Effects of Orthodontic Mechanics on Tooth

Enamel: A Review
Neslihan Arhun and Ayca Arman

Orthodontic treatment has the potential to cause some damage to dental

enamel during cleaning with abrasives before etching, the acid etching process
itself, enamel fractures caused by forcibly removing brackets, mechanical re-
moval of composite remnants with rotary instruments or in the rebonding of
failed brackets. In addition the enamel surface may be demineralized as the
result of bacterial biofilm (dental plaque) around orthodontic attachments and
also may get worn or eroded due to contact with ceramic brackets. Structural
damage may also be caused intentionally by clinicians when reducing enamel
by interproximal enamel stripping to gain space. Clinicians should make every
effort to minimize damage to dental tooth enamel. In addition patients should
be well informed about the importance of optimal oral hygiene. (Semin Orthod
2007;13:281-291.) © 2007 Elsevier Inc. All rights reserved.

f orthodontic treatment is to be of benefit to 4. Demineralization and white spot lesions associ-

I the patient, the advantages of treatment
should far outweigh any adverse sequelae. To
prevent, minimize, and manage the possible ad-
verse effects of orthodontic mechanics, the cli-
nician should be aware of the problems that may
occur during the treatment period.1 It is well
known that tooth enamel is the most mineral-
ized tissue of the human body with the compo-
sition of 96 wt.% inorganic material and 4 wt.%
organic material and water. Despite the latter,
procedures performed as part of orthodontic
treatment may cause physical damage to tooth
enamel. Potential damage to enamel associated
with orthodontic treatment may include:
1. Cleaning with abrasives before etching,
2. Loss of surface enamel with acid etching,
3. Intentional enamel reduction or stripping,
From the Department of Conservative Dentistry and Department
of Orthodontics, Faculty of Dentistry, Baskent University, Ankara,
Turkey.
Address correspondence to Dr. Neslihan Arhun, Baskent Uni-
versitesi, Dishekimligi Fakultesi, Dis Hastaliklari ve Tedavisi
Anabilim Dali, 11. sok No: 26, 06490 Bahçelievler-Ankara,
Türkı̇ye. Phone: ⫹90 312 215 13 36; E-mail: neslihan@baskent.
edu.tr
© 2007 Elsevier Inc. All rights reserved.
1073-8746/07/1304-0$30.00/0
doi:10.1053/j.sodo.2007.08.009
ated with bacterial action from dental plaque,
5. Enamel loss due to parafunctional activity
and contact with metal or ceramic brackets,
6. Enamel fractures caused during bracket re-
moval,
7. Mechanical removal of composite remnants
with rotary instruments, and
8. Rebonding of failed brackets.
This present review addresses all these factors
and provides information on how to prevent or
at least minimize these side effects associated
with orthodontic treatment.
Potential Damages During Bonding
Advances in adhesive technology and the introduc-
tion of new materials and bonding techniques
have greatly influenced and revolutionized orth-
odontic practice. Contemporary adhesives can be
divided into two systems: etch and rinse (E&R)
and self-etch adhesives/primers (SEP).2 The first
system (E&R) uses phosphoric acid etching and
primer/adhesive resin application as two separate
phases, while the latter (SEP) combines etching
and priming together in a single phase and the
adhesive resin in another phase, or uses etch-
prime-adhesive as an all-in-one procedure. With all
of the currently available adhesive systems, the de-
gree of depth of penetration of the acid during

Seminars in Orthodontics, Vol 13, No 4 (December), 2007: pp 281-291 281

282 Arhun and Arman
etching depends on the type and concentration of
the acid, the duration of etching, and chemical
composition of the enamel surface.3
Before any acid etching, the enamel surface
should be cleaned. An initial prophylaxis with a
bristle brush for 10 to 15 seconds per tooth may
abrade away as much as 10 ␮m of enamel
whereas about 5 ␮m may be lost when a rubber
cup is used.4 Traditionally the enamel surface
has been prepared by etching with phosphoric
acid at concentrations ranging from 30% to 50%
for 15 to 60 seconds, followed by rinsing and
drying of the surface.5,6 One of the effects of
etching with phosphoric acid is the dissolution
of hydroxyl apatite of enamel causing deminer-
alization of the most superficial layer of enamel.7
Phosphoric acid causes a selective dissolution of
either enamel prism cores or boundaries and
creates microporosity of the enamel surface
ranging in depth from 5 to 50 ␮m.5 To control
excessive enamel loss, maleic and polyacrylic
acids have been used as alternatives for phos-
phoric acid, but resulted in a reduction of bond
strength.8 Although the enamel etching tech-
nique is a useful and accepted orthodontic pro-
cedure for bonding orthodontic brackets, there
is a need to improve this method to maintain
clinically useful bond strength and at the same
time minimizing the amount of enamel loss.9
More recently self-etching adhesive systems
have been developed and introduced to over-
come some of the shortcomings of E&R systems.
