Bonding and Debonding From Metal to

Ceramic: Research and its Clinical Application

Samir E. Bishara, BDS, DDS, DOrtho, MS, and Adam W. Ostby, BS, DDS
Over the last 50 years, the bonding of various resins to enamel has also
developed a niche in orthodontics. The direct bonding technique revolves
around the concept of attaching orthodontic appliances to tooth structure
using adhesives, and this technique has become a foundation of contemporary orthodontics.
Although the specific techniques and materials used in bracket bonding
have changed, the basic procedure has remained relatively constant. In
general, the technique for orthodontic bonding includes 3 steps using an
etchant, a primer, and an adhesive. More recently, these 3 steps have been
combined into 2 or even 1 step. At the present time, numerous bonding
materials, techniques, and protocols have been established that have the
ability to provide the clinician with adequate bracket/adhesive/enamel
(shear bond strength [SBS]), over the course of treatment. However, bracket
SBS is influenced by many variables which may or may not be under the
control of the clinician.
It is important for the clinician to be aware of how these variables affect
SBS and apply this knowledge in their selection of the optimal bonding
adhesive/technique. In addition, because of the lack of standardization of
bond strength testing, the clinician should be cognizant that accurately
comparing bond strengths between different studies may be difficult. (Semin Orthod 2010;16:24-36.) 2010 Elsevier Inc. All rights reserved.

The Basic Bonding Technique

he applicability of using adhesive bonding
resins in dentistry has significantly increased
with the introduction of the enamel acid-etch
technique by Buonocore in 1955. By demonstrating a 100-fold increase in retention of small
polymethylmethacrylate buttons to teeth that
had been etched with 85% phosphoric acid for
30 seconds, Buonocore introduced modern adhesive dentistry techniques.1 Over the last 50

From the Department of Orthodontics, College of Dentistry, University of Iowa, Iowa City, IA; College of Dentistry, University of
Minnesota, Minneapolis, MN.
Address correspondence to Samir E. Bishara, BDS, DDS,
DOrtho, MS, Department of Orthodontics, College of Dentistry,
University of Iowa, Iowa City, IA 52242-1001; E-mail: samirbishara@uiowa.edu
2010 Elsevier Inc. All rights reserved.
1073-8746/10/1601-0$30.00/0
doi:10.1053/j.sodo.2009.12.009

24

years, the bonding of various resins to enamel

has also developed a place in orthodontics. The
direct bonding technique revolves around the
concept of attaching orthodontic appliances to
tooth structure using adhesives, and this technique has become a foundation of contemporary orthodontics.
Although the specific techniques and materials used in bracket bonding have changed, the
basic procedure has stayed relatively constant. In
general, the technique for orthodontic bonding
includes 3 steps using an etchant, a primer, and
an adhesive. More recently these 3 steps have
been combined into 2 or even 1 step.
Further studies determined that microporosities created during the acid-etching process allowed for the incorporation of small resin tags
into the enamel surface, thereby creating microscopic mechanical interlocks between the
enamel and resin.2-4 The concept of adhesion
has been extensively studied, and currently a

Seminars in Orthodontics, Vol 16, No 1 (March), 2010: pp 24-36

Bonding and Debonding From Metal to Ceramic

combination of mechanical, adsorption, diffusion, and electrostatic theories are typically used
to describe the phenomena.5 Mechanical theories propose that adhesion occurs primarily
through microscopic interlocks between the adherent and adhesive. The increase in the contacting surface area between the 2 results in a
greater number of interlocks, and thus, in
greater adhesive forces.
The conventional acid-etch bonding process
involves 4 steps: (1) enamel surface cleansing,
(2) enamel conditioning (etching), (3) primer
application, and (4) adhesive application. The
purpose of enamel cleansing is to eliminate debris or contaminants that may interfere with the
conditioner or primer reaching the enamel surface during their application. Typically, enamel
cleansing is accomplished using rubber prophylactic cups and pumice for approximately 10
seconds per tooth. Enamel conditioning (etching) has traditionally been accomplished using
37% orthophosphoric acid, which has the capability of dissolving enamel rods to create the
microporosities necessary for resin tag development. The priming agent is used to help the
adhesive monomers diffuse the complete depth
of the enamel etch pattern. This is followed by
the application of an adhesive resin, which is
typically either self-setting and/or polymerized
by light curing. By following this standardized
procedure, clinicians have been successfully
bonding orthodontic brackets and other appliances directly or indirectly to teeth, with sufficient strength to withstand most of the forces
routinely experienced in the oral cavity during
orthodontic treatment.

Oral Hygiene and the Role of Fluoride

Studies have shown that fixed orthodontic appliances induce a rapid increase in the volume of
dental plaque and that such plaque has a lower
pH than that in nonorthodontic patients.6,7
Thus, the plaque-retentive properties around
fixed appliances predispose the patient to an
increased cariogenic risk. Furthermore, there is
a rapid shift in the composition of the bacterial
flora of the plaque following the introduction of
these appliances. More specifically, the levels of
acidogenic bacteria, such as S. mutans, become
significantly elevated in orthodontic patients. If
these bacteria have an adequate supply of fer-

25

mentable carbohydrates, acid byproducts will be

produced, lowering the pH of the plaque. As the
pH drops below the threshold for remineralization, carious decalcification occurs. The first
clinical evidence of this demineralization is visualized as a white spot lesion (WSL). Such lesions
have been clinically induced under loose bands
within a span of 4 weeks, which is often the
period between 1 orthodontic appointment and
the next.8 This is a significant finding and is
important for both the patient and the clinician
to realize.
In the highly cariogenic environment adjacent to orthodontic appliances or under loose
bands, these lesions can rapidly progress, and if
left untreated, may produce carious cavitation
that will need an appropriate restoration. Thus,
the prevention, diagnosis, and treatment of
WSLs is crucial to prevent tooth decay as well as
minimize tooth discoloration that could compromise the esthetics of the smile.
Perhaps the most important prophylactic measure to prevent the occurrence of WSLs in orthodontic patients is implementing a good oral hygiene regimen, including proper tooth brushing
with a fluoridated dentifrice. Dentifrices typically
contain either sodium fluoride, monofluorophosphate, stannous fluoride, amine fluoride, or a
combination of these compounds. As orthodontic
patients are at an increased caries risk, a fluoride
concentration below 0.1% in dentifrices is not recommended.9 This is because an appropriate level
of fluoride ions is needed to provide an anticaries
benefit by promoting enamel remineralization.
When fluoride ions are incorporated into the surface of enamel, a fluoroapatite crystal structure is
formed that has a lower solubility in the oral environment compared with hydroxyapatite. For less
compliant orthodontic patients, the use of a fluoridated dentifrice alone may be ineffective in preventing the development of carious lesions, and
supplemental sources of fluoride are often suggested, particularly when these patients do not
follow the suggested proper oral hygiene regimen.
This short introduction emphasized the critical importance of maintaining proper oral hygiene in patients who will be undergoing orthodontic treatment to minimize tooth decay and
decalcification. This is true regardless of the
bonding technique and/or materials that are
used by the clinician.

