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Suitability of orthodontic brackets for rebonding and reworking following

removal by air pressure pulses and conventional debracketing techniques

Article in The Angle Orthodontist · July 2010

DOI: 10.2319/102809-605.1 · Source: PubMed

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 Original Article

Suitability of orthodontic brackets for rebonding and reworking following

removal by air pressure pulses and conventional debracketing techniques
Michael Knösela; Simone Mattysekb; Klaus Jungc; Dietmar Kubein-Meesenburgd;
Reza Sadat-Khonsarie; Dirk Ziebolzf

ABSTRACT
Aim: To test the null hypothesis that there are no significant differences in the reusability of
debonded brackets with regard to debonding technique and adhesive used.
Method: Ninety-six osteotomed third molars were randomly assigned to two study groups (n 5 48)
for bonding of a 0.018-inch bracket (Ormesh, Ormco) with either a composite adhesive (Mono-
Lok2; RMO) or a glass ionomer cement (GIC; Fuji Ortho LC;GC). Each of these two groups were
then randomly divided into four subgroups (n 5 12) according to the method of debonding using (1)
bracket removal pliers (BRP; Dentaurum), (2) a side cutter (SC; Dentaurum), (3) a lift-off
debracketing instrument (LODI; 3M-Unitek), or (4) an air pressure pulse device (CoronaFlex;
KaVo). The brackets were subsequently assessed visually for reusability and reworkability with 23
magnification and by pull testing with a 0.017- 3 0.025-inch steel archwire. The proportions of
reusable brackets were individually compared in terms of mode of removal and with regard to
adhesives using the Fisher exact test (a 5 5%).
Results: The null hypothesis was rejected. Not taking into account the debonding method,
brackets bonded with GIC were judged to a significant extent (81%; n 5 39; P , .01) to be
reworkable compared with those bonded with composite (56%; n 5 27). All brackets in both
adhesive groups removed with either the LODI or the CoronaFlex were found to be reusable,
whereas 79% (46%) of the brackets removed with the BRP (SC) were not. The proportion of
reusable brackets differed significantly between modes of removal (P , .01).
Conclusion: With regard to bracket reusability, the SC and the BRP cannot be recommended for
debonding brackets, especially in combination with a composite adhesive. (Angle Orthod.
2010;80:649–655.)
KEY WORDS: Debonding; Rebonding; Bracket reusability; CoronaFlex

INTRODUCTION
a
Associate Professor, Department of Orthodontics and
Dentofacial Orthopedics, Center of Dentistry, Georg-August- The bracket adhesive technique is an important and
University, Göttingen, Germany.
routine part of contemporary orthodontics because it
b
Research Scientist, Department of Orthodontics and
Dentofacial Orthopedics, Center of Dentistry, Georg-August- provides the basis for ensuring a controlled force and
University, Göttingen, Germany. torque transmission from the archwire on the teeth.
c
Assistant Professor, Department of Medical Statistics, The enamel-adhesive-bracket interface has to provide
Georg-August-University, Göttingen, Germany. both aspects of reliable attachment of the bracket
d
Professor and Department Chair, Department of Orthodon-
tics and Dentofacial Orthopedics, Center of Dentistry, Georg- during treatment and also easy and quick removal
August-University, Göttingen, Germany. following treatment with the least possible amount of
e
Associate Professor, Department of Orthodontics and damage to the enamel surface.
Dentofacial Orthopedics, Center of Dentistry, Georg-August- Another important aspect is that of economics. The
University, Göttingen, Germany.
cost factor can be significantly reduced if the bracket
f
Assistant Professor, Department of Preventive Dentistry,
Periodontology and Cariology, Center of Dentistry, Georg- debonding is carried out in such a way that it does not
August-University, Göttingen, Germany. damage the brackets during removal; that is, the
Corresponding author: Priv-Doz Dr Michael Knösel, Depart-
ment of Orthodontics and Dentofacial Orthopedics, Georg-
August-University, Center of Dentistry, Robert-Koch-Str. 40 Accepted: December 2009. Submitted: October 2009.
37099 Göttingen, Germany 37099 G 2010 by The EH Angle Education and Research Foundation,

(e-mail: mknoesel@yahoo.de) Inc.