Through use of chemically modified acidic
monomers, self-etch systems demineralize and
penetrate dental hard tissues simultaneously
without the requirement of a separate etching-
rinsing-drying step.10 Combining conditioning
and priming into a single treatment step results
in improvement in both time and cost-effective-
ness for clinicians as well as patients. One impor-
tant advantage of simultaneous etching and
priming is that the primer penetrates the entire
depth of etch, ensuring an excellent mechanical
interlock.11 Scanning electron microscopic (SEM)
investigations of current self-etching adhesives
have demonstrated enamel etching patterns to
be morphologically similar to that of phosphoric
acid-etched enamel.12 Nevertheless, achieving a
sufficient etching pattern to intact enamel still
remains an obstacle for self-etching adhesives.13
Although self-etch systems have been claimed
to reduce technique sensitivity clinically, ques-
tions have arisen on the reliability of these sys-
tems in achieving durable bonds to enamel.14-16
It was shown that when self-etching primers are
used, the degree of penetration by the adhesive
to the etched enamel is less than of the conven-
tional acid etch technique. However, the greater
the depth that the adhesive tags penetrate the
enamel, the greater the risk of damage to the
enamel during debonding.17
Optimum bond strength in orthodontics should
permit adequate bracket retention while ensuring
safe debonding procedures, rather than achieving
the greatest possible bond strength. Studies eval-
uating composite-to-enamel bond strength ob-
tained with self-etching adhesive systems reveal
values of 20 to 30 MPa,18 which are in the same
range as that reported for enamel etched with
phosphoric acid.19 Other studies that compared
self-etching primers with conventional, multistep
adhesives demonstrated similar bond strengths
with both systems, even though the etching pat-
tern was shallower for SEPs.13 Miyazaki and co-
workers20 reported higher bond strength to
enamel when the specimens were prepared with
agitating the primer on the enamel surface. The
results of recent studies suggested that etching
before priming is not necessary when using SEPs
as the resultant bond strength is sufficient for
orthodontic purposes and that decalcification by
phosphoric acid may be avoided.21,22
To date, most studies that examined the surface
characteristics of enamel were limited to qualita-
tive evaluations with SEM. Microscopic analyses
can provide only visualization of surface mor-
phology, necessitating the use of further meth-
ods to determine the extent of surface modifica-
tions quantitatively. Van Waes and coworkers23
used a computerized 3-dimensional scanner to
measure enamel loss caused by orthodontic
bonding and debonding after phosphoric acid
etching and reported an average of 7.4 ␮m
enamel loss. Using field emission scanning elec-
tron microscopy, Kawasaki and coworkers24 ob-
served more dissolution of the enamel surface
from phosphoric acid etching than from SEPs.
Enamel Damage During Debonding
Procedures
The objectives of debonding are to remove the
attachment and all the adhesive resin from the
tooth and to restore the surface as closely as
 Orthodontic Mechanics and Tooth Enamel
possible to its pretreatment condition. To achieve
these objectives, correct bonding and debond-
ing are of fundamental importance. There are
several factors involved in debonding, the most
important of which are the type of bracket and
adhesive used, instruments used for bracket
removal, and the armamentarium for resin
removal.25 The ideal orthodontic bracket bond-
ing method should provide adequate bond
strengths to satisfactorily retain orthodontic
brackets, withstand the forces of mastication, the
stress exerted by the arch wires and patient
abuse, and, if possible, help prevent or reduce
the amount of demineralization during treat-
ment. At the same time the bond strength
should be at a level to allow for bracket debond-
ing without causing damage to the enamel
surface. Various studies have suggested bond
strengths ranging from 2.8 to 10 MPa as being
adequate for clinical situations.26,27 The maximum
bond strength should be less than the cohesive
strength of enamel, which is approximately 14
MPa, to allow for the removal of the bracket
without causing damage to the enamel.28 Based
on these reports, Bishara and Fehr suggested
that bond strengths lower than 12.75 MPa would
be safe for the enamel.29
There are numerous studies on the bond
strength of brackets using various materials and
methods making comparison of the results of
the studies difficult and sometimes impossible.
Fox and coworkers compared the results from
published bond strength studies and pointed
out the difficulty observed due to difference in
test configurations and experimental methodol-
ogies followed.30 Variability in the location of
force application and the relative positions of
the members of the bonding system can result in
substantial difference in the measured force that
causes bond failure. In addition, the crosshead
speed of the universal testing machine and the
configuration of the testing jig should also be
considered.30 The universal testing machine is a
stable and rigid device that can only produce
pure shear forces; however, a clinician intro-
duces a combination of shear, tensile, and tor-
sional forces when performing in vivo debond-
ing. Further, the rate of loading for a universal
testing machine is constant whereas the rate of
loading for in vivo debonding is not standardized
or constant. Moreover, extracted teeth stored in
distilled water are much drier than vital teeth
283
and, therefore, are more susceptible to enamel
damage. Also, moisture, temperature, and other
variables are known to weaken bond strength at
the enamel-adhesive interface.31 Therefore, in
vitro bond strength values might be higher than
those obtained in vivo. However, it is obvious
that the in vitro studies provide a guide for the
clinician in selecting the bracket/adhesive of his
choice to be used in vivo.
No reliable protocol for estimating the in vivo
strength provided by orthodontic bonding sys-
tems has been described. Calculating in vivo
bond strength required for reliable clinical orth-
odontic debonding procedures brings in various
other parameters such as adhesive systems used,
bracket base design, enamel morphology, appli-
ance force systems, and more importantly the
clinician’s technique. Bishara and coworkers at-
tempted to measure the actual force applied by
the pliers during debonding and found that this
method transmits 30% less force to the enamel
compared with a pure shear force.32 This en-
lightens us of the fact that clinically we apply a
reduced amount of debonding force, which
places much less stress on the enamel surface,
reducing the risk of fracture damage.
The process of debonding a bracket from the
tooth has the potential to result in iatrogenic
damage to the surface of the enamel. The sites
of failure can be between the bracket and the
adhesive, within the adhesive itself, or between
the tooth surface and the adhesive. There are
two schools of thought regarding the amount of
adhesive remaining on the teeth surface after
debonding. One favors the failure at bracket-
adhesive interface leaving the adhesive resin on
the enamel surface25,33 and the second at the
enamel-adhesive resin interface leaving much
less adhesive left on the enamel surface.34 It
should be kept in mind that whenever debond-
ing forces exceed the enamel strength, the result
will be enamel fracture and crazing. Martin and
Garcia-Godoy through their research suggested
use of a weaker adhesive with a lower strength
value so that failure while debonding occurs at
the resin enamel interface. This can reduce both
the enamel damage as well as the residual
cleanup effort.35
There are numerous studies that evaluate the
condition of enamel surface and amount adhe-
sives remaining on tooth surface after debond-
ing. The adhesive remnant index (ARI) devel-
284 Arhun and Arman
oped by Artun and Bergland, which assessed the
type of bond failure and amount of remnant
adhesive over the tooth surface, has been an
important tool in many studies.36 The problem
with ARI is that it tends to oversimplify the very
complex issues of bond failure, but it does have
the advantage of allowing statistical analysis and
study comparisons.
