CONTINUING EDUCATION

Effect of pumice prophylaxis on the bond strength of

orthodontic brackets
Steven J. Lindauer, DMD, MDSc, a Henry Browning, b Bhavna Shroff, DDS, MDSc, °
Frank Marshall, DDS, d Ralph H. B. Anderson, DDS, e and Peter C. Moon, MS, PhD t
Richmond, Va.

Pumice prophylaxis has long been accepted as a prerequisite for achieving adequate enamel
etching during orthodontic bonding procedures. Three methods were used in this study to examine
the effects of pumice prophylaxis on the bond strength of orthodontic brackets: (1) shear bond
strength of brackets that were bonded to extracted premolars after surface preparation procedures,
which either included or did not include prior pumice prophylaxis, was evaluated; (2) scanning
electron microscopy (SEM) was used to examine the surface characteristics of teeth that had been
etched with and without prior purnice prophylaxis; and (3) rate of bracket failure in patients who
had had brackets bonded with and without prior pumice prophylaxis was recorded during an
average treatment time of 18 months. No significant differences were noted in bond strength,
general etched enamel surface characteristics, or bracket retention rates. Some specific differences,
however, were noted on SEM in localized areas of the etched enamel surfaces, although these did
not appear to affect the bond strength or bracket retention rates ultimately attained. (Am J Orthod
Dentofac Orthop 1997;111:599-605.)

S i n c e direct bonding of orthodontic prophylaxis is a prerequisite for achieving adequate