DOI: 10.2319/102809-605.1 649 Angle Orthodontist, Vol 80, No 4, 2010

650 KNÖSEL, MATTYSEK, JUNG, KUBEIN-MEESENBURG, SADAT-KHONSARI, ZIEBOLZ

brackets can be reused following different forms of as an alternative to conventional orthodontic compos-
processing, for either rebonding incorrectly positioned ites. However, later studies confirmed the assumption
brackets or recycling, requiring only a fraction of the that composites produce significantly higher bond
price for a new bracket. strengths during bracket fixation than light-cured GIC.12
Matasa1 investigated differences in the damage to The aim of this in vitro study was therefore to
brackets as a result of different debonding techniques. optimize bracket removal to enable their reusability
Damage can be done to the wings of the bracket, in with rebonding after incorrect bonding and for rework-
addition to deformation of the bracket base or slot. If ing, by testing four different debonding instruments
these occur, it will no longer be possible to reuse or (side cutter, bracket removal pliers, lift-off debracketing
rework the bracket. instrument, and an air pressure crown remover;
Orthodontic bracket recycling, which is perhaps CoronaFlex, Kavo, Biberach/Riss, Germany) used in
more appropriately referred to as bracket processing prosthodontics for the removal of crowns and bridges)
or bracket reworking, as brackets are not reshaped but and two different types of orthodontic adhesives (a
only separated from stains and adhesive remnants composite adhesive and a GIC).
using heat and chemical agents, followed by cleaning The null hypothesis was that there are no significant
and polishing results in brackets that reach standards differences in terms of the reusability of debonded
of quality comparable to those shown by unused brackets in relation to the debonding technique and
brackets2 and are able to withstand the same draw-off adhesive used.
strengths.3
Because of the increasing importance of the eco- MATERIALS AND METHODS
nomic aspect of orthodontics, the use of reworked
Teeth
brackets has been adopted by a growing number of
orthodontists. In a questionnaire distributed among 300 Ninety-six third molars that were freshly osteotomed
members of the British Orthodontic Society, 48% said due to a lack of space were included in the study. The
they used processed brackets for economic reasons.4 exclusion criteria of enamel damage (fractures, de-
Another rationale for using a bracket-preserving mineralization, or decay) were assessed by visual
method of debonding is the intentional removal and inspection using a 23 magnifier. The patients or their
rebonding of incorrectly positioned brackets,5 a chal- guardians gave informed consent for donation of the
lenge orthodontists regularly face. Even the slightest extracted third molars for study purposes. Both for
deformations of the bracket slot can result in lowered better handling and a simulation of the viscoelastic
fitting accuracy of the inserted archwire, producing cushioning and elastic dental fiber suspension, the
unwanted friction.6 cleaned teeth were each embedded in small blocks of
Therefore, in addition to the enamel-preserving silicon (Silaplast; Detax, Ettlingen, Germany; Figure 1)
aspect of debonding, it is important for many ortho- and stored in physiological saline at 20uC, which was
dontists to choose a method of bracket removal that renewed every second day.
does not deform or damage the bracket and allows for The teeth were randomly assigned to one of two
instant rebonding. study groups (n 5 48) for either bonding with composite
To ensure the reusability of a bracket, it is important adhesive or with GIC. Then the two groups were each
to choose both an appropriate adhesive and the right once more randomly divided into four subgroups (n 5
instrument for debonding. Current bracket adhesives 12), and these were allocated one of the four bracket-
are mostly based on diacrylates. Their bonding debonding methods described in the following sections.
strength has been tested in numerous studies, and
they have produced good results,7,8 which to a Brackets
substantial extent is due to the conditioning of the
Maxillary premolar metal brackets (0.018-inch slot
enamel surface by etching and subsequent mechan-
system; Ormesh; Ormco, Orange, CA), which were
ical retention to microporosity.9
identical on both the left and right sides, proved to fit
Apart from composites, glass ionomeric cements
neatly to the buccal surface of the third molars. The
(GIC) are in common use in orthodontics. In contrast to
brackets had a common meshlike base to provide
composite adhesives, they do not work by using
better adhesive retention.13
mechanical retention but instead by acid-base interac-
tion between GIC and enamel.10 Compton et al.11
Adhesives
reported that light-cured GIC had a higher bonding
strength compared with chemically hardened GIC and We used two types of adhesive for bracket bonding
suggested the use of GIC with prior conditioning of the following the manufacturers’ instructions for applica-
enamel surface with a weak acid to enhance cohesion tion. Representative for the composites, Mono-Lok2

Angle Orthodontist, Vol 80, No 4, 2010

BRACKET DEFORMATION DURING BONDING 651

Figure 1. Instruments used for debonding with the corresponding force systems generated (red), moments (blue), and effective force (dotted) on
the bracket base. Please see the online version of this article for the color version of figure 1.