The use of ceramic brackets for orthodontic
treatment is increasing as greater numbers of
adult patients, who are concerned about appear-
ance, are being treated. Numerous studies that
have evaluated the bond strengths of ceramic
brackets have demonstrated a significantly stron-
ger bond strength in comparison with conven-
tional metal brackets. Increased bond strength
with ceramic brackets resulted in bond failure at
the enamel surface, rather than at the bracket
adhesive interface, resulting in more enamel
fractures.37-39 Two particular properties of ce-
ramics— hardness and brittleness— have neces-
sitated the use of special debonding instruments
to prevent both the enamel and bracket frac-
ture. The earliest type of debonding instruments
used on ceramic brackets, which applied heavy
shear-torsion forces, resulted in enamel fracture
or cracks. Swartz recommended a sharp-edged
debonding instrument placed at the enamel-ad-
hesive interface for ceramic brackets.40 Applying
the load to the 2 sides of the bracket simulta-
neously with the pliers increases the chance of
creating a crack in the brittle adhesive. Storm
suggested that a rotational motion with a specially
designed ceramic bracket debonding instrument
would be safer for the enamel surface.37 Alterna-
tive methods of debonding ceramic brackets have
been proposed such as ultrasonic, electrothermal,
and laser techniques.41
To enhance the retention of adhesive to the
metal base of orthodontic brackets, various
chemical and mechanical retentive designs have
been suggested. Mechanical retention was en-
hanced by placing undercuts in the cast bracket
bases or by welding different diameter mesh
wires to the bracket base as well as incorporat-
ing different designs in the mesh itself. Other
innovative approaches included using laser-
structured bases,42 using metal plasma-coated
bracket bases,43 fusing metallic or ceramic par-
ticles to the bases,44 and sandblasting bracket
base mesh surfaces.45 In addition, highly filled
adhesives provide higher bond strengths. The
inorganic filler makes the material more abra-
sion resistant, increases the shear bond strength
values, and decreases the coefficient of thermal
expansion to values closer to those of enamel to
prevent long-term microleakage.46 It should be
emphasized, however, that increasing the bond
strength may increase the susceptibility to enamel
fracture during debonding.
It has been concluded that a minimal adhe-
sive thickness is necessary to achieve optimal
bond strength. Increased thickness has been re-
ported to weaken the joint, due to introduction
of imperfections and increased polymerization
shrinkage.47 Minimal thickness of the adhesive
also helps in reducing the debonding forces
markedly, thereby preventing enamel cracks as
well as surface irregularities.
Interdental Stripping: Intentional
Damage
Interdental stripping, also called as interproximal
enamel reduction, enamel reproximation, or
slenderization, is a common clinical procedure
in orthodontic therapy. Among various tech-
niques available today, the most commonly used
ones are handheld or motor-driven abrasive
strips, and tungsten carbide or diamond burs.48
The main indications for this technique include
reshaping the approximal contacts, managing
Bolton discrepancy problems, treating mild or
moderate crowding, and stabilizing the dental
arch. Since many orthodontists now are increas-
ingly focusing on nonextraction therapy, the
popularity of enamel reduction has increased.
There are, however, possible detrimental ef-
fects of interdental enamel stripping procedures
that are being discussed. Although it has been
claimed that 0.3 to 0.4 mm of enamel can be
safely removed without rendering the enamel
prone to dissolution,49 the ultramorphological
characteristics of the altered enamel surface can
cause various problems such as increased fre-
quency of caries, periodontal disease, and tem-
perature sensitivity. Studies have shown that
stripping can increase the susceptibility of prox-
imal enamel surfaces to demineralization and
also lead to greater plaque retention and in-
creased risk of secondary caries. This is mainly
because of the residual furrows on the enamel
surface compared with nontreated ones.50,51
 Orthodontic Mechanics and Tooth Enamel
Figure 1. (A) White spot lesions seen on anterior teeth after debonding of brackets. (B) White spot and caries
lesions seen around brackets during fixed orthodontic treatment. (Color version of figure is available online.)
However, other studies failed to establish a
significant relationship between enamel strip-
ping and caries susceptibility, reporting that
enamel reduction does not expose the teeth to
caries and that a demineralization period is gen-
erally followed by spontaneous remineralization
of hard tissues.52,53 The results of a recent study
demonstrated that polishing enamel after strip-
ping techniques to achieve similar morphologi-
cal characteristics as intact enamel was not pos-
sible. The researchers did observe, however,
comparatively smoother and less plaque reten-
tive enamel surfaces when Sof-Lex polishing
disks (3M Dental, St. Paul, MN) were used.54
Enamel Wear
Abrasion of enamel surfaces can occur when
teeth make contact with either metal or ceramic
brackets. The latter is common on upper canine
tips, as the cusp tip hits the lower canine brack-
ets during retraction. It may also be seen on the
incisal edges of upper anterior teeth where ce-
ramic brackets are placed on lower incisors of a
patient who has an increased overbite. The cli-
nician should always ensure that no enamel
damage is occurring due to bracket placement.
One method to achieve the latter is to delay the
placement of brackets that are likely to make
contact with opposing teeth, and thus assist in
the prevention of enamel wear.