brackets first became popular in the 1970s, thorough
pumice prophylaxis, followed by enamel etching, has
been the recommended routine for achieving a
strong enamel-resin bond. Optimum enamel condi-
tioning occurs with phosphoric acid concentrations
between 30% and 50%, 1-3 although some investiga-
tors have found that concentrations as low as 5% or
10% can be used without significantly decreasing
bond strength. 4,s Similarly, although 30- to 60-sec-
ond etching times are still commonly recommended,
application of etchant for as little as 15 seconds has
been found to also be effective.6-8 Until recently,
there has been little doubt that an initial pumice
From the Department of Orthodontics, School of Dentistry, Medical
College of Virginia, Virginia Commonwealth University, Richmond, Va.
Supported in part by the AD Williams Fund of the Medical College of
Virginia.
aAssociate professor, Department of Orthodontics, VCU/MCV School of
Dentistry.
bGraduate student, VCU/MCV School of Dentistry.
°Associate professor, Department of Orthodontics, University of Maryland
Dental School.
d In private practice.
~Graduate student, Department of Orthodontics, University of Louisville
School of Dentistry.
fAssociate professor, Department of General Practice, VCU/MCV School
of Dentistry.
Reprint requests to: Dr. Steven J. Lindauer, Department of Orthodontics,
School of Dentistry, Medical College of Virginia, Virginia Commonwealth
University, Richmond, VA 23298-0566.
Copyright © 1997 by the American Association of Orthodontists.
0889-5406/97/$5.00 + 0 8/1/70373
enamel etching?
Buonocore's original technique for direct bond-
ing to enamel included a step to remove surface
material from a tooth before the application of an
acid etchant. 1° Evidence supporting the necessity of
prophylactic cleaning for improved bond strength
was first presented by Miura et al. in 1973.11 They
measured shear strengths of plastic brackets bonded
with methyl methacrylate and a silane coupling
agent after various surface preparation procedures.
Scanning electron microscopy (SEM) studies have
shown that pumice prophylaxis before acid treat-
ment removes organic material from the enamel
surface, such as acquired pellicle, which has been
hypothesized to inhibit optimum etching from oc-
curring.11,12
In 1983, Main et al. ~3 conducted a study to
explore ways of streamlining enamel surface treat-
ment procedures for the application of pit and
fissure sealants. They found that acid etching alone,
without prior pumice prophylaxis, was adequate for
removing acquired pellicle. This was confirmed by
SEM and bond-strength tests in which teeth with
and without pellicle before acid etching were com-
pared and no differences were found. Donnan and
Ball, TMin 1988, reported the results of a clinical trial
in which 175 pairs of contralaterally matched pit and
fissure sealants were placed in 59 patients. Half of
the sealants were applied after pumice prophylaxis,
followed by acid etching, and half after acid etching
599
600 L i n d a u e r et al.
Table I. A v e r a g e s h e a r b o n d s t r e n g t h o f b r a c k e t s
Average shear bond strength
n MPa +- SD
Pumiced
Chemical cure
Buccal 13 9.6 ± 4.6
Lingual 6 9.0 ± 4.4
Light cure
Buccal 11 9.1 ± 4.6
Lingual 6 11.1 _+ 5.8
Not pumiced
Chemical cure
Buccal 10 8.8 ± 3.8
Lingual 5 7.6 -+ 2.2
Light cure
Buccal 11 8.1 + 5.7
Lingual 6 6.9 -+ 4.1
alone. In 1 year, no differences were found in the
retention rates of the sealants between the two
groups. At the National Sealant Conference held in
Columbus, Ohio, in August of 1994, the Ohio De-
p a r t m e n t of Health described their elementary
school sealant program in which all sealants are
placed without preliminary pumice prophylaxis.
They reported a 95% retention rate after 1 year.
The purpose of the current study is to determine
whether pumice prophylaxis, p e r f o r m e d before acid
etching, enhances the bond strength and retention
rate of orthodontic brackets. This was accomplished
in three ways. First, a laboratory test was conducted
in which brackets were bonded to extracted premo-
lars after surface preparation protocols, which did
or did not include pumice prophylaxis before acid
etching; the shear bond strengths of the brackets in
the two groups were then compared. Second, SEM
was used to examine and to compare tooth surfaces
that had been etched with and without preliminary
pumice prophylaxis. Third, a clinical trial was car-
ried out in which patients beginning orthodontic
treatment had brackets bonded on one side of the
mouth with pumice prophylaxis, followed by acid
etching, and the other side after acid etching alone;
bracket retention rates were c o m p a r e d between
sides after an average of 18 months of active treat-
ment.
MATERIAL AND METHODS
Bond Strength Tests
Forty-five human premolars extracted for orthodontic
treatment were collected and stored in saline. Stainless
steel brackets (Ultratrimm, Dentaurum) were applied
within 12 hours, with either a light-cure (Transbond XT,
3-M Unitek) or a two-paste chemical-cure (Accubond,
GAC) bonding resin. For 24 of the teeth, surface prepa-
ration was accomplished according to the manufacturers'
specifications, which included a thorough prophylactic
American Journal of Orthodontics and Dentofacial Orthopedics
June 1997
treatment with plain pumice and 30 seconds of acid
etching with 37% phosphoric acid. The pumice prophy-
laxis step was omitted for the remaining 21 teeth. When-
ever possible, for maxillary premolars and mandibular
second premolars, both the buccal and lingual surfaces
were used, bringing the total number of brackets bonded
to 68.
Bonded teeth were stored in saline for 7 days. The
bracketed premolars were then mounted in plaster, and
the shear bond strengths were measured with an Instron
Universal Testing Machine (Instron Corp.). Bond
strengths were calculated and recorded in MPa (1 × 106
N/mS), the debonding force per unit of bracket base area.
Comparisons were made between pumiced and nonpum-
iced, buccal and lingual, and light-cure and chemical-cure
groups with three-way analysis of variance (ANOVA),
with SAS/Stat (SAS Inc.) software.
Scanning Electron Microscopy
Thirty premolars extracted for orthodontic purposes
were collected and immediately fixed in 2% glutaralde-
hyde/0.1 M cacodylate solution at 4° C. Fifteen randomly
selected premolars received a pumice prophylaxis for 15
seconds, were subsequently rinsed with distilled water for
20 seconds, air dried, and etched with a 37% orthophos-
phoric acid gel for 60 seconds. The teeth were then rinsed
with distilled water, air dried, and sputter coated with
gold-palladium. The remaining 15 premolars were pre-
pared in the same manner, but without undergoing pum-
ice prophylaxis. The specimens were then observed and
compared with a JEOL-T2000 SEM at magnifications
ranging from 150 to 1000 times.
Clinical Bracket Retention
A total of 85 patients scheduled to begin orthodontic
treatment, either limited or comprehensive, participated
in the clinical portion of the study. For each patient, one
side of the mouth, right or left, was randomly chosen to
receive or not receive pumice prophylaxis as part of the
surface preparation procedure for bonding orthodontic
brackets. All patients brushed their own teeth before
bonding. Otherwise, bonding was accomplished as recom-
mended by the manufacturer by using a single-step chem-
ical-cure bonding agent (Rely-a-bond, Reliance). A total
of 1354 teeth were involved, including 681 in the pumiced,
and 673 in the nonpumiced groups.
Bracket failures were recorded 2 years after the
initiation of the study regardless of when actual bonding
occurred. Since patient recruitment continued for a pe-
riod of 1 year, the average duration of treatment at the
time of data recording was estimated to be approximately
18 months. If a bracket was debonded during the experi-
mental period, it was recorded as a failure and any
rebonded brackets were not considered as part of the
study. The number of bracket failures between the pum-
iced and nonpumiced sides was compared with a Chi-
square analysis.
American Journal of Orthodontics and Dentofacial Orthopedics Lindauer et aL 601
Volume 111, No. 6