(Rocky Mountain Orthodontics, Denver, Colo) was LC (GC Co-operation, Tokyo, Japan), a light-cured,
used, a one-paste hybrid composite of methacrylmono- resin-modified GIC that is characterized by enhanced
mers and polymers, with prior enamel etching using bond strength compared with conventional GIC.11,14
37% phosphoric acid. For the GIC, we used Fuji Ortho Prior enamel conditioning was achieved by etching with

Angle Orthodontist, Vol 80, No 4, 2010

652 KNÖSEL, MATTYSEK, JUNG, KUBEIN-MEESENBURG, SADAT-KHONSARI, ZIEBOLZ

Table 1. Application Steps for Both the Composite Adhesive Mono-Lok2 and the Glass Ionomere Cement Fuji Ortho LC
Adhesive Group Size (n) Application Steps
Mono-Lok2 (Rocky Mountain 48 1. Cleaning of enamel surface for 30 s using fluoride-free polishing (Zirkate; L.D.
Orthodontics, Denver, Colo) Caulk Co, Milford, Del)
2. Enamel conditioning with 37% phosphoric acid for 30 s with subsequent rinsing
with water for 1 min and air drying
3. Primer application with single-use brush on enamel and bracket base
4. Adhesive application to bracket base
5. Immediate bracket positioning on enamel, by slight exertion of pressure for 45 s
6. Removal of excessive adhesive with a scaler
Fuji Ortho LC (GC Cooperation, 48 1. Cleaning of the enamel surface for 30 s using fluoride-free polishing (Zirkate;
Tokyo, Japan) L.D. Caulk Co, Milford, Del)
2. Enamel conditioning with 10% polyacrylic acid for 10 s
3. Mixing of fluid and powder according to the manufacturer’s instructions (ratio:
1:3) for 20 s
4. Application of adhesive to bracket base
5. Immediate positioning of the bracket on the enamel
6. Ultraviolet light curing for 40 s (wavelength: 470 nm)
7. Removal of excessive adhesive with a scaler

10% polyacrylic acid. Application steps for both toggle, releasing a short impact pulse of 3000 N for 10
adhesives are shown in Table 1. milliseconds, which removed the adhesion.

Debonding Criteria and Assessment of Reusability of

Debonded Brackets
Removal of the brackets was carried out 24 hours
after bonding. Four different debonding instruments At first, the brackets were visually inspected using a
were employed: (1) a medium-sized side cutter (SC; 23 magnification for deformations to the bracket base,
Dentaurum, Ispringen, Germany), (2) bracket removal wings, or slot, compared directly with an unused (new)
pliers (BRP; Dentaurum; Ispringen, Germany), (3) a bracket of the same type (Figure 2a), as recovery of
lift-off debracketing instrument (LODI; 3M Unitek, brackets with visual deformations cannot be reworked at
Monrovia, Calif), and (4) an air pressure pulse device a reasonable cost.6 Only slight deformations of the slot
(CoronaFlex; Kavo, Biberach, Germany), which is inhibit the wire insertion, or at least the gliding of the
used in prosthodontics for the removal of crowns and bracket along the archwire (Figures 2b,c). Therefore,
bridges (Figure 1a-d). brackets were subsequently tested with a straight 0.017-
Although variations in the use of the debonding 3 0.025-inch archwire (Ormco) for deadlock or crepita-
instruments are possible, debracketing was performed tion, which are signs of slot deformation. The assess-
in the typical, standardized manner. The SC was ment criterion for being not reworkable and nonreusable
orientated in such a way that it was inserted diagonally was whether the archwire resulted in any noticeable
at the bracket base at the cervical and incisor portion friction or jamming, either during complete manual
of the bracket wing. The bracket was removed by pulling through the slot (Figure 2c) or by regular insertion
gentle squeezing of the pliers and an additional into the slot. Both tests were carried out twice by two
clockwise rotational movement. orthodontists in the Dentistry Centre at the University of
The BRP was used by gripping below the bracket Göttingen, Germany. A bracket was judged to be
wings. By closing and downward tipping of the pliers, a reusable if it passed both tests. Testing was implement-
rotational axis was created at the apical bracket ed prior to and after debonding: all 96 brackets fresh
margin, thereby releasing the bracket. from the factory were therefore intact at baseline.
The LODI was positioned by linking its hanger to the
upper left bracket wing and simultaneously resting the Statistical Analyses
instrument on the tooth. Compression of the pliers
caused the bracket to lift off on application of a pulling The proportion of reusable brackets was compared
force. between instruments and adhesives, respectively,
The CoronaFlex was used by positioning its toggle using the Fisher exact test. The significance level for
parallel to the adhesive-enamel interface. By pulling the tests was chosen to be a 5 5%. All analyses were
the trigger, a piston with a weight of 2.5 g was impelled performed using the software R (version 2.8, www.
by an air pressure of 2.2 bar along the shaft on the r-project.org).