Susceptibility to Caries and White Spot
Formation
Demineralization is a common side effect asso-
ciated with fixed appliance orthodontic treat-
ment. The development of white spot lesions
(WSL) is almost inevitable when oral hygiene is
285
poor (Fig 1A and B). The components of the
appliance and the bonding materials promote
plaque accumulation and bacterial colonization,
especially Streptococcus mutans and Lactobacillus,55
with subsequent acid production leading to de-
calcification. This might produce an alteration
in the appearance of the enamel surface.56,57
The incidence rate of enamel decalcification
ranges from 2% to 96% and it is mainly the
result of change in the pH of the oral environ-
ment favoring diffusion of calcium and phos-
phate ions out of enamel.58 Visible white lesions
may develop within 4 weeks. Fast developing
white spots are most often defects of the enamel
surface that may remineralize almost completely
within a few weeks of the removal of cariogenic
challenge. However, lesions that develop slowly
during the course of orthodontic treatment
remineralize extremely slowly.59
The WSL is considered to be a precursor of
enamel caries by making the area slightly softer
than surrounding sound enamel.60 Previous
studies that evaluated the mechanical and crys-
tallographic characteristics of these incipient
carious lesions demonstrated about 10% reduc-
tion in the mineral content of enamel. This
reduction in the inorganic content of WSL is an
important contributing factor to their increased
abrasion in vivo61 making it more prone to
enamel loss during debonding procedures.62 In
severe cases, frank cavitation is seen that re-
quires restorative intervention. It is reported
that any tooth in the mouth can be affected by
the process with the common ones being maxil-
lary lateral incisors, maxillary canines, and man-
dibular premolars.63 This has obvious esthetic
implications and highlights the need for caries
rate assessment before the beginning of treat-
ment. While the demineralized surface remains
286 Arhun and Arman
intact, there is a possibility of remineralization
and reversal of the lesion. It is suggested that
there is poor correlation between length of
treatment and the incidence or number of white
spot formations.64 O’Reilly and Featherstone56
suggested that the demineralization occurs very
rapidly in susceptible individuals, even within
the first month of fixed appliance treatment.
Controlling dental plaque and inflammation
due to the presence of orthodontic appliances is
very difficult in orthodontic patients with fixed
appliances. Various attempts have been made to
minimize WSL formation and incipient caries
lesions associated with orthodontic treatment,
the most common being the promotion of the
formation of fluorapatite (which is formed by
the addition of fluoride into the enamel struc-
ture), which aids in the remineralization of small
decalcified lesions and reduction in formation
of new lesions, thereby reducing tooth decay.65
Fluoride concentrations of less than 0.05 ppm
are reported to be beneficial in reduction of
carious lesions.66 Acid-resistant coatings of calcium
fluoride or titanium fluoride on the enamel sur-
face and the use of fluoride in combination with
different antimicrobials have been suggested to
improve the cariostatic effect of fluoride at low
pH.67 Long-term, low-dose fluoride availability,
in contrast to one-time topical application in
high doses, might increase the caries-resistant
fluorapatite concentration in enamel, helping
the prevention and reduction of demineraliza-
tion.65,66 The introduction of fluoride-releasing
adhesive systems, resin composites, and glass
ionomer cements for bracket bonding offered a
means of fluoride delivery adjacent to bracket-
enamel interface independent of patient coop-
eration and has attracted considerable interest.
However, the ability of these materials to reduce
decalcification clinically remains equivocal.68 It
was reported that glassionomer cements do not
provide complete caries protection under loose
bands or in areas where the cement is missing.69
Other fluoride-release mechanisms include flu-
oride-releasing elastic ligature and depot devices
on upper molar bands.
Remineralization by release of fluoride is im-
portant, but the antibacterial effect is another
important property of fluoride because inactiva-
tion of bacteria means a direct strategy to elim-
inate the cause of dental caries. Nowadays, bio-
active adhesive systems that possess antibacterial
effects or intensive remineralization ability are
considered to be beneficial. Recently, a fluoride-
releasing antibacterial bonding agent has been
developed by combining the physical advan-
tages of dental adhesive technology and anti-
bacterial effect. The antibacterial activity of
MDPB (12-methacryloyloxydodecyl-pyridinium
bromide) incorporated in the antibacterial ad-
hesive systems demonstrated inhibition of caries
formation, especially along the enamel mar-
gins.70 Imazato and coworkers have been con-
ducting investigations on the uses of MDPB
since 1995. They could incorporate MDPB into
the self-etching primer and adhesive resin and
demonstrate in vitro antibacterial activity, bond-
ing ability, cytotoxicity, and pulpal response.
They have confirmed that MDPB-containing
primer has got antibacterial effects in vivo when
used in animal models.71,72 However, further
studies are essential to test both the in vivo prop-
erties of this material along with its effectiveness
as an antibacterial and fluoride-releasing agent
in reduction of WSL.
Chemical agents such as chlorhexidine or
benzydamine used in the form of mouth rinses
or oral sprays have shown to be useful adjuncts
in plaque and inflammation control.73 Varnish
forms of the other antibacterial solutions such
as benzydamine, triclosan, and xylitol could be
helpful in orthodontic patients for suppressing
levels of oral mutans or the other microbes for
long periods, when used before the placement
of fixed orthodontic appliances.