26

S.E. Bishara and A.W. Ostby

As will be detailed in this article, the bonding

procedure has been significantly modified over
the last 20 years to decrease technique sensitivity
for the clinician as well as help minimize enamel
loss for the patient, and mitigate the unwanted
effects of plaque accumulation.
It has been suggested that a shear bond
strength (SBS) of 6.0-8.0 MPa is adequate for
bonding orthodontic brackets to teeth.9,10 While
this range is generally regarded as a minimum
bond strength for successful bonding, lower
bond strengths may be adequate for initial bonding, as forces of the archwires used for initial
leveling are, in general, less than those applied
at a later stage in treatment.

Modifying the Bonding Procedure and

its Effects on Bond Strength
Etching
Etching Time
Manufacturers of bonding systems typically
recommend specific conditioning protocols.
Clinicians and researchers often investigate
various modifications to these protocols to improve the bonding process. The effect of
changing the conditioning time on the etching pattern has been investigated in depth,
yielding differing results.11-15 Several studies
have demonstrated that reducing etching time
from 30 to 15 seconds does not result in lower
bond strengths.11-13 It has also been reported
that a significant reduction in bond strengths
will occur when decreasing etching time beyond
a certain point.12,13 Olsen et al16 specifically investigated the effect of enamel etching time on
the SBS of orthodontic brackets. Their findings
indicated that a 5 second etch time with 37%
phosphoric acid was insufficient to successfully
bond brackets. When the etch time was reduced
from the recommended 30 seconds to either 15
or 10 seconds, no significant difference in SBS
was observed. Therefore, it can be concluded
that a shorter etching time of only 15 seconds
can provide clinically acceptable SBSs when
used to bond orthodontic brackets and also minimize the extent of enamel loss.

bonding procedures. While this etchant provides a deep etching pattern and suitable bond
strengths, irreversible enamel loss during the
procedure has been a concern to the clinician.
Thus, in an effort to reduce the amount of
enamel loss during the etching process, other
less aggressive etchants have been investigated.
Maleic acid was introduced as an alternative
etching material in the early 1990s in an attempt
to control the depth of the enamel etches. Studies have demonstrated that the use of 10% maleic acid as the etchant had no significant effect
on the SBS of orthodontic brackets.17,18 Furthermore, scanning electron microscopy showed
that the etch patterns produced by 10% maleic
acid were morphologically similar but shallower
than those produced by 37% phosphoric acid.19
Another enamel conditioner that has been investigated is polyacrylic acid. The use of 10%
and 20% polyacrylic acid for bonding was introduced by Smith.20 He found that polyacrylic acid
cements adhered to dental enamel because of
the interaction of the aqueous polyacrylic acid
component with the enamel surface. The acid
produced mild etching of the enamel surface
and also resulted in a crystalline deposit which
bonded firmly to the enamel surface and resisted mechanical removal.21 The crystals were
shown to be calcium sulfate dihydrate (gypsum),
and their formation depended mainly on the
sulfate ion concentration in the polyacrylic acid
solution. When studied for use in bonding
brackets, Bishara et al determined that the SBS
of brackets bonded to enamel with either 10%
or 20% polyacrylic acid were significantly lower
than brackets bonded to enamel conditioned
with 37% phosphoric acid.22
More recently, to improve the retentive properties of the adhesive to the enamel during
bonding, Espinosa et al23 deprotenized the
enamel surface using 5.25% sodium hypochlorite (NaOCl) before applying phosphoric acid.
According to the authors, using this technique
increased both the quality of the etching pattern
as well as the surface area of the enamel available for proper bonding.
The Primer

Type of Etchant
A 37% orthophosphoric acid concentration
has typically been used for traditional bracket

Traditionally, the use of acid etchants followed

by the application of priming materials was an
essential part of the bonding procedure. Prim-

Bonding and Debonding From Metal to Ceramic

ing agents are usually nonfilled or very lightly

filled acrylic resins that often contain 2-hydroxyethyl methacrylate (HEMA) or dimethacrylate.
The primary purpose of the primer is to allow
good surface wetting and penetration of the adhesive into the etched enamel. The latter allows
for the formation of resin tags deeper into the
enamel surface, thus creating a mechanical
bond. In an effort to reduce the number of steps
involved in the bonding procedure, researchers
evaluated whether the acid conditioner could be
combined with the priming agent, thus reducing
the bonding procedure by 1 step.
Self-Etching Primers
One of the first reports on the use of self-etching
primers (SEPs) during the bonding procedure
demonstrated that when used with a highly filled
composite resin, these acidic primers provided
comparable SBS as the traditional acid-etch/
primer/adhesive systems.18 While these conditioners were initially developed for use on dentin, researchers have determined that adhesive
systems combining conditioning and priming
can also be successfully used to bond orthodontic brackets to enamel.24-26 It has been demonstrated that SBSs of brackets bonded using different self-etch primers were not significantly
different from brackets bonded with the conventional acid-etch technique.24,26 It is interesting
to note that scanning electron microscopies
have shown that SEPs produce a less defined
etch pattern than that produced by phosphoric
acid.27
While all SEPs are acidic, those available on
the market vary in their pH levels and aggressiveness. Recently, a report indicated that the
differences in the pH of the SEPs used to bond
brackets does not significantly affect the SBS of
the brackets.27 More specifically, aggressive selfetchants with lower pH levels did not provide
greater bonding strengths. At the same time, it
has also been demonstrated that SEPs that produce a minimal etch pattern can still provide
adequate bracket SBS.28

Effect of Contamination on SBS

As stated earlier, adequate isolation during the
bonding procedure is a critical variable that can
jeopardize bond strengths if not maintained.