Average Shear Bond Strengths

+-4.6
14 " =r= . . . . . . . . . . . . . .--.5,2 . . . . . . . . . . . . . . . . +-4,6
+-4.0 - +-4.5

~, 12
~'~o
I +-4,4 -F

~ 6
o 4
2
9.6 8.9 I ~B . 9
~ e -~ ~
o ~ o =
"C= r.) O
o
~
~
=
= ~= 1~ "~
~ ~ o M
~ ;3
Z
o

Fig. 1. Average shear bond strengths (+_ SD) of brackets bonded to extracted premolars
compared by surface preparation technique, bonding material used, and tooth surface
bonded.

Fig. 2. SEM of etched pumiced tooth demonstrating type 1 etching pattern (magnifica-
tion = 750x).

RESULTS
Bond Strength
Results of the shear bond strength tests are
presented in Table I. Average values ranged from a
low of 6.0 ± 4.1 MPa for the nonpumiced, light-
cured, lingual surfaces, to a high of 11.1 ± 5.8 MPa
for the pumiced, light-cured, lingual surfaces. The
average bond strengths recorded for all of the
pumiced groups were higher than those of the
nonpumiced groups. Three-way ANOVA revealed
no significant differences, however, between any of
the groups tested (F = 0.91; p > 0.20). When
brackets from individual groupings were combined
to include all pumiced or nonpumiced, light- or
602 Lindauer et aL American Journal of Orthodontics' and Dentofacial Orthopedics
June 1997

Fig. 3. SEM of etched pumiced tooth demonstrating evenly distributed perikamata and
deep scratches, which resulted from pumice pretreatment (magnification = 150x).

Fig. 4. SEM of etched nonpumiced tooth demonstrating type 1 etching pattern (magnifi-
cation = lO00x).

chemical-cured, and lingual or buccal surfaces, ab-
solute differences between group averages became
smaller. These comparisons are shown in Fig. 1 and
demonstrate that the largest discrepancy was be-
tween the pumiced (9.6 ___ 4.6 MPa) and nonpum-
iced (7.8 _+ 4.4 MPa) groups. When lingual surfaces
were eliminated from the analysis, average bond
strength for the pumiced group dropped to 9.4 _+ 4.6
MPa and increased to 8.4 +_ 4.8 MPa for the
nonpumiced group. For all groups, the most com-
mon point of bracket failure was at the bracket-resin
interface.
Scanning Electron Microscopy
A full range of etching patterns were observed by
SEM in the pumiced and nonpumiced specimens
including types 1, 2, and 3, as described by Silver-
stone et al. 15 In pumiced teeth, the type 1 etching
American Journal of Orthodontics and Dentofacial Orthopedics Lindauer e¢ al. 603
Volume 111, No. 6

Fig. 5. SEM of etched nonpumiced tooth demonstrating type 2 etching pattern (magnifi-
cation = lO00x).