Recent research has focused on the argon
laser’s ability to cure composite resins used in
orthodontic appliances. Using the argon laser
for this purpose equates to time savings, but a
more interesting application is its ability to alter
the enamel, rendering it less susceptible to
demineralization. It was also shown that combin-
ing laser irradiation with fluoride treatment can
have a synergistic effect on acid resistance pre-
venting formation of WSL and dental caries.74
In restorative dentistry, microleakage is de-
fined as the seeping and leaking of fluids and
bacteria between tooth/restoration interface.75
From the orthodontic point of view; it is possible
that there is likelihood for formation of WSL at
and under the adhesive-enamel interface due to
microleakage. James and coworkers76 were the
first to point out increased risk of decalcification
due to microleakage around orthodontic brack-
 Orthodontic Mechanics and Tooth Enamel
ets. A recent in vitro study showed that mic-
roleakage tends to occur less under ceramic
brackets than it does under the metal ones. De-
spite all mechanical drawbacks of ceramic brack-
ets, this finding might be of use in long-term
clinical practice. However, further studies should
be conducted to clarify in vitro and in vivo cor-
relation of microleakage under and around
brackets. In comparison with ceramic brackets,
the metal brackets yielded worse microleakage
resistance.77
When the teeth are heated and cooled by the
ingestion of hot or cold foods, expansion and
contraction occur. If the coefficient of thermal
expansion for a restorative material does not
match that of the tooth, they expand and con-
tract at different rates. Repeated expansion and
contraction of teeth and restorative materials at
different rates results in fluids being sucked in
and pushed out at the margins of a restoration,
resulting in a process known as percolation.75
The linear thermal coefficient of expansion of
enamel and ceramic/metal brackets and the ad-
hesive systems do not match closely (ie, for resin
composites ␣ ⫽ 20-55 ppm/°C, stainless steel
bracket [316L] ␣ ⫽ 16 ppm/°C, and enamel
␣ ⫽ 12 ppm/°C).78 Metal brackets contract and
expand more than ceramic brackets, enamel, or
the adhesive systems, producing microgaps be-
tween the bracket and the adhesive system caus-
ing leaking of oral fluids and bacteria beneath
the brackets.
When demineralization is present after treat-
ment, the clinician should wait for at least 2
months to allow the lesion to be remineralized
by the effect of saliva. If it is seen that the saliva’s
capacity is not enough for spontaneous reminer-
alization, topical fluoride is indicated. Although
high-dose fluoride (20,000-25,000ppm) is effec-
tive, it is recommended to apply frequent low
doses such as by the use of toothpastes (1000-
1500 ppm) or fluoride mouthwashes (0.05%
sodium fluoride daily rinse or 0.2% sodium flu-
oride weekly rinse).79 Acid/pumice microabra-
sion has also been advocated to improve the
esthetics of stabilized lesions. Persistent lucen-
cies (persistent white spot lesions) can be
abraded with 18% hydrochloric acid in fine
pumice in sequences of 30 seconds for a maxi-
mum of 10 times. After the last application the
tooth is washed well and a fluoride varnish ap-
plied.80
287
Enamel Damage During Adhesive
Removal and Rebonding Failed Brackets
Although the primary orthodontic goal lies in
returning the enamel surface to its original state
following removal of orthodontic attachments,
the adhesive removal procedures after debonding
may remove up to 55.6 ␮m of surface enamel.81
The failure at the bracket-adhesive interface
decreases the probability of enamel damage,
but has the disadvantage of requiring the me-
chanical removal of the residual adhesive after
debonding.
The search for an efficient and safe method
of adhesive resin removal following debonding
has resulted in the introduction of a wide array
of instruments and procedures. These include
manual removal with the use of a hand scalers or
a band removing pliers,82 tungsten carbide burs
(TCBs) with low or high speed hand pieces,83
Sof-Lex disks,84 and special composite finishing
systems with zirconia paste or slurry pumice as
well as ultrasonic applications.85 Also novel ap-
proaches involving carbon dioxide laser applica-
tion and air powder abrasive systems have been
promising.86,87
Along with the introduction of novel meth-
ods, the armamentarium of conventional instru-
ments has included the introduction of specially
designed burs that are less aggressive to the
enamel.88 All the reported techniques produce
different degrees of polish and some introduced
abrasion anomalies accompanied by a signifi-
cant loss of enamel. When TCBs are used at high
speed, they can cause damage to enamel as they
are harder than the enamel82 (Fig 2). Van Waes
and coworkers23 and Zachrisson and Årtun89
Figure 2. Enamel scratches after debonding and ad-
hesive remnant removal with high-speed tungsten-car-
bide bur. (Color version of figure is available online.)
288 Arhun and Arman

Figure 3. Representative SEM photographs of enamel surfaces after different resin-removal methods at 1500⫻
magnifications. (A) Enamel surface after resin removal with low-speed tungsten-carbide bur (TCB). (B) Enamel
surface after resin removal with high-speed TCB. (C) Enamel surface after resin removal with Sof-Lex disks.
(D) Enamel surface after resin removal with microetcher. (Adapted from Eminkahyagil and coworkers. Angle
Orthod 76:314-321, 2006.)

concluded that a TCB at low speed produced the
finest scratch pattern with the least enamel loss
of 7.4 ␮m. Retief and Denys90 recommended
using TCBs at high speed with adequate air cool-
ing, while Rouleau and coworkers82 and Camp-
bell91 suggested water spray instead of air cool-
ing. Remnant removal with Sof-Lex aluminum
oxide finishing disks shows a progressive de-
crease in surface irregularities, but is the most
time-consuming method and leaves too much
remnant on the enamel surface92 (Fig 3). Be-
sides, Campbell found that disks and rubber
wheels are effective, but may be cumbersome for
clinicians.91 These techniques may have adverse
effects on the pulpal tissues if not dissipated with
an appropriate coolant.