Angle Orthodontist, Vol 80, No 4, 2010

BRACKET DEFORMATION DURING BONDING 653

Figure 2. Examples of (a, left) deformed and (a, right) intact brackets. (b) Misfit of archwire due to slot deformation. (c) Pull testing.

RESULTS rejected. All brackets of both adhesive groups

removed with the LODI and also those removed with
Adhesive Factor
the impulse device were reusable; that is, they were
Leaving the method used for the bracket removal intact according to the standard used in the evaluation.
out of the analysis, of those brackets bonded with Fuji The results of the assessment for bracket reusability
Ortho LC, 81% (n 5 39) were judged to be reworkable. for the BRP and the SC were worse (Table 2) and
Of those bonded with Mono-Lok2, 56% (n 5 27) were differed significantly when compared with one another
judged to be reworkable (Table 2). Statistically, the (P 5 .04). Particularly in combination with the
proportions of reusable brackets was therefore signif- MonoLok bonding, the BRP and SC results were
icant (P , .01), and accordingly, the null hypothesis discouraging (Table 2).
was rejected. In general, brackets bonded with Fuji
Ortho LC were subjectively easier to remove com- DISCUSSION
pared with those bonded with MonoLok.
The proportion of reusable debonded brackets may
be influenced by three factors: the mode of enamel
Instrument Factor
conditioning, the adhesive used, and the mode of
The proportions of reusable brackets also differed debonding.
significantly between instruments (P , .01), so that the The composite adhesive MonoLok2 was used in
second element of the null hypothesis was also combination with prior enamel conditioning by etching
with 37% phosphoric acid, to enhance the interface
Table 2. Comparison of Bracket Reusability Between Instruments area between the adhesive and the enamel by
and Adhesives dissolving enamel prisms away to a depth of 22 mm,
Bracket Reusable thereby providing a basis for mechanical adhesive
P (Fisher
Factor No Yes Exact Test) retention.15
Fuji Ortho LC requires enamel conditioning with 10%
Instrument ,.01
Bracket removal pliers 19 (79%) 5 (21%)
polyacrylic acid. Its penetration depth can be judged as
CoronaFlex 0 (0%) 24 (100%) moderate compared with the use of 37% phosphoric
Lift-off debracketing 0 (0%) 24 (100%) acid.16 Its purpose is not to enhance mechanical
instrument retention but to reduce interface (surface) tension, to
Side cutter 11 (46%) 13 (54%) provide the basis for chemical bonding between the
Adhesive ,.01 enamel and GIC.17
Fuji Ortho LC 9 (19%) 39 (81%) Contemporary light-cured GIC produces clinically
Mono-Lok2 21 (44%) 27 (56%)
acceptable results for bond strength,14,18 although they