27

Various studies have evaluated the SBSs of different bonding systems on both normal and contaminated enamel surfaces.29-33 Success of resin
bonding systems to enamel was negatively affected by contamination with oral fluids, such as
saliva and plasma.29,33 There was a reduction of
about 50% in the mean SBSs when resin composite was bonded directly to saliva-contaminated etched enamel surfaces when compared
with the bond strength to uncontaminated surfaces.29,33 When specifically testing the effects of
saliva contamination on the SBS of orthodontic
brackets when using a SEP, it was reported that
adequate SBS could be maintained if contamination occurred either before or after the application of the SEP. However, contamination both
before and after the application of the SEP resulted in a significantly weaker SBS34 It is of
interest to note that when teeth were contaminated with blood, a significant reduction in SBS
was observed, independent of when the contamination occurred during the bonding process.35
A new material namely, BisCover (Bisco,
Schaumburg, Ill.) was recently evaluated as a
protective polish, before adhesive application
when bonding brackets. The application of
BisCover as a separate layer underneath the adhesive had no significant effect on bracket SBS36
Furthermore, contamination with blood or saliva after the application of BisCover had no
significant effect on bracket SBS, whereas contamination before BisCover application significantly decreased SBS values. Additionally, blood
contamination was shown to have a more detrimental effect on SBS than saliva contamination.36
The results of these studies indicate that in
general, following blood contamination during
the bracket bonding procedure, it may be advisable to reinitiate the procedure rather than apply a new coat of the primer, SEP, or BisCover.
Similarly, when there is too much saliva contamination before and after the application of SEP it
is also advisable to reinitiate the bonding sequence.

Bonding Material
Composite Resins
Traditional bracket bonding procedures have
typically used composite resins as the adhesive of

28

S.E. Bishara and A.W. Ostby

choice to bond to enamel. This is because these

materials have provided a consistently adequate
bond strength when using various etchants as
well as SEPs.16,17,25,26 Still, in an effort to find a
more ideal bonding adhesive, researchers have
investigated the use of fluoride releasing materials for bracket bonding and met various degrees of success. The materials used for bonding
included: glass ionomers, resin-modified glass
ionomers (RMGIs), compomers, and cyanoacrylates.

adhesives.61 Although RMGIs are typically used

with a polyacrylic acid conditioner, recently, a
new no-rinse self-conditioner was used with a
RMGI and provided adequate SBS for bonding
brackets.68 Because of the recent improvements
in the fluoride releasing capabilities and the
adequate SBS of RMGI, it has been suggested
that these adhesives should/will play a greater
role (ie, be more widely used) in bonding orthodontic brackets in the future.69

Compomers
Glass Ionomers and Resin-Modified
Glass Ionomers
In general, the duration of orthodontic treatment places the patient at an increased caries
risk for a prolonged period. As a result, continuous fluoride release from any or all the ingredients of the bonding system particularly around
the periphery of the bracket base would be extremely beneficial. Thus, the use of fluoride containing sealants and adhesives to bond brackets
has been investigated. Glass ionomer cements
(GICs) have some desirable characteristics,
namely, their ability to chemically bond to tooth
structure37,38 in addition to their sustained fluoride release following bonding.39-46 Of particular interest, the rate of fluoride release was
shown to increase in the plaque adjacent to
brackets bonded with GICs.47 However, because
of their lower bond strengths48-54 their use for
bonding orthodontic brackets became fairly limited. In an attempt to increase the bond
strengths of GICs, resin particles were added to
their formulation to create RMGI bonding systems. These adhesives release fluoride ions like
conventional GICs but can also be successfully
used to bond orthodontic brackets because of
their relatively higher bond strengths.55-60 Studies indicated that earlier RMGI adhesives had
lower SBS compared with composite resins,61-63
particularly within the first half hour after bonding.64 Recently these products were found to
have an increased SBS and are able to bond
orthodontic brackets successfully.62-67 It was also
reported that no significant differences were
found between the SBS of brackets bonded with
a RMGI or a composite adhesive following thermocycling.67 Additionally, in vivo studies have
shown no significant differences in bracket failure rates between the RMGIs and composite

Another class of materials known as polyacid

modified resin composites, or compomers, has
also been studied for their potential use in
bracket bonding. Essentially, compomers contain a GIC but at levels that are insufficient to
produce an acid/base reaction in the dark
whereas the RMGI cements discussed earlier retain a significant acid/base reaction as part of
their overall curing process and only their initial
hardening depends on photoactivation.70 In
contrast, the curing of compomers depends
solely on photopolymerization, with the acid/
base reaction being initiated by water from the
oral environment and being responsible for the
fluoride release.71 This major compositional difference between these 2 classes of hybrid materials, that is, the presence of an initial acidic
reaction could, therefore, explain the adequate
bond strength of the resin modified glass ionomer that can be obtained with no enamel pretreatment,66 whereas a composite resin requires
enamel etching with phosphoric acid.72,73 An in
vivo study conducted by Millet et al74 found
similar failure rates between brackets bonded
with either a compomer or a resin composite
when the enamel surfaces were etched with
phosphoric acid.
Cehreli and Altay75 found that using a nonrinse
conditioning (NRC) solution produced a smooth
yet adequately rough enamel surface without a
need for a prolonged etching time. They observed that the alterations were limited to the
superficial enamel layer with no damage to the
enamel prisms. As a result, they recommended
treating the enamel with NRC and bonding the
brackets with a compomer adhesive. While the
potential for using compomers for bracket
bonding is apparent, Bishara et al76 demonstrated that using the NRC with a compomer

Bonding and Debonding From Metal to Ceramic

provided significantly lower SBS when compared with an acid-etch/composite control. In

a recent study, Vicente et al77 found similar
results.

Cyanoacrylates
As described earlier, combining conditioning
and priming into a single step or eliminating
the need for one of these 2 components can
potentially result in a reduction in application
time and improvement in cost-effectiveness for
the clinician. In addition to SEPs, which have
been shown to be successful in bonding brackets,25-27 other adhesive systems have been designed to meet the same purpose of reducing
the number of steps involved in the bonding
procedure.
A cyanoacrylate adhesive, Smartbond (Gestenco
International, Gothenburg, Sweden) that does not
need any primer was introduced. From a clinical
perspective, Smartbond can be considered a
2-step (because it requires an etching step), 1
component orthodontic adhesive that sets on its
own, that is, it does not need to be light cured to
obtain an effective bond. In contrast, when using
this adhesive, it is necessary that it comes in
contact with water on the enamel surface in
order for the uncured monomer to be activated
and to polymerize. The presence of water in
proximity to a thin layer of adhesive will ensure
that most of the activated monomer will be converted into the more stable and cured polymer
within a short period. Therefore, it is very important to follow the manufacturers instruction
literally and to apply a thin layer of the adhesive
to ensure a quick and uniform setting. An initial
report that tested a cyanoacrylate adhesive to
bond orthodontic brackets to enamel indicated
that it provided clinically acceptable bond force
levels within the first half hour after bonding.78
Additionally, SBS increased 24 hours after bonding.79 While the cyanoacrylate adhesive provided
adequate SBS at 30 minutes and 24 hours after
bonding, further studies demonstrated that this
adhesive lost 50% of its bond strength after water storage for 30 days80 and up to 80% of its
initial strength following thermocycling.81 Cyanoacrylate materials have the advantage of reducing the number of steps during bonding;
however, the clinician needs to be aware that
this adhesive has a relatively short working time

29

and may not provide adequate bond strengths in

the oral environment over time.

