ORIGINAL ARTICLE

Quantitative analysis of enamel on

debonded orthodontic brackets
Nathan J. Cochrane,b,y Thomas W. G. Lo,a Geoffrey G. Adams,b and Paul M. Schneidera
Melbourne, Australia

Introduction: Iatrogenic damage to the tooth surface in the form of enamel tearouts can occur during removal of
fixed orthodontic appliances. The aim of this study was to assess debonded metal and ceramic brackets
attached with a variety of bonding materials to determine how frequently this type of damage occurs.
Methods: Eighty-one patients close to finishing fixed orthodontic treatment were recruited. They had metal
brackets bonded with composite resin and a 2-step etch-and-bond technique or ceramic brackets bonded
with composite resin and a 2-step etch-and- bond technique, and composite resin with a self-etching primer
or resin-modified glass ionomer cement. Debonded brackets were examined by backscattered scanning
electron microscopy with energy dispersive x-ray spectroscopy to determine the presence and area of
enamel on the base pad. Results: Of the 486 brackets collected, 26.1% exhibited enamel on the bonding ma-
terial on the bracket base pad. The incidences of enamel tearouts for each group were metal brackets, 13.3%;
ceramic brackets, 30.2%; composite resin with self-etching primer, 38.2%; and resin-modified glass ionomer
cement, 21.2%. The percentage of the bracket base pad covered in enamel was highly variable, ranging from
0% to 46.1%. Conclusions: Enamel damage regularly occurred during the debonding process with the degree
of damage being highly variable. Damage occurred more frequently when ceramic brackets were used (31.9%)
compared with metal brackets (13.3%). Removal of ceramic brackets bonded with resin-modified glass ionomer
cement resulted in less damage compared with the resin bonding systems. (Am J Orthod Dentofacial Orthop
2017;152:312-9)

T
he aim of bracket debonding is to remove appli-
ances and any bonding material from the teeth,
restoring the original esthetics and contours while
minimizing iatrogenic enamel loss during the proced-
ure.1 Appliance and bracket removal does cause some
damage to the tooth surface.2 This can occur at bracket
removal if the enamel fails cohesively, resulting in
cracks3 and tearouts,4,5 or it can occur during removal
of adhesive remnants.6
Many bonding materials and methods are available
for the placement of orthodontic brackets. All of these
a
Orthodontic Unit, Melbourne Dental School, University of Melbourne, Mel-
bourne, Australia; private practice, Melbourne, Australia.
b
Melbourne Dental School, Cooperative Research Centre for Oral Health Science,
University of Melbourne, Melbourne, Australia.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Supported by a grant from the Australian Dental Research Foundation and the
Australian Society of Orthodontists, Foundation for Research and Education.
y
Deceased.
Address correspondence to: Paul M. Schneider, Melbourne Dental School, Level
5, 720 Swanston St, Carlton, VIC 3053, Australia; e-mail, pmschn@unimelb.edu.
au.
Submitted, February 2014; revised and accepted, January 2017.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2017.01.020
have their own unique material properties that influence
their mode of failure during orthodontic bracket
removal.7 It is estimated that bonded orthodontic
brackets need a bond strength of 5.9 to 7.8 MPa to be
retained.8 Many bonding systems meet or exceed this
requirement.9 For example, metal brackets bonded to
enamel with conventional 2-step etch and bond with
Transbond XT composite resin (3M Unitek, Monrovia,
Calif) had a reported bond strength of 20.2 MPa,10 the
strength of self-etching primer (SEP) with Transbond
XT was 11.1 MPa,11 and the strength of Fuji Ortho LC
resin-modified glass ionomer cement (RMGIC) (GC Cor-
poration, Tokyo, Japan) was 13.6 MPa.10 Ceramic
brackets may also have high bond strengths to enamel.
Using a 2-step etch-and-bond technique, Heliosit com-
posite resin had a reported bond strength of
24.25 MPa.12 Therefore, in some situations, the bond
strength of the adhesive to the enamel may be higher
than the cohesive strength within the enamel, resulting
in cracks or tearouts at debonding.10,12,13
Although enamel loss as tearouts during orthodon-
tic bracket removal has frequently been reported
in vitro, there are few clinical studies on this topic.14 Us-
ing backscattered scanning electron microscopy,