Another frequent and undesirable problem
during treatment is bracket failure. This is usu-
ally the result either of parafunctional forces
exerted by the patients or of poor bonding tech-
nique. The time it takes to clean, prepare, and
bond a new bracket can be disruptive in a busy
practice and might also lengthen the overall
treatment time. Scarring of enamel following
rebonding procedures is inevitable but can be
reduced by choosing the right protocol. TCBs
used at low speed with appropriate air cooling
may be the method of choice with an accept-
able enamel surface and provides good re-
bond strength.92
Conclusion
Enamel damage can be considered as an inevi-
table sequela to orthodontic treatment, with var-
ious procedures producing varied effects. The
aim of every orthodontic practitioner should be
to minimize damages to enamel, helping im-
prove the longevity of teeth as well as dentition
as a whole. This can be done by keeping abreast
with the recent technologies and using them in
a proper manner. This brings in the necessity to
have a fundamental knowledge of preventive
dentistry principles and the clinical skill to apply
those in the proper manner.
 Orthodontic Mechanics and Tooth Enamel
References
1. Shaw WC, O’Brien KD, Richmond S, et al: Quality con-
trol in orthodontics: risk/benefit considerations. Br
Dent J 170:33-37, 1992
2. Van Meerbeek B, De Munck J, Mattar D, et al: Micro
tensile bond strengths of an etch&rinse and self-etch
adhesive to enamel and dentin as a function of surface
treatment. Oper Dent 28:647-660, 2003
3. Cehreli SB, Eminkahyagil N: Effect of active pretreat-
ment of self etching primers on the ultramorphology of
intact primary and permanent tooth enamel. J Dent
Child 73:86-90, 2006
4. Thompson RE, Way DC: Enamel loss due to prophylaxis
and multiple bonding/debonding of a orthodontic at-
tachment. Am J Orthod 79:282-295, 1981
5. Barkmeier WW, Scheiffer SE, Gwinnett AJ: Effects of 15
vs 60 second enamel acid conditioning on adhesion and
morphology. Oper Dent 11:111-116, 1986
6. Osorio R, Toledano M, Garcia-Godoy F: Bracket bond-
ing with 15-60 second etching and adhesive remaining
on enamel after debonding. Angle Orthod 69:45-48,
1999
7. Retief DH: Clinical applications of enamel adhesives.
Oper Dent 5(suppl):44-49, 1992
8. Olsen ME, Bishara SE, Damon P, et al: Evaluation of
Scotchbond Multi Purpose and maleic acid as alternative
methods of bonding orthodontic brackets. Am J Orthod
Dentofacial Orthop 111:498-501, 1997
9. Yamada R, Hayakawa T, Kasai K: Effect of using self
etching primer for bonding orthodontic brackets. Angle
Orthod 72:558-564, 2002
10. Haller B: Recent developments in dentin bonding. Am J
Dent 13:44-50, 2000
11. Buyukyilmaz T, Usumez S, Karaman AI: Effect of self
etching primers on bond strength—are they reliable?
Angle Orthod 73:64-70, 2003
12. Friedl KH, Oberlander H, Schmalz G, et al: Bond
strength of composite resins using a new one-step adhe-
sive system. J Dent Res 79:3633, 2000
13. Kanemura N, Sano H, Tagami J: Tensile bond strength
to and SEM evaluation of ground and intact enamel
surfaces. J Dent 27:523-530, 1999
14. Toledano M, Osorio R, de Leonardi G, et al: Influence
of self-etching primer on the resin adhesion to enamel
and dentin. Am J Dent 14:205-210, 2001
15. Bishara SE, Ajlouni R, Laffoon JF, et al: Effects of mod-
ifying the adhesive composition on the bond strength of
orthodontic brackets. Angle Orthod 72:464-467, 2002
16. Grubisa HS, Heo G, Raboud D, et al: An evaluation and
comparison of orthodontic bracket bond strengths
achieved with self etching primer. Am J Orthod Dento-
facial Orthop 126:213-219, 2004
17. Bishara SE, Von Wald L, Laffoon JF, et al: Effect of a self
etch primer/adhesive on the shear bond strength of
orthodontic brackets. Am J Orthod Dentofacial Orthop
119:621-624, 2001
18. Miyazaki M, Hirohata N, Takagaki K, et al: Influence of
self etching primer drying time on enamel bond
strength of resin composites. J Dent 27:203-207, 1999
289
19. Dorminey JC, Dunn WJ, Taloumis LJ: Shear bond
strength of orthodontic brackets bonded with a modi-
fied 1-step etchant-and-primer technique. Am J Orthod
Dentofacial Orthop 124:410-413, 2003
20. Miyazaki M, Hinoura K, Honjo G, et al: Effect of self
etching primer application method on the bond strength.
Am J Dent 15:412-416, 2002
21. Arhun N, Arman A, Sesen C, et al: Shear bond strength
of orthodontic brackets with 3 self-etch adhesives. Am J
Orthod Dentofacial Orthop 129:547-550, 2006
22. Eminkahyagil N, Korkmaz Y, Gokalp S, et al: Shear bond
strength of orthodontic brackets with newly developed
antibacterial self etch adhesive. Angle Orthod 75:843-
848, 2005
23. Van Waes H, Matter T, Krejci I: Three-dimensional mea-
surement of enamel loss caused by bonding and
debonding orthodontic brackets. Am J Orthod Dentofa-
cial Orthop 112:666-669, 1997
24. Kawasaki M, Hayakawa T, Takizawa T, et al: Assessment
the performance of a methyl methacrylate based resin
cement with self etching primer for bonding orthodon-
tic brackets. Angle Orthod 73:702-709, 2003
25. Profitt W: Contemporary Orthodontics. St Louis, CV
Mosby, 1986
26. Lopez JI: Retentive shear strengths of various bonding
attachment bases. Am J Orthod Dentofacial Orthop 77:
669-678, 1980
27. Reynolds I: A review of direct orthodontic bonding. Br J
Orthod 2:1711-178, 1975
28. Bowen RL, Rodriguez MS: Tensile strength and modu-
lud of elasticity of tooth structure and several restorative
materials. J Am Dent Assoc 64:378-387, 1962
29. Bishara SE, Fehr DE: Ceramic brackets, something old,
something new, a review. Semin Orthod 3:178-188, 1997
30. Fox NA, McCabe JF, Buckley JG: A critique of bond
strength testing in orthodontics. Br J Orthod 21:33-43,
1994
31. Philips HW: JCO interviews. J Clin Orthod 14:391-411,
1980
32. Bishara SE, Fonseca JM, Fehr DE, et al: Debonding
forces applied to ceramic brackets simulating clinical
conditions. Angle Orthod 64:277-282, 1994
33. Bennett CG, Shen C, Waldron JH: The effects of
debonding on the enamel surface. J Clin Orthod 18:330-
334, 1984
34. Bishara SE, Von Wald L, Laffoon JF: Effect of altering
the type of enamel conditioner on the shear bond
strength of a resin-reinforced glass ionomer adhesive.