New Bonding Adhesives

Manufacturers are continuously introducing
new restorative and adhesive systems in dentistry
that are not cytotoxic and are more reliable, that
is, stronger, adhere better, less liable to leak at
the margins, and easier to handle. Orthodontists
have benefited from these new innovations, including the use of SEPs, stronger adhesives, and
more efficient light sources.
Although the resin matrix significantly influences the properties of composite resins, there
have been few fundamental changes in that aspect of the restorative-adhesive system since the
introduction of dimethacrylates in the form of
bisphenol A glycidyl dimethacrylate (Bis GMA).
This is because the material has proved to be
relatively reliable for both restorative and orthodontic purposes. Studies indicated that the bisphenol A component in the structure of the
monomer Bis GMA may have an estrogenic effect, whereas the Bis GMA itself has also been
found to be cytotoxic in a number of cell culture
systems.82,83
Some of the new products that have been
introduced in the last several years include Ormocer, nano-composites, and one-step adhesives.82-87
Ormocer
In an attempt to overcome some of the limitations and concerns associated with the traditional composites, namely cytotoxic and estrogenic potentials, a new packable restorative
material was introduced called Ormocer, which is
an acronym for organically modified ceramic
technology. Ormocer materials contain inorganicorganic copolymers in addition to the inorganic
silanated filler particles. Ormocers are described
as 3-dimensionally cross-linked copolymers. The
abundance of polymerization opportunities in
these materials allows Ormocers to cure without
leaving a residual monomer, thus having greater
biocompatibility with the tissues. Ormocer was
formulated in an attempt to overcome the problems created by the polymerization shrinkage of
conventional composites because their coefficient of thermal expansion is very similar to
natural tooth structure. It has been suggested

30

S.E. Bishara and A.W. Ostby

that the newly introduced Ormocer restorative

materials have a lower wear rate, low shrinkage,
and greater biocompatibility than regular adhesives.82-87 In evaluating an Ormocer based material for a potential use in orthodontics, Ajlouni
et al88 found that within the initial half hour
following bonding, the adhesive Admira (Voco,
Cuxhaven, Germany) can achieve SBS values that
are similar to those obtained with Transbond
XT (3M Unitek, Monrovia, CA). A disadvantage with Ormocer from an orthodontic perspective is that in its present formulation it is
not viscous enough to hold the bracket in
position during bonding.
Nano-Composites
While composite based adhesives and resins are
constantly being reformulated to produce more
ideal restorative materials, orthodontists have
been able to adopt some of these innovations
and use them in clinical practice. Recent research activity has been in the area of polymer
nano-composites. This new class of materials has
a unique internal structure and properties which
contain nano-fillers that are 0.005-0.01 m in
size. Geraldeli and Perdigao89 found that nanofilled composites had a marginal seal in enamel
and dentin comparable to total-etch adhesives.
In another study Dabanoglu et al90 found that a
high filler degree combined with small particle
dimensions reduced abrasion by up to 50% compared with composites of lower filler degree or
those with organic (prepolymerized) fillers. A
report that tested a nano-filled composite, Grandio, (Voco, Cuxhaven, Germany) as an alternative bracket bonding adhesive demonstrated
that brackets bonded using Grandio were not
significantly different from those bonded with a
conventional orthodontic composite resin. However, Grandio was found to be difficult to manipulate when placing brackets and 15% of
brackets bonded using this material essentially
failed before registering any force during testing.91
One-Step Adhesives
Another area of orthodontic adhesive research
has focused on self-adhesive cements, which
have the potential to further simplify the bonding process, that is, by reducing the process of
bonding orthodontic brackets to a true one-step

procedure. With these advances, the clinician

can effectively reduce chair time and increase
cost-effectiveness, resulting in increased convenience and reduced costs for the patient.
These products are typically manufactured
for use in operative dentistry and are marketed
to be used on enamel and dentin without the
need for any surface preparation. This is possible because the product combines the etchant,
primer, and adhesive resin into a single paste
that is mixed immediately before use. Recently,
2 separate self-etch adhesives, RelyX Unicem
(3M ESPE, Seefeld, Germany) and Maxcem
(Kerr, Sybron Dental Specialties, Orange, California), were evaluated for bonding brackets. It
was demonstrated that within the first half hour
after bonding, these one-step adhesives produced a SBS that was significantly weaker than
controls.92,93
In summary, while these new products are not
yet recommended for bracket bonding at this
time, their potential in being used for orthodontic purposes is obvious and with further material
advances, may be possible in the future.

Effect of Tooth Whitening on

Bond Strength
As patients are becoming more esthetically
conscious, various whitening systems are being
used to bleach enamel. Some of the external
bleaching systems are applied by the clinician as
an office procedure, using a strong solution of
hydrogen peroxide subjected to either heat or
light to speed up the reaction. Recently, newer
bleaching systems containing carbamide peroxide became commercially available and can be
used at home. Since some adults who are interested in orthodontic treatment might have also
had their teeth bleached or might be interested
in the procedure, the effects of enamel bleaching on orthodontic bracket bond strength was
investigated. One report indicated that the
bleaching process using 10% carbamide peroxide, an over-the-counter product, does not result
in a significant change in the SBS to enamel.94
In another study evaluating the effect of in-office
and at-home bleaching on SBS, the results indicated that there were no significant effects on
the SBSs of orthodontic brackets to enamel
when the bonding procedure occurred 7 and 14
days after bleaching. In contrast, the authors

Bonding and Debonding From Metal to Ceramic

observed a large variation in the SBS at 1 week

after the in-office bleaching. As a result, they
concluded that it is prudent to postpone bonding orthodontic brackets for at least 2 weeks
following bleaching.95

Metal Versus Ceramic Brackets

The introduction of the direct bonding technique facilitated the construction of orthodontic
appliances that are more esthetic and thus, minimally obtrusive. The direct bonding of metal
brackets was first introduced during the early
1970s, and shortly after, plastic brackets were
marketed as the esthetic alternative to metal
brackets. These polycarbonate brackets quickly
lost favor because of discoloration and slot distortion caused by water absorption.11,96-100 This
led manufacturers to modify the plastic brackets
by reinforcing the slots with metal and ceramic
fillers.101 Despite these improvements, the clinical problems of distortion and staining persisted.
In the mid-1980s, the first brackets made of
monocrystalline sapphire and polycrystalline ceramic materials became widely available.101,102
Ceramic brackets, unlike plastic brackets, resist
staining and slot distortion and are chemically
inert to fluids that are likely to be ingested.
However, the following disadvantages are associated with ceramic brackets: (1) the inability to
form chemical bonds with adhesives without a
coupling agent, (2) a low fracture toughness,101
that is, brittleness that can cause the bracket to
fracture, and (3) an increased frictional resistance between metal arch wires and ceramic
brackets.103,104
Because of the inert composition of the aluminum oxide from which the ceramic brackets
are made, chemical cohesion between the ceramic base and the adhesive resin is not possible. Consequently, the early ceramic brackets
used a silane coupler to act as a chemical
mediator between the ceramic bracket base and
the diacrylic or acrylic adhesive resin.100,105,106
Chemical retention resulted in an extremely
strong bond that caused the enamel-adhesive
interface to be stressed during debonding.100,101
At the present time, there are 3 different retention mechanisms available by which the base of
the ceramic bracket can be made to adhere to