312
Cochrane et al 313

Boyde5 reported that enamel tearouts were clearly

Table I. Presence of enamel, percentage of bracket
observable on the bonding surfaces of clinically de-
base covered with enamel, BARI score, and frequency
bonded ceramic orthodontic brackets attached with
of bracket fracture for the various bracket-bonding
composite resin. However, the influence of bracket
material combinations
and adhesive type was not explored. A more recent, en-
ergy dispersive x-ray spectrometry evaluation of clini- Metal
cally debonded metal brackets attached with a 2-step Ceramic brackets* brackets*
etch-and-bond retained composite resin showed that CGICy CSEPz CEC§ MECy
as the amount of resin on the base pad increased, so (n 5 66k) (n 5 144k) (n 5 126k) (n 5 150k)
did the amount of calcium (assumed to be enamel).4 Presence of enamel
No 80.3 61.8 69.8 86.7
This study did not report the overall frequency of dam-
Yes 19.7 38.2 30.2 13.3
age or examine the extent of damage when ceramic Percentage of bracket base covered with enamel
brackets were used. Therefore, more clinical investiga- 0% 80.3 61.8 69.8 86.7
tion into the frequency and extent of this problem is .0%-\1% 15.2 16.7 12.7 8.7
warranted to ensure that bracket-adhesive combina- 1%-\5% 3.0 9.0 7.9 3.3
5%-\10% 1.5 5.6 4.0 1.0
tions are selected to minimize iatrogenic enamel loss
$10% 0.0 6.9 5.6 1.0
as tearouts during bracket removal. BARI
The aim of this clinical study was to determine the Score 0 53.0 36.8 49.2 39.3
extent and frequency of iatrogenic damage to enamel Score 1 37.9 29.9 30.2 49.3
when debonding metal and ceramic orthodontic Score 2 9.1 9.0 4.8 6.0
brackets attached by various bonding materials in vivo. Score 3 0.0 11.8 5.6 2.7
Score 4 0.0 10.4 7.9 2.7
Score 5 0.0 2.1 2.4 0.0
Bracket fracture
MATERIAL AND METHODS No 87.9 93.8 73.8 100.0
Yes 12.1 6.3 26.2 0.0
Ethics approval for the study was obtained from the
Human Research Ethics Committee (number 1136902) *Cell values are percentage of surfaces; yOrthodontist A treated 11
of the University of Melbourne in Australia. Patients patients with CGIC and 25 patients with MEC; zOrthodontists B
close to finishing fixed orthodontic treatment were re- and C treated 15 and 9 patients with CSEP, respectively;
§
cruited from 5 private orthodontic practices. Practices Orthodontists D and E treated 13 and 8 patients with CEC, respec-
tively; kNumber of surfaces: each patient contributed 6 surfaces.
were invited to participate if they met the
following inclusion criteria: (1) the clinicians in the prac-
tice used either metal In-Ovation R brackets (GAC Inter- Therefore, patients fell into 1 of the following 4
national, Bohemia, NY) or ceramic In-Ovation C brackets groups: MEC, metal bracket attached with Transbond
(GAC International); (2) they used 1 of the 3 following XT composite resin bonded to the tooth with a 2-step
adhesive protocols: 37% phosphoric acid etch, Orthosolo etch-and-bond technique; CEC, ceramic bracket attached
bond (Ormco, Orange, Calif), and Transbond XT com- with Transbond XT composite resin bonded to the tooth
posite resin (3M Unitek); pumice with a cup, SEP (Trans- with a 2-step etch-and-bond technique; CSEP, ceramic
bond Plus Self Etching Primer, 3M Unitek), and bracket attached with Transbond XT composite resin
Transbond XT composite resin; or pumice with a cup, bonded to the tooth with SEP; or CGIC, ceramic bracket
Fuji Ortho Conditioner (10% polyacrylic acid), and attached with RMGIC. The numbers of patients from
RMGIC (Fuji Ortho LC encapsulated; GC Corporation); each office are shown in Table I.
and (3) the clinicians needed to debond ceramic brackets In total, 81 patients were recruited into this study.
using the sharp blades of the debonding pliers at the Brackets from the maxillary right to left canine were
level of the base pad, placing a wedging force at the ad- collected and sterilized by 4.1 kGy gamma irradiation.
hesive level, and debonding metal brackets using the de- Of the 486 brackets collected, 49 fractured at removal,
bracketing instrument (444-761; 3M Unitek). This so only 437 brackets were visualized by backscattered
instrument has a wire hook that goes under a bracket scanning electron microscopy under 60 times magnifi-
wing and is stabilized against the adjacent enamel, cation (low vacuum; no coating; backscatter mode;
enabling the bracket to be pulled off the adhesive and spot size 4; 15 kV; resolution 2048 3 1768; Quanta
tooth in a safe and comfortable manner. It is a reproduc- 200F scanning electron microscope; FEI, Hillsboro,
ible and standardized technique. The instrument cannot Ore). An elemental map of calcium, phosphorus,
be used on ceramic brackets because of their brittleness. aluminum, and silicon on the bracket base was also

