Any other relevant test required during the data analysis time, will be done accordingly.

DOES THE STUDY REQUIRE ANY INVESTIGATIONS TO BE CONDUCTED ON

PATIENTS OR ON OTHER HUMANS OR ANIMALS? IF SO, PLEASE DESCRIBE
BRIEFLY.

7.7 Not applicable.

HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION

yes

REFERENCES
1.Pereira T, Jansen W, Pithon M, Souki B, Tanaka O, Oliveira D. Effects of enamel
deproteinization on bracket bonding with conventional and resin-modified glass ionomer
cements. Eur J Orthod. 2012;35(4):442-446.

2. Espinosa R, Valencia R, Uribe M, Ceja I., Saadia M. Enamel deproteinization and its effect
on acid etching: An in vitro Study. J Clin Pediatr Dent. 2008;33(1):13-19.

3. Tufekci E, Dixon J, Gunsolley J, Lindauer S. Prevalence of white spot lesions during

orthodontic treatment with fixed appliances. Angle Orthod. 2011;81(2):206-210.

4. Justus R, Cubero T, Ondarza R, Morales F. A new technique with sodium hypochlorite to

increase bracket shear bond strength of fluoride-releasing resin-modified glass ionomer
cements: comparing shear bond strength of two adhesive systems with enamel surface
deproteinization before etching. Semin Orthod. 2010;16(1):66-75.

5. Gorelick L, Geiger A.M, Gwinnett A.J. Incidence of white spot formation after bonding and
banding. Am J Orthod.1982 Feb; 81(2):93-8.

6. Saroglu I., Aras S., Oztas D.,Effect of deproteinization on composite bond strength in
hypocalcified amelogenesis imperfecta. Oral Diseases. 2006;12(3):305-308.

7. Cheng H, Chen C, Li C, Tsai H, Chou T, Wang W. Bond strength of orthodontic light-cured

resin-modified glass ionomer cement. . Eur J Orthod. 2010;33(2):180-184.

8. Ahuja B, Yeluri R, Sudhindra Baliga M, Munshi A. Enamel Deproteinization before Acid

Etching – A Scanning Electron Microscopic Observation. J Clin Pediatr Dent. 2010;35(2):169-
172.

9. Trindade A, Pereira T, Smith Neto P, Horta M, Pithon M, Akaki E et al. Consequences of

enamel preparation with sodium hypochlorite, polyacrylic and phosphoric acids for the
bonding of brackets with resin-modified glass ionomer cements. Materials Research.
2013;16(6):1423-1427.
10. Espinosa R, Valencia R, Uribe M, Ceja I, Cruz J, Saadia M. Resin Replica in Enamel
Deproteinization and its Effect on Acid Etching. J Clin Pediatr Dent. 2010;35(1):47-51.

11. Harleen N, Ramakrishna Y, Munshi A. Enamel Deproteinization Before Acid Etching and
its Effect on the Shear Bond Strength – An in vitro Study. J Clin Pediatr Dent. 2011;36(1):19-
24.

12. Bishara S.E, Gordan V .V, VonWald L, Jakobsen J.R. Shear bond strength of Composite,
glass ionomer, and acid primer adhesive. Am J Orthod Dentofacial Orthop 1999; 115:24-28.
 9 SIGNATURE OF THE CANDIDATE

10 REMARKS OF GUIDE

Dr. ANJALI NARAYAN

11 NAME AND DESIGNATION OF GUIDE
PROFESSOR
DEPARTMENT OF ORTHODONTICS
& DENTOFACIAL ORTHOPEDICS

11.1 SIGNATURE

Dr. RABINDRA S. NAYAK

11.2 HEAD OF THE DEPARTMENT
PROFESSOR AND HEAD
DEPARTMENT OF ORTHODONTICS
& DENTOFACIAL ORTHOPEDICS

11.3 SIGNATURE

11.4 REMARKS OF PRINCIPAL

11.5 SIGNATURE