Am J Orthod Dentofacial Orthop 118:288-294, 2000
35. Martin S, Garcia-Godoy F: Shear bond strength of orth-
odontic brackets cemented with a zinc oxide-polyvinyl
cement. Am J Orthod Dentofacial Orthop 106:615-620,
1994
36. Artun J, Bergland S: Clinical trials with crystal growth
conditioning as an alternative to acid etch enamel pre-
treatment. Am J Orthod 85:333-340, 1984
37. Storm ER: Debonding ceramic brackets. J Clin Orthod
24:91-94, 1990
38. Joseph VP, Rossouw E: The shear bond strengths of
stainless steel and ceramic brackets used with chemically
and light activated composite resins. Am J Orthod
Dentofacial Orthop 97:121-125, 1990
290 Arhun and Arman
39. Viazis AD, Cavanaugh G, Bevis RR: Bond strength of
ceramic brackets under shear stress: an in vitro report.
Am J Orthod Dentofacial Orthop 98:214-221, 1990
40. Swartz ML: Ceramic brackets. J Clin Orthod 22:82-88,
1988
41. Bishara SE, Trulove TS: Comparisons of different
debonding techniques for ceramic brackets: an in vitro
study. Am J Orthod Dentofacial Orthop 98:145-153,
1990
42. Sorel O, Alam R, Chagneau F, et al: Comparison of bond
strength between simple foil and laser structured base
retention brackets. Am J Orthod Dentofacial Orthop
122:260-266, 2002
43. Droese V, Diedrich P: Tensile bond strength of metal
plasma coated bracket bases. Fortschr Kufer Orthop
53:142-152, 1992
44. Smith DC, Meijer R: Improvements in bracket base de-
sign. Am J Orthod 83:277-281, 1983
45. MacColl GA, Rossouw PE, Titley KC, et al: The relation-
ship between bond strength and orthodontic bracket
base. Am J Orthod Dentofacial Orthop 113:276-281,
1998
46. Ostertag AJ, Dhuru VB, D. Ferguson DJ, et al: Shear,
tortional and tensile bond strengths of ceramic brackets
using three adhesive filler concentrations. Am J Orthod
Dentofacial Orthop 100:251-258, 1991
47. Andrews LF: Interviews on the straight wire appliance.
J Clin Orthod 24:493-508, 1990
48. Keim RG, Gottlieb EL, Nelson AH, et al: JCO study of
orthodontic diagnosis and treatment procedures Part 1.
Results and trends. J Clin Orthod 30:553-568, 2002
49. Tuverson DL: Anterior interocclusal relations. Part 1.
Am J Orthod 78:361-370, 1980
50. Twesme DA, Firestone AR, Heaven TJ, et al: Air-rotor
stripping and enamel demineralization in vitro. Am J
Orthod Dentofacial Orthop 105:142-152, 1994
51. Joseph VP, Rossouw PE, Basson NJ: Orthodontic micro-
abrasive reproximation. Am J Orthod Dentofacial Or-
thop 102:351-359, 1992
52. Crain G, Sheridan JJ: Susceptibility to caries and peri-
odontal disease after air-rotor stripping. J Clin Orthod
24:84-85, 1990
53. el-Mangoury NH, Moussa MM, Mostafa YA, et al: In vivo
remineralization after air rotor stripping. J Clin Orthod
25:75-78, 1991
54. Arman A, Cehreli SB, Ozel E, et al: Qualitative and
quantitative evaluation of enamel after various stripping
methods. Am J Orthod Dentofacial Orthop 130:131.e7-
131.e14, 2006
55. Fournier A, Payant L, Bouchin R: Adherence of Strep-
tococcus mutans to orthodontic brackets. Am J Orthod
Dentofacial Orthop 14:414-417, 1998
56. O’Reilly MM, Featherstone JD: Demineralization and
remineralization around orthodontic appliances: an in
vitro study. Am J Orthod Dentofacial Orthop 92:33-40,
1987
57. Gwinnett JA, Ceen F: Plaque distribution on bonded
brackets. Am J Orthod 75:667-677, 1979
58. Mitchell L: Decalcification during orthodontic treat-
ment with fixed appliances—an overview. Br J Orthod
19:199-205, 1992
59. Ogaard B, ten Bosch J: Regression of white spot enamel
lesions. A new optical method for quantitative longitu-
dinal evaluation in vivo. Am J Orthod Dentofacial Or-
thop 106:238-242, 1991
60. Agaard B: Oral microbiological changes, long-term
enamel alterations due to decalcification, and caries
prophylactic aspects, in Bratley WA, Eliades T (eds):
Orthodontic Materials: Scientific and Clinical Aspects.