American Journal of Orthodontics and Dentofacial Orthopedics September 2017  Vol 152  Issue 3
314 Cochrane et al

Fig 1. A, Backscattered scanning electron microscopy image of ceramic orthodontic bracket adhered
with composite resin; B, the image overlaid with elemental maps showing aluminum, silicon, calcium,
phosphorus, and iron. Elemental maps showing only C, calcium and D, phosphorus that were used to
create the image mask.

made using energy dispersive x-ray spectrometry (reso-
lution setting, 1024; acquisition time, frame count 3;
pixel dwell time, 50 mS; process time, 5; energy range
(KeV); auto; INCA SDD x-ray microanalysis system for
elemental analysis; Oxford Instruments, Abingdon,
United Kingdom).
One investigator (T.W.G.L.) used these images to
determine the absence or presence of enamel on the
bracket base pad by assuming that a pixel that contained
both calcium and phosphorus was enamel (Fig 1). None
of the bonding materials used in this study contained
detectable calcium or phosphorus, and any calcium or
phosphorus that was not on the bonding materials was
assumed to be calculus and excluded from the analysis.
Calcium and phosphorus elemental maps images were
opened in Image J (U.S. National Institutes of Health,
Bethesda, Md), multiplied together to reduce detector
noise, and converted into a binary mask. This mask
indicated the pixels that were assumed to be enamel
(calcium multiplied by phosphorus) on the bonding sur-
face of the bracket. Ten masks and their respective back-
scattered scanning electron microscopy images were
then used to determine the minimum grey value for
enamel that was subsequently used for the analysis of
all other backscattered scanning electron microscopy
images. The mean and standard deviation of this
threshold were 114 6 30 grey values. Backscattered
scanning electron microscopy images of each bracket
were viewed through Image J as 8-bit images and cali-
brated using the scale bar in each image. The area of
the image where bonding material was not present
was set to black (grey value 5 0) using the paintbrush
tool (this removed any areas of presumed calculus).
The histogram of the image was then acquired, and all
pixels above the minimum threshold of 114 were
counted to quantify the area of enamel in square

September 2017  Vol 152  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Cochrane et al 315

Fig 2. Backscattered scanning electron microscopy images with overlaid elemental maps for repre-
sentative brackets from each group showing various degrees of damage. In the overlaid images,
blue denotes iron or aluminum, purple denotes silicon, green denotes calcium, and orange denotes
phosphorus.

millimeters. The bracket area for each tooth type was
determined by measuring the mean area of 10 brackets
from the same tooth type in Image J after the scale
had been set as described earlier. The percentage area
of the bracket base pad that was covered in enamel
was calculated to account for the variations in the
base pad area.
The amount of adhesive remnant on the bracket was
categorized using a modified bracket adhesive remnant
index (BARI): 0, no adhesive present; 1, less than a quarter
of the adhesive left covering the bracket base; 2, more
than a quarter but less than half the adhesive left covering
the bracket base; 3, more than half but less than three
quarters of the adhesive left covering the bracket base;
4, more than three quarters but less than all of the adhe-
sive left covering the bracket base; and 5, the whole
bracket base is covered with adhesive. Bracket fractures
were also coded. When they occurred, it was assumed
that all of the adhesive remained on the tooth surface,
and therefore these samples were given a BARI score of 0.
To assess the reproducibility of the outcome mea-
sures, the elemental map images from 18 patients were