31

the adhesive: (1) chemical, (2) mechanical, and

(3) a combination of both.105
The fracture toughness refers to the ability of
the material to resist breakage.101 Ceramics are
extremely brittle, so less energy is necessary to
cause a fracture of the bracket.100,107,108 In fact,
even the smallest surface imperfections or cracks
can significantly reduce the load that is necessary to fracture a ceramic bracket.100,101
Because of the earlier reports of bracket fracture and enamel surface damage that occurred
during the debonding of ceramic brackets, clinicians continue to be concerned.100,102,109-112
To reduce the rate of irreversible enamel surface
damage, several methods of debonding ceramic
brackets have been suggested. These methods
include (1) conventional methods that use pliers, (2) an ultrasonic method that uses special
tips, and (3) the electrothermal method that
involves an apparatus that transmits heat to
the adhesive through the bracket.100,112 Although all 3 methods can be used successfully
to debond brackets, the use of pliers to apply
a shear or tensile force on the bracket is perhaps the most convenient and continues to be
the most popular method used for debonding
brackets.
While some studies have reported no enamel
damage when debonding ceramic brackets with
the appropriate pliers,113,114 other researchers
have reported an increase in enamel cracks or
crack length following debonding.115-117 Bishara
et al115 reported that 18% of teeth had an increase in the number or severity of enamel
cracks following the debonding of ceramic
brackets. Three other studies have reported
enamel damage ranging from 0% to 20% after
debonding ceramic brackets with pliers. The
range of enamel damage was related to the type
of bracket, bracket base design, and adhesive
system used.116-118 As a result, the clinician
needs to be careful in debonding ceramic brackets and follow the manufacturers instructions
regarding their recommended method for
debonding their brackets.

Conclusions
At the present time numerous bonding materials, techniques, and protocols have been established that have the ability to provide the clinician with adequate bracket/adhesive/enamel

32

S.E. Bishara and A.W. Ostby

SBS, over the course of treatment. However, as

has been described, bracket SBS is influenced by
many variables which may or may not be under
the clinicians control. Thus, it is important for
the clinician to be aware of how these variables
affects SBS and apply this knowledge to help
select the optimal bonding adhesive/technique.

In Vitro Versus in Vivo Shear Bond Strength

Additionally, it is important to realize that due
to the difficulties involved with accurately and
consistently testing bond strengths intraorally,
most orthodontic bonding systems are evaluated by performing SBS tests on universal testing machines. However, there are many variables in the oral environment that may affect
bond strengths and cannot be simulated on an
in vitro model.119 Thus, it has been suggested
that the SBS values obtained in in vitro bond
strength tests may not be clinically applicable.120 As a result, efforts have been made to
compare in vivo and in vitro SBS to elucidate
the differences. In one study, the brackets
were bonded to premolars which were
planned for extraction. These teeth were subjected to the oral environment for 1 week, at
which time the patients returned and had the
teeth with the bonded brackets extracted.
Teeth were mounted and subjected to bond
strength testing, and the values were compared with SBS obtained on previously extracted teeth which had been subjected to in
vitro testing. The authors observed a 72% decrease in tensile bond strength and a 48%
decrease in SBS when the in vivo premolars
were compared with the in vitro samples.121
Recently, Hajrassie and Khier122 demonstrated
similar reductions in intraoral bracket SBS
when comparing them to an in vitro control.
Using a special appliance designed to debond
brackets in vivo while recording SBS, the authors found that the mean in vivo bond
strengths were approximately 40% less than
those in the in vitro groups. These findings
were consistent when bond strength tests were
performed 10 minutes 24 hours 1 week, and 4
weeks after bonding. Therefore, it is important for the clinician to realize that most bond
strength tests are performed in vitro, and that

intraoral bond strengths may not be as high as

those reported using in vitro models.
Additionally, due to the lack of standardization of bond strength testing, the clinician
should be cognizant to the fact that accurately
comparing bond strengths between different
studies may be difficult.123

References
1. Buonocore MG: A simple method of increasing the
adhesion of acrylic filling materials to enamel surfaces.
J Dent Res 34:849-853, 1955
2. Buonocore MG, Matsui A, Gwinnett AJ: Penetration of
resin dental materials into enamel surfaces with reference to bonding. Arch Oral Biol 13:61-70, 1968
3. Gwinnett AJ, Buonocore MG: Adhesion and caries
prevention: a preliminary report. Br Dent J 119:7780, 1965
4. Gwinnett AJ, Matsui A: A study of enamel adhesives.
The physical relationship between enamel and adhesive. Arch Oral Biol 12:1615-1620, 1967
5. Summitt JB, Robbins JW, Hilton TJ, et al: Fundamentals
of Operative Dentistry: A Contemporary Approach, 3rd
ed. Carol Stream, IL, Quintessence Publishing Co, Inc.,
2006:chap 8
6. Chatterjee R, Kleinberg I: Effect of orthodontic band
placement on the chemical composition of human incisor plaque. Arch Oral Biol 75:667-677, 1979
7. Gwinnet JA, Ceen F: Plaque distribution on bonded
brackets. Am J Orthod 75:667-677, 1979
8. gaard B, Rolla G, Arends J: Orthodontic appliances
and enamel demineralization. Part 1: lesion development. Am J Orthod Dentofacial Orthop 94:68-73,
1988
9. gaard B, Bishara SE, Duschner H: Enamel effects
during bonding-debonding and treatment with fixed
appliances, in Graber TM, Eliades T, Athanasiou AE
(eds): Risk Management in Orthodontics: Experts
Guide to Malpractice. Carol Stream, IL, Quintessence
Publishing Co, Inc., 2004, pp 30, -32:chap 3
10. Powers JM, Messersmith LM: Enamel etching and bond
strength, in Brantley WA, Eliades T (eds): Orthodontic
Materials: Scientific and Clinical Aspects. New York,
NY, Theime, 2000, pp 105-122
11. Britton JC, McInnes P, Weinberg R, et al: Shear bond
strength of ceramic orthodontic brackets to enamel.
Am J Orthod Dentofacial Orthop 98:348-353,
1990
12. Barkmeier WW, Gwinnett AJ, Shaffer SE: Effects of
enamel etching time on bond strength and morphology. J Clin Orthod 19:165-178, 1985
13. Beech DR, Jalaly T: Bonding of polymers to enamel:
influence of deposits formed during etching, etching
time and period of water immersion. J Dent Res 59:
1156-1162, 1980
14. Mardaga WJ, Shannon IL: Decreasing the depth of etch
for direct bonding orthodontics. J Clin Orthod 16:130132, 1982