Fig. 6. SEM of etched nonpumiced tooth with debris and/or dental plaque remnants
evident (magnification = lO00x).

pattern, which is the characteristic honeycomb pat- Table IL Clinical bracket failure during an average treatment
tern of hollowed prisms with intact ena,nel periph- time of 18 m o n t h s

eries, was the most commonly observed (Fig. 2). Surface preparation I Totalbonded 1 Number failed
Some specimens also exhibited a reverse etching
Pumiced 681 45 (6.6%)
pattern (type 2 pattern) with preferential etching of Not pumiced 673 50 (7.4%)
the peripheries. At lower magnification, ewmly distrib-
uted perikamata were observed on the enamel surface
and deep scratches resulting from pumice pretreat- group. Both type 1 (Fig. 4) and type 2 (Fig. 5)
ment were present in a random pattern (Fig. 3). patterns were evident. In some areas, however,
In the nonpumiced sample, etching patterns dental plaque and/or debris were observed contam-
were generally similar to those in the pumiced inating the etched enamel surface (Fig. 6).
604 Lindauer et al.
Clinical Bracket Retention
During the 2-year study period, a total of 95 of
the 1354 brackets originally bonded failed. This
represents an overall failure rate of 7% but does
not include the cumulative effect of repeated
bracket failures on the same tooth. Complete
results are presented in Table II. Of the 95
bracket failures, 45 were on the pumiced teeth
and 50 were on the nonpumiced teeth. Chi-square
analysis confirmed that there were no significant
differences in failure rates between the two groups
(X2 = 0.28; p > 0.20). Maxillary and mandibular
second premolars accounted for more bracket
failures in both groups than those of all other
teeth combined.
DISCUSSION
Generally, there were no clear differences shown
between the teeth etched with and without prior
pumice prophylaxis by any of the three methods
used in this study. Although slightly greater than
average shear bond strengths were noted in the
pumiced groups, the difference was not statistically
significant. Because most bond failures in this in
vitro test occurred at the resin-bracket interface
rather than at the enamel surface, it is likely that any
deviations observed were not due to differences in
the surface preparation technique.
Scanning electron microscopy observations
confirmed that acid etching is an effective mech-
anism whether or not a pumice prophylaxis is
performed before the procedure. There was some
indication, however, that plaque or pellicle re-
mained on the teeth in the nonpumiced sample in
some areas after etching. In addition, scratches
were observed on pumiced teeth, which left the
surfaces uneven.
Any differences observed during the two in
vitro test procedures were not evident clinically
when the two surface preparation techniques were
compared. In the sample of 1354 teeth bonded in
85 patients, failure rates over an average ortho-
dontic treatment time of 18 months were 6.6%
and 7.4% for the pumiced and nonpumiced
groups, respectively. Most of the failures occurred
at the second premolars suggesting that research
efforts should be specially focused on improving
bonding to these teeth. Since in vitro bond failure
occurred at the bracket-resin interface most often,
concentration on improving bond strength at the
bracket itself might prove valuable. This approach
was supported in a recent study by Newman et
American Journal of Orthodontics and Dent@cial Orthopedics
June 1997
al. 16 in which various bracket base treatments
were shown to improve bond strength. Alterna-
tively, banding some second premolars or using a
more heavily filled bonding material are also
possible solutions.
In terms of bracket retention, there does not
appear to be any advantage to performing a pumice
prophylaxis before preparation of the tooth surface for
bonding. Cleaning the tooth, however, may be advis-
able to remove plaque and debris that may otherwise
remain trapped at the enamel-resin interface after
bonding. Requiring the patient to brush aggressively
before bonding may be adequate to achieve an accept-
ably clean surface. On the other hand, pumice prophy-
laxis does not appear to affect the bonding procedure
adversely. Any scratching of the enamel that occurs
because of pumicing, as observed in this study under
SEM, would be negligible compared with the surface
disturbances caused by removing excess composite
material left on the tooth after debonding. 17,1s
CONCLUSION
The results of this study did not provide any clear
support for pumice prophylaxis as a prerequisite for
achieving adequate enamel etching during orthodontic
bonding procedures. In vitro bond strengths were similar
in pumiced and nonpumiced samples as were the etching
patterns observed under SEM. Pumiced surfaces showed
scratches under SEM, whereas nonpumiced surfaces
showed retained plaque and debris in some areas after
etching. Clinically, bracket failure rates were similar
whether or not a pumice prophylaxis was performed as
part of the bonding procedure. Some mechanism to clean
the teeth before orthodontic bonding is still recom-
mended, however, to remove gross plaque accumulations
before brackets are placed.
We thank Dr. Robert K. Maumen for his help with
SEM analysis.
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