Angle Orthodontist, Vol 80, No 4, 2010

654 KNÖSEL, MATTYSEK, JUNG, KUBEIN-MEESENBURG, SADAT-KHONSARI, ZIEBOLZ

are below those for conventional composites.19,20 The pulling force exerted by the SC is generated by
Moreover, they are easier to handle than are compos- the wedge effect of the pliers’ cutting end (Figure 1b).
ites such as MonoLok2 as they do not require a Compression of the pliers creates a deformation of the
completely dry operation area,18 which is of advantage bracket base. As these forces are identical in
in, for example, the unforeseen necessity of instant magnitude but opposite in direction, they cancel each
rebonding of lost or incorrectly positioned brackets other out and do not contribute to the release of the
during practice hours or bonding lingual mandibular bracket. The insertion at two points of the bracket
teeth. generates a force couple (ie, a moment with an initial
On the subject of enamel damage following debond- axis of rotation at the center of the bracket and a force
ing, Kusy21 raised the question of whether and when that is perpendicular to the enamel surface). There-
higher bond strengths are necessary and recommend- fore, regardless of the adhesive used, the SC resulted
ed the use of GIC for orthodontic purposes. Our in a majority of the brackets’ having deformations at
findings indicate that a side effect of these lower bond the base or at the slot. We can therefore conclude that
strengths of GIC appears to be a significantly reduced the compression of brackets by an insertion of
proportion of brackets that are not reusable after opposite forces, as described for the BRP and the
debonding (Table 2). Putting the method of bracket SC method, may be decisive in excluding brackets as
removal to one side and focusing on the adhesive being suitable for rebonding.
factor, almost half of the brackets bonded with The equivalent force system generated by the LODI
MonoLok2 were not in such a condition as to allow is a pull-off force perpendicular to the bracket base,
reuse or reworking, whereas in the GIC group, less which creates a moment that is parallel to the enamel
than 20% of the brackets had corresponding deforma- surface (Figure 1c). There was no compression of the
tions. This result is not only in agreement with previous bracket, and although there was a pulling force
findings of higher bond strengths for composites than insertion at one bracket wing, all brackets debonded
for GIC8,14,18 but also seems to confirm our subjective with the LODI remained intact afterward. This result is
impression that the brackets used in our study that in accordance with findings from previous studies.23,24
were bonded with Fuji Ortho LC were easier to flip off The equivalent force system created by the Corona-
compared with those bonded with MonoLok2. Flex is a force and a moment that are both parallel to
Beyond a diversity of debonding methods and their the enamel surface and to the bracket base (Fig-
modifications, variations in the application of the tested ure 1d). In combination with the immediate elimination
devices themselves are possible, with the result of of the adhesive layer, the absence of compressive
different force influence lines. We therefore propose to forces and the moment parallel to the enamel provide
base discussions of the effects of debonding methods an explanation for the preservation of all brackets
not only on the type of the instrument but also on a clear during debonding.
description of the way it was applied, as variations may
have an influence on bracket deformation. Clinical Implications
The equivalent force systems created by the
Irrespective of the adhesive used, the LODI and the
different instruments during removal of the brackets
CoronaFlex provided the best results in relation to the
may provide an explanation for the proportions of
reusability of debonded brackets. If conventional
nonreusable brackets. The use of the BRP produces
debonding techniques (BRP, SC) are used, the use
symmetrical force insertion on all four bracket wings
of a GIC is favored, since its lower bond strength
(Figure 1a). These forces are transmitted to bracket
compared with composite adhesives18 seems to result
base and slot but do not contribute to bracket removal,
in a significantly higher portion of reusable brackets. In
as they cancel each other, but they do contribute to a
addition, the insertion of a gauge or archwire matching
deformation of bracket base and especially bracket
the slot width during debonding may be considered a
slot. The equivalent force system created by the BRP
useful step to prevent the slot from collapsing.
is a force perpendicular to enamel surface and bracket
base, which creates a moment parallel to the bracket
CONCLUSIONS
base (Figure 1a). The result is wing and slot deforma-
tion, which absorbs forces that would otherwise be N The proportions of reusable or reworkable brackets
transmitted on the enamel. In this context, Benett et differed significantly depending on the mode of
al.22 described the BRP method as more enamel removal and the adhesive used (P , .01).
preserving than those methods that produce forces on N In the case of those bonded with the GIC Fuji Ortho
the bracket base, as does the SC, but they also LC, a significantly higher number of brackets could
reported that brackets removed with the removal pliers be recovered or reused compared with those bonded
were not suitable for rebonding. with the composite MonoLok2 (P , .01).

Angle Orthodontist, Vol 80, No 4, 2010

BRACKET DEFORMATION DURING BONDING 655

N All brackets removed with the LODI and with the orthodontic bonding agent. Am J Orthod Dentofacial Orthop.
impulse device were reusable, that is, intact accord- 1992;101:138–144.
12. Cook PA, Youngson CC. An in vitro study of the bond
ing to the evaluation criterion, regardless of the strength of a glass ionomer cement in the direct bonding of
adhesive used, whereas 79% (46%) of the brackets orthodontic brackets. Br J Orthod. 1988;15:247–253.
removed with the removal pliers (SC) were not. 13. Maijer R, Smith DC. Variables influencing the bond strength
N When assessed in terms of bracket reusability, of metal orthodontic bracket bases. Am J Orthod. 1981;79:
especially in combination with the MonoLok2 com- 20–33.
14. Cacciafesta V, Jost-Brinkmann PG, Süßenberger U,
posite adhesive, the SC and the BRP cannot be
Miethke RR. Effects of saliva and water contamination on
recommended for debonding brackets. the enamel shear bond strength of light-cured glass ionomer
cement. Am J Orthod Dentofacial Orthop. 1998;113:
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