Bonding and Debonding From Metal to Ceramic

15. Wickwire NA, Rentz D: Enamel pretreatment: a critical

variable in direct bonding systems. Am J Orthod 64:
499-512, 1973
16. Olsen ME, Bishara SE, Boyer DB, et al: Effect of
varying etching times on the bond strength of ceramic brackets. Am J Orthod Dentofacial Orthop
109:403-409, 1996
17. Olsen ME, Bishara SE, Damon P, et al: Evaluation of
scotchbond multipurpose and maleic acid as alternative methods of bonding orthodontic brackets. Am J
Orthod Dentofacial Orthop 111:498-501, 1997
18. Bishara SE, Gordan VV, VonWald L, et al: Effect of an
acidic primer on shear bond strength of orthodontic
brackets. Am J Orthod Dentofacial Orthop 114:243247, 1998
19. Triolo PT Jr, Swift EJ Jr, Mudgil A, et al: Effects of
etching time on enamel bond strengths. Am J Dent
6:302-304, 1993
20. Smith DC: A new dental cement. Br Dent J 125:381-394,
1968
21. Smith DC, Cartz L: Crystalline interface formed by
polyacrylic acid and tooth enamel. J Dent Res 52:1155,
1973
22. Bishara SE, Fehr DE, Jakobsen JR: A comparative
study of the debonding strengths of different ceramic brackets, enamel conditioners, and adhesives.
Am J Orthod Dentofacial Orthop 104:170-179,
1993
23. Espinosa R, Valencia R, Uribe M, et al: Enamel deproteinization and its effect on acid etching: an in vitro
study. J Clin Pediatr Dent 33:13-20, 2008
24. Bishara SE, Oonsombat C, Ajlouni R, et al: Comparison
of the shear bond strength of 2 self-etch primer/adhesive systems. Am J Orthod Dentofacial Orthop 125:348350, 2004
25. Bishara SE, VonWald 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
26. Vicente A, Bravo LA, Romero M, et al: Shear bond
strength of orthodontic brackets bonded with self-etching primers. Am J Dent 18:246-260, 2005
27. Pashley DH, Tay FR: Aggressiveness of contemporary
self-etching adhesives. Part II: etching effects on unground enamel. Dent Mater 17:430-444, 2001
28. Ostby AW, Bishara SE, Denehy GE, et al: Effect of
self-etchant pH on the shear bond strength of orthodontic brackets. Am J Orthod Dentofacial Orthop
134:203-208, 2008
29. Benderli Y, Gokce K, Buyukgokcesu S: In vitro shear
bond strength of adhesive to normal and fluoridated
enamel under various contaminated conditions. Quintessence Int 30:570-575, 1999
30. Hormati AA, Fuller JL, Denehy GE: Effects of contamination and mechanical disturbance on the quality of acid-etched enamel. J Am Dent Assoc 100:34-38,
1980
31. Thomson JL, Main C, Gillespie FC, et al: The effect of
salivary contamination on fissure sealant enamel bond
strength. J Oral Rehabil 8:11-18, 1981

33

32. Silverstone LM, Hicks MJ, Featherstone MJ: Oral fluid

contamination of etched enamel surfaces: an SEM
study. J Am Dent Assoc 110:329-332, 1985
33. Xie J, Powers JM, McGuckin RS: In vitro bond strength
of two adhesives to enamel and dentin under normal
and contaminated conditions. Dent Mater 9:295-299,
1993
34. Bishara SE, Oonsombat C, Ajlouni R, et al: The effect of
saliva contamination on shear bond strength of orthodontic brackets when using a self-etch primer. Angle
Orthod 72:554-557, 2002
35. Oonsombat C, Bishara SE, Ajlouni R: The effect of
blood contamination on the shear bond strength of
orthodontic brackets with the use of a new self-etch
primer. Am J Orthod Dentofacial Orthop 123:547-550,
2003
36. Sayinsu K, Isik F, Sezen S, et al: Effect of blood and
saliva contamination on bond strength of brackets
bonded with a protective liquid polish and a light-cured
adhesive. Am J Orthod Dentofacial Orthop 131:391394, 2007
37. Kent BE, Lewis GG, Wilson AD: The properties of a
glass ionomer cement. Br Dent J 135:322-326, 1973
38. Hotz P, McClean JW, Sced I, et al: The bonding of glass
ionomer cements to metal and tooth substrates. Br
Dent J 242:41-47, 1977
39. Arthur J, Bergland S: Clinical trials with crystal growth
conditioning as an alternative to acid-etch enamel pretreatment. Am J Orthod Dentofacial Orthop 85:333340, 1984
40. Prosser HJ, Powis DR: The characterization of glassionomer cements: the physical properties of current
materials. J Dent Res 12:231-240, 1984
41. Causton BE: Bonding class II composite to etched glassionomer cement. Br Dent J 163:321-324, 1987
42. Aboush YE, Jenkins CB: An evaluation of the bonding
of a glass-ionomer restorative to dentin. Br Dent J
161:179-184, 1986
43. Van Kijken JW, Horsdt PM: In vivo adaptation of restorative materials to dentin. J Prosthet Dent 56:677681, 1986
44. Wilson AD, Groffman DM, Kuhn AT: The release of
fluoride and other chemical species from a glass-ionomer cement. Biomaterials 6:431-434, 1985
45. Swift EJ Jr: Effects of glass ionomers on recurrent caries. Oper Dent 14:40-43, 1989
46. McCourt JW, Cooley RL, Huddleston AM: Fluoride
release from fluoride-containing liners/bases. Quintessence Int 21:41-45, 1990
47. Hallgren A, Oliveby A, Twetman S: Fluoride concentration in plaque adjacent to orthodontic brackets retained with glass ionomer cements. Br J Orthod 21:2326, 1994
48. Bishara SE, Gordan VV, VonWald L, et al: Shear bond
strength of composite, glass ionomer, and acidic
primer adhesive. Am J Orthod Dentofacial Orthop 115:
24-28, 1999
49. Klockowski R, Davis EL, Joynt RB, et al: Bond
strength and durability of glass ionomer cements
used as bonding agents in the placement of orthodontic brackets. Am J Orthod Dentofacial Orthop
96:60-64, 1989