American Journal of Orthodontics and Dentofacial Orthopedics September 2017  Vol 152  Issue 3
316
Fig 3. Distribution of damage for each bracket-adhesive combination. A nonlinear y-axis was chosen
to better display the frequencies of the more severely damaged samples.
rescored on a separate occasion by the same examiner
without reference to the initial scores. The images
selected for the reproducibility study by our statistician
(G.G.A.) covered the entire range of values of the
outcome measures.
Statistical analysis
All statistical analyses were carried out using a soft-
ware package (Stata version 12; StataCorp, College Sta-
tion, Tex). Cross-tabulations and chi-square tests were
used to evaluate whether there was a difference in the
presence of enamel, degree of enamel damage, and
BARI when different bracket and bonding material
combinations were used. Logistic regression analysis
was used to evaluate whether different tooth types
were more susceptible to damage for the various bracket
and bonding material combinations. For this analysis,
enamel damage was dichotomized as damage or no
damage. Ordered logistic regression was used to evaluate
whether there is a difference in BARI scores when various
bracket and bonding material combinations are removed
from different tooth types. For the reproducibility study,
the BARI scores from the 2 sets of measurements were
compared using the kappa statistic, and the percentage
area of base pad covered by enamel values were
compared using a generalized linear model, and an
intraclass correlation coefficient was calculated. In all
analyses, significance levels were adjusted for the
clustered study design (brackets from the same patient)
using the svy option. P values less than 0.05 were
considered statistically significant.
September 2017  Vol 152  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Cochrane et al
RESULTS
The frequency of enamel presence on the bonding ma-
terial on the bracket base pad is shown in Table I; there
were differences between the groups (P 5 0.001). Of the
486 brackets collected, 26.1% had detectable enamel on
the base pad. The MEC group had a significantly lower
incidence of tearouts compared with the CEC group
(P 5 0.015). There were significant differences in enamel
damage when ceramic brackets attached with different
materials were compared, with the CEC and CSEP groups
having similar amounts of enamel on the base pad,
whereas the CGIC group had significantly less (P 5 0.047).
In all bracket-adhesive combinations, enamel tea-
routs were present on the adhesive on the bracket base
pad (Table I). Representative bracket images from each
group exhibiting no, minor, and major damage are
shown in Figure 2. The 2 common presentations of
enamel on the adhesive were either lines of enamel
that followed the spacing of the perikymata or bulk tea-
routs as shown in Figure 2. The percentage area of base
pad covered by enamel represents the degree of enamel
damage during bracket removal. Among the brackets ex-
hibiting enamel damage, the percentages of base pad
covered with enamel were broad, ranging from approx-
imately 0% to 46.1% (Fig 3). The greatest iatrogenic
damage was 46.1% in the CSEP group, followed by
31.3% in the CEC group, 11.2% in the MEC group,
and 5.4% in the CGIC group. Although damage could
be severe, this was largely limited to the CEC and CSEP
groups (Fig 3), and only 4% of all brackets had more
than 10% of their area covered by enamel.
Cochrane et al
Table II. Cross tabulation of percentages of bracket bases covered with enamel and the percentages of brackets with a
particular BARI score
Score 0 Score 1
(n 5 209y) (n 5 180y)
Percentage of bracket base covered with enamel
0% 99.5 70.6
. 0%-\1% 0.5 25.0
1%-\5% 0.0 3.3
5%-\10% 0.0 0.6
$10% 0.0 0.6
*Cell values are percentages of surfaces; yNumber of surfaces: each patient contributed 6 surfaces.
Approximately half the brackets in the CGIC and
CEC groups failed completely at the bracket-
adhesive interface (BARI score, 0), whereas the other
half had mixed modes of failure (BARI scores, 1-4).
Brackets from the CSEP and MEC groups had mixed
modes of failure as seen by the frequencies of BARI
scores of 1 to 4 in Table I. This can also be seen in