Stutgard, Thieme, 2001, p 127
61. Linton JL: Quantitative measurements of remineraliza-
tion of incipient caries. Am J Orthod Dentofacial Or-
thop 110:590-597, 1996
62. Tufekci E, Mirrill TE, Pintado MR, et al: Enamel loss
associated with orthodontic adhesive removal on teeth
with white spot lesions: an in vitro study. Am J Orthod
Dentofacial Orthop 125:733-740, 2004
63. Geiger AM, Gorelick L, Gwinnett AJ, et al: The effect of
a fluoride program on white spot formation during orth-
odontic treatment. Am J Orthod Dentofacial Orthop
93:29-37, 1988
64. Gorelick L, Geiger AM, Gwinnett AJ: Incidence of white
spot formation after bonding and banding. Am J Orthod
81:93-98, 1982
65. Mellberg JR, Mallon DE: Acceleration of remineraliza-
tion in vitro by sodium mono fluori phosphate and
sodium fluoride. J Dent Res 63:1130-1155, 1984
66. Margolis HC, Mareno EC, Murphy BJ: Effect of low levels
of fluoride in solution on enamel demineralization in
vitro. J Dent Res 65:23-29, 1986
67. Buyukyilmaz T, Øgaard B: Caries-preventive effects of flu-
oride-releasing materials. Adv Dent Res 9:377-383, 1995
68. Turner PJ: The clinical evaluation of a fluoride contain-
ing orthodontic bonding material. Br J Orthod 201:307-
313, 1993
69. Rezk-Lega F, Ogaard B, Arends J: An in vivo study on the
merits of two glass ionomers for the cementation of
orthodontic bands. Am J Orthod Dentofacial Orthop
99:162-167, 1991
70. Han L, Edward C, Okamoto A, et al: A comparative study
of fluoride-releasing adhesive resin materials. Dent Ma-
ter 21:9-19, 2002
71. Imazato S, Torii M, Tsuchitani Y, et al: Incorporation of
bacterial inhibitor into resin composite. J Dent Res 73:
1437-1443, 1994
72. Imazato S, Kinomoto Y, Tarumi H, et al: Antibacterial
activity and bonding characteristics of an adhesive resin
containing antibacterial monomer MDPB. Dent Mater
19:313-319, 2003
73. Zachrisson BU: Cause and prevention of injuries to teeth
and supporting structures during orthodontic treat-
ment. Am J Orthod 69:285-300, 1976
74. Hicks MJ, Flaitz CM, Westerman GH, et al: Enamel caries
initiation and progression following low fluence (en-
ergy) argon laser and fluoride treatment. J Clin Pediatr
Dent 20:9-13, 1995
75. Gladwin M, Bagby M: Clinical Aspects of Dental Materi-
als Theory, Practice and Cases. Baltimore, MD, Lippin-
cott Williams & Wilkins, 2004
76. James JW, Miller BH, English JD, et al: Effects of high
speed curing devices on shear bond strength and mic-
roleakage of orthodontic brackets. Am J Orthod Dento-
facial Orthop 123:555-561, 2003
 Orthodontic Mechanics and Tooth Enamel
77. Arhun N, Arman A, Cehreli SB, et al: Microleakage
beneath metal and ceramic brackets bonded with a con-
ventional and an antibacterial adhesive system. Angle
Orthod 76:1028-1034, 2006
78. Van Noort R: Introduction to Dental Materials. 1st ed.
London, UK, Mosby, 1994, pp 53-54
79. Bergstrand F, Twetman S: Evidence for the efficacy of
various methods of treating white-spot lesions after
debonding of fixed orthodontic appliances. J Clin
Orthod 37:19-21, 2003
80. Welbury RR, Carter NE: The hydrochloric acid-pum-
ice microabrasion technique in the treatment of post
orthodontic decalcification. Br J Orthod 108:181-185,
1993
81. Fitzpatrick DA, Way DC: The effects of wear, acid etch-
ing, and bond removal on human enamel. Am J Orthod
Dentofacial Orthop 72:671-681, 1997
82. Rouleau BD Jr, Marshall GW Jr, Cooley RO: Enamel
surface evaluations after clinical treatment and re-
moval of orthodontic brackets. Am J Orthod 81:423-
426, 1982
83. Hong YH, Lew KK: Quantitative and qualitative assess-
ment of enamel surface following five composite re-
moval methods after bracket debonding. Eur J Orthod
17:121-128, 1995
291
84. Howell S, Weekes WT: An electron microscopic evalua-
tion of the enamel surface subsequent to various
debonding procedures. Aust Dent 35:245-252, 1990
85. Burapavong V, Marshall GW, Apfel DA, et al: Enamel
surface characteristics on removal of bonded orthodon-
tic brackets. Am J Orthod 74:176-187, 1978
86. Smith SC, Walsh LJ, Taverne AA: Removal of orthodon-
tic bonding residues by CO2 laser radiation: surface
effects. J Clin Laser Med Surg 17:13-18, 1999
87. Wright GZ, Hatibovic-Kofman S, Millenaar DW, et al:
The safety and efficacy of treatment with air abrasion
technology. Int J Paediatr Dent 9:133-140, 1999
88. Radlanski RJ: A new carbide finishing bur for bracket
debonding. J Orofac Orthop 62:296-304, 2001
89. Zachrisson BU, Årtun J: Enamel surface appearance af-
ter various debonding techniques. Am J Orthod 75:121-
127, 1979
90. Retief DH, Denys FR: Finishing of enamel surfaces after
debonding of orthodontic attachments. Angle Orthod
49:1-10, 1979
91. Campbell PM: Enamel surfaces after orthodontic bracket
debonding. Angle Orthod 65:103-110, 1995
92. Eminkahyagil N, Arman A, Cetinsahin A, et al: Effect of
resin removal methods on enamel and shear bond
strength of rebonded brackets. Angle Orthod 76:314-
321, 2006