34

S.E. Bishara and A.W. Ostby

50. Cook PA, Youngson CC: An in vitro study of bond

strength of glass ionomer cement in the direct bonding of orthodontic brackets. Br J Orthod 15:247-253,
1988
51. Fajen VB, Duncanson MG, Nanda RS, et al: An in vitro
evaluation of bond strength of three glass ionomer
cements. Am J Orthod Dentofacial Orthop 97:316-322,
1990
52. Wiltshire WA: Shear bond strengths of a glass ionomer
for direct bonding in orthodontics. Am J Orthod
Dentofacial Orthop 106:127-130, 1994
53. Miquel JAM, Almeida MA, Chevitarese O: Clinical comparison between a glass ionomer cement and a composite for direct bonding of orthodontic brackets. Am J
Orthod Dentofacial Orthop 107:484-487, 1995
54. Miller JR, Mancl L, Arbuckle G, et al: A three-year
clinical trial using a glass ionomer cement for the bonding of orthodontic brackets. Angle Orthod 66:309-312,
1996
55. Diaz-Arnold AM, Holmes DC, Wistrom DW, et al: Shortterm fluoride release/uptake of glass ionomer restoratives. Dent Mater 11:96-101, 1995
56. Forsten L: Resin-modified glass ionomer cements: fluoride release and uptake. Acta Odontol Scand 53:222225, 1995
57. Forss J: Release of fluoride and other elements from
light-cured glass ionomers in neutral and acidic conditions. J Dent Res 72:1257-1262, 1993
58. Forsten L: Fluoride release of glass ionomers. J Esthet
Dent 6:216-222, 1994
59. McCourt JW, Cooley RL, Barnwell S: Bond strength of
light-cure fluoride-releasing base-liners as orthodontic
bracket adhesives. Am J Orthod Dentofacial Orthop
100:47-52, 1991
60. Komori A, Ishikawa H: Evaluation of a resin-reinforced
glass ionomer cement for use as an orthodontic bonding agent. Angle Orthod 67:189-195, 1997
61. Summers A, Kao E, Gilmore J, et al: Comparison of
bond strength between a conventional resin adhesive
and a resin-modified glass ionomer adhesive: an in vitro
and in vivo study. Am J Orthod Dentofacial Orthop
126:200-206, 2004
62. Rix D, Foley TF, Mamandras A: Comparison of bond
strength of three adhesives: composite resin, hybrid
GIC, and glass-filled GIC. Am J Orthod Dentofacial
Orthop 119:36-42, 2001
63. Coups-Smith KS, Rossouw PE, Titley KC: Glass ionomer
cements as luting agents for orthodontic brackets. Angle Orthod 73:436-444, 2003
64. Bishara SE, VonWald L, Olsen ME, et al: Effect of time
on the shear bond strength of glass ionomer and composite orthodontic adhesives. Am J Orthod Dentofacial
Orthop 116:616-620, 1999
65. Fricker JP. A 12-month clinical evaluation of a lightactivated glass polyalkenoate (ionomer) cement for the
direct bonding of orthodontic brackets. Am J Orthod
105:502-505, 1994
66. Silverman E, Cohen M, Demke R, et al: A new lightcured glass ionomer cement that bonds brackets to
teeth without etching in the presence of saliva. Am J
Orthod 108:231-236, 1995

67. Bishara SE, Ostby AW, Laffoon J, et al: Shear bond

strength comparison of two adhesive systems following
thermocycling. Angle Orthod 77:337-341, 2007
68. Bishara SE, Ostby AW, Laffoon J, et al: A self-conditioner for resin-modified glass ionomers in bonding
orthodontic brackets. Angle Orthod 77:711-715,
2007
69. Eliades T: Orthodontic materials research and applications. Part 1: current status and projected future developments in bonding and adhesives. Am J Orthod
Dentofacial Orthop 130:445-451, 2006
70. McLean JW, Nicholson JW, Wilson AD: Proposed
nomenclature for glass ionomer dental cements and
related materials. Quintessence Int 25:587-589, 1994
71. Eliades G, Kakaboura A, Palaghias G: Acid-base reaction and fluoride release profiles in visible light-cured
polyacid-modified composite restoratives (compomers).
Dent Mater 14:57-63, 1998
72. Cehreli ZC, Usmen E: Effect of surface conditioning
on the shear bond strength of compomers to human
primary and permanent enamel. Am J Dent 12:26-30,
1999
73. Millett DT, Cattanach D, McFadzean R, et al: Laboratory evaluation of a compomer and a resin modified
glass ionomer cement for orthodontic bonding. Angle
Orthod 69:58-64, 1999
74. Millett DT, McCluskey LA, McAuley F, et al: A comparative clinical trial of a compomer and a resin adhesive
for orthodontic bonding. Angle Orthod 70:233-240,
2000
75. Cehreli ZC, Altay N: Effects of a nonrinse conditioner
and 17% ethylenediaminetetraacetic acid on the etch
pattern of intact human permanent enamel. Angle
Orthod 70:22-27, 2000
76. Bishara SE, Laffoon JF, VonWald L, et al: Evaluation of
nonrinse conditioning solution and a compomer as an
alternative method of bonding orthodontic brackets.
Angle Orthod 71:461-465, 2001
77. Vicente A, Navarro R, Mena A, et al: Effect of surface
treatments on the bond strength of brackets with a
compomer. Am J Dent 19:271-274, 2006
78. Bishara SE, VonWald L, Laffoon JF, et al: Effect of using
a new cyanoacrylate adhesive on the shear bond
strength of orthodontic brackets. Angle Orthod 71:466469, 2001
79. Bishara SE, Laffoon JF, VonWald L, et al: Effect of time
on the shear bond strength of cyanoacrylate and composite orthodontic adhesives. Am J Orthod Dentofacial
Orthop 121:297-300, 2002
80. Ajlouni R, Bishara SE, Oonsombat C: Effect of water
storage on the shear bond strength of a cyanoacrylate
adhesive: clinical implications. World J Orthod 5:250253, 2004
81. Bishara SE, Ajlouni R, Laffoon JF: Effect of thermocycling on the shear bond strength of a cyanoacrylate
orthodontic adhesive. Am J Orthod Dentofacial Orthop 123:21-24, 2003
82. Schedle A, Franz A, Rausch-Fan X, et al: Cytotoxic
effect of dental composites, adhesive substances,
compomers and cements. Dent Mater 14:429-440,
1998

Bonding and Debonding From Metal to Ceramic

83. Prati C, Chersoni S, Mongiorgi R, et al: Resin-infiltrated

dentin layer formation of new bonding systems. Oper
Dent 23:185-194, 1998
84. Combe EC, Burke FJT: Contemporary resin-based composite materials for direct placement restorations:
packables, flowables and others. Dent Update 27:326336, 2000
85. Watts DC, Marouf AS: Optimal specimen geometry
in bonded-disk shrinkage-strain measurements on
light cured biomaterials. Dent Mater 16:447-451,
2000
86. Cattani-Lorente M, Bouillaguet S, Godin CH, et al:
Polymerization shrinkage of Ormocer based dental restorative composites. Eur Cell Mater 1:25-26,
2001
87. Hickel R, Dasch W, Janda R, et al: New direct restorative materials. Int Dent J 48:3-15, 1998
88. Ajlouni R, Bishara SE, Soliman MM, et al: The use
of Ormocer as an alternative material for bonding
orthodontic brackets. Angle Orthod 75:106-108,
2005
89. Geraldeli S, Perdigao J: Microleakage of a new restorative system in posterior teeth [abstract 27621]. J Dent
Res, 2003
90. Dabanoglu A, Kunzemann KH, Hickel R, et al: Three
body wear resistance of resin composites. Presented at
the EFCD Conference, 2003, Munich, Germany
91. Bishara SE, Ajlouni R, Soliman MM, et al: Evaluation of a new nano-filled restorative material for
bonding orthodontic brackets. World J Orthod 8:812, 2007
92. Bishara SE, Ostby AW, Ajlouni R, et al: Early shear bond
strength of a one-step self-adhesive on orthodontic
brackets. Angle Orthod 76:689-693, 2006
93. Bishara SE, Ajlouni R, Laffoon JF, et al: Comparison of
shear bond strength of two self-etch primer/adhesive
systems. Angle Orthod 76:123-126, 2006
94. Bishara SE, Soliman AH, Olson M: Effect of enamel
bleaching on the bonding strength of orthodontic
brackets. Am J Orthod Dentofacial Orthop 104:444447, 1993
95. Bishara SE, Oonsombat C, Soliman MM, et al: The
effect of tooth bleaching on the shear bond strength of
orthodontic brackets. Am J Orthod Dentofacial Orthop
128:755-760, 2005
96. Reynolds I: A review of direct orthodontic bonding. Br J
Orthod 2:171-178, 1975
97. Chaconas S, Caputo A, Niu G: Bond strength of ceramic brackets with various bonding systems. Angle
Orthod 61:35-42, 1990
98. Newman G: Adhesion and orthodontic plastic attachments. Am J Orthod 56:573-588, 1969
99. Hershey H: The orthodontic appliance: esthetic considerations. J Am Dent Assoc 115:29E-34E, 1987
100. Bishara S, Trulove T: Comparisons of different debonding techniques for ceramic brackets: an in vitro study.
Part I. Background and methods. Am J Orthod Dentofacial Orthop 98:145-153, 1990
101. Winchester L: Bond strengths of five different ceramic
brackets: an in vitro study. Eur J Orthod 13:293-305,
1991

35

102. Harris A, Joseph V, Rossouw P: Shear peel bond

strengths of esthetic orthodontic brackets. Am J
Orthod Dentofacial Orthop 102:215-219, 1992
103. Pratten D, Popli K, Germane N, et al: Frictional
resistance of ceramic and stainless steel orthodontic
brackets. Am J Orthod Dentofacial Orthop 98:398403, 1990
104. Bishara S, Fehr D, Jakobsen J: A comparative study of
the debonding strengths of different ceramic brackets,
enamel conditioners, and adhesives. Am J Orthod
Dentofacial Orthop 104:170-179, 1993
105. Johnson R: A new method for direct-bonding orthodontic attachments to porcelain teeth using a silane
coupling agent: an in vitro evaluation. Am J Orthod
78:233-234, 1980
106. Newman S, Dressler K, Grenadier M: Direct bonding of
orthodontic brackets to esthetic restorative materials
using a silane. Am J Orthod 86:503-506, 1984
107. Scott G: Fracture toughness and surface cracksthe
key to understanding ceramic brackets. Angle Orthod
58:5-8, 1988
108. Kusy R: Morphology of polycrystalline alumina brackets
and its relationship to fracture toughness and strength.
Angle Orthod 58:197-203, 1988
109. Joseph V, Rossouw P: The shear bond strengths of
stainless steel and ceramic brackets using chemically,
and light activated composite resins. Am J Orthod
Dentofacial Orthop 97:121-125, 1990
110. Schwartz M: Ceramic brackets. J Clin Orthod 22:82-88,
1988
111. Birnie D: Orthodontic materials update. Ceramic
brackets. Br J Orthod 17:71-75, 1990
112. Bishara S, Trulove T: Comparisons of different debonding techniques for ceramic brackets: an in vitro study.
Part II. Findings and clinical implications. Am J Orthod
Dentofacial Orthop 98:263-273, 1990
113. Theodorakopoulou LP, Sadowsky PL, Jacobson A, et al:
Evaluation of the debonding characteristics of 2 ceramic brackets: an in vitro study. Am J Orthod Dentofacial Orthop 125:329-336, 2004
114. Arici S, Minors C: The force levels required to mechanically debond ceramic brackets: an in vitro comparative
study. Eur J Orthod 22:327-334, 2000
115. Bishara SE, Fonseca JM, Boyer DB: The use of debonding pliers in the removal of ceramic brackets: force
levels and enamel cracks. Am J Orthod Dentofacial
Orthop 108:242-248, 1995
116. Liu JK, Chung CH, Chang CY, et al: Bond strength
and debonding characteristics of a new ceramic
bracket. Am J Orthod Dentofacial Orthop 128:761765, 2005
117. Mundstock KS, Sadowsky PL, Lacefield W, et al: An in
vitro evaluation of a metal reinforced orthodontic ceramic bracket. Am J Orthod Dentofacial Orthop 116:
635-641, 1999
118. Artun J: A post treatment evaluation of multibonded
ceramic brackets in orthodontics. Eur J Orthod 19:219228, 1997
119. Eliades T, Brantly WA: The inappropriateness of conventional orthodontic bond strength assessment protocols. Eur J Orthod 22:13-23, 2000

36

S.E. Bishara and A.W. Ostby

120. Fox NA, McCabe JF, Buckley JG: A critique of bond strength
testing in orthodontics. Br J Orthod 21:33-43, 1994
121. Stieg MA: An in vitro comparison of shear and tensile
bond strengths for orthodontic brackets directly bonded
to enamel, porcelain and gold [masters thesis]. Iowa City,
IA, The University of Iowa, 1987

122. Hajrassie MKA, Khier SE: In-vivo and in-vitro comparison

of bond strengths of orthodontic brackets bonded to
enamel and debonded at various times. Am J Orthod
Dentofacial Orthop 131:384-390, 2007
123. Swift MS: Limitations of in vitro orthodontic bond
strength testing. J Clin Orthod 41:207-210, 2007