Figure 2, where normally only part of the adhesive
was on the bracket, with the other adhesive presum-
ably remaining on the tooth. The only groups with
complete enamel-adhesive interface failure (BARI
score, 5) were the CEC and CSEP groups (2.4% and
2.1%, respectively). When the BARI scores were cross
tabulated with the percentage of the bracket base
covered with enamel, there was a significant trend
for less enamel damage with low BARI scores and
greater enamel damage when more adhesive was pre-
sent (Table II; P \0.001).
As can be seen in Table I, bracket fracture did not
occur in the metal bracket group. However, 14.6% of
the ceramic brackets were fractured during removal.
Most bracket fractures occurred in the CEC group, fol-
lowed by the CGIC and then the CSEP groups
(P \0.001).
Significant differences existed in the frequency of
damage to the different maxillary tooth types. Irre-
spective of the bracket and adhesive combination, a
higher proportion of lateral incisors (32.7%) exhibited
enamel on the base of the bracket compared with the
central incisors (21.0%) and canines (24.1%)
(P 5 0.031). This trend continued when all ceramic
brackets, irrespective of adhesive methods, were
considered together (40.2%, 25.9%, and 28.6%,
respectively; P 5 0.046).
The BARI scores from the 2 sets of measurements
agreed for 104 of the 108 images (96.3%), and the kappa
statistic was 0.95. For the percentage area of base pad
covered by enamel measure, the difference between
the 2 sets of measurements was insignificant (mean
American Journal of Orthodontics and Dentofacial Orthopedics
317
BARI*
Score 2 Score 3 Score 4 Score 5
(n 5 34y) (n 5 28y) (n 5 29y) (n 5 6y)
38.2 7.1 31.0 16.7
20.6 17.9 13.8 16.7
17.7 39.3 20.7 16.7
17.7 21.4 6.9 0.0
5.8 14.3 27.6 50.0
difference, 0.017; standard error, 0.036; P 5 0.65),
and the intraclass correlation coefficient was 0.99.
DISCUSSION
The force used to debond brackets can be applied
to the bracket or to the bonding material, with failure
occurring at the weakest interface or within the mate-
rial with the weakest cohesive strength. In this study,
clinicians applied a “lift-off” force to the wings of
the metal brackets or force to the adhesive of the
ceramic brackets. None of the metal brackets collected
in this study fractured when removed. The BARI scores
indicated failure predominantly at the bracket-
adhesive interface (BARI scores, 0 or 1; 88.6%). With
this technique, 13.3% of all metal brackets collected
did contain some enamel on the bonding material,
with mixed modes of failure demonstrating that
some force was transmitted to the enamel. This
finding agrees with those of Boyde5 and Pont et al,4
who both showed that enamel can be present on de-
bonded brackets. The amount of enamel on the metal
bracket adhesive was small, with only 2% of the
brackets having more than 5% of their bracket area
covered in enamel.
The literature indicates that removal of ceramic
brackets is more commonly associated with enamel frac-
tures, cracks, and tearouts.3,15,16 To reduce this damage,
mechanically retained ceramic brackets were
introduced13; their use compared with chemically re-
tained brackets with nearly half the incidence of cracks.3
In this study, only In Ovation C brackets, which are me-
chanically retained, were examined. Force application to
the adhesive resulted in frequent bracket fractures for all
ceramic bracket-adhesive combinations (CEC group,
about 1 in 4 brackets; CGIC group, about 1 in 10
brackets; CSEP group, about 1 in 20 brackets) with sig-
nificant differences between the CSEP and CEC groups
(P \0.001) and also between the CGIC and CEC groups
September 2017  Vol 152  Issue 3
318
(P 5 0.009). Bracket fracture is problematic because
ceramic remnant removal may lead to inadvertent iatro-
genic enamel damage.13
The amount of enamel damage when ceramic
brackets were removed was also greater when compared
with metal brackets (CEC, 30.2% vs MEC, 13.3%;
P 5 0.015). Approximately 1 in 3 ceramic brackets had
enamel on the bonded surface. This is consistent with
the rigidity of ceramic brackets that allows the transmis-
sion of force through to the bonding material and the
enamel. Photoelastic stress analysis has shown that
any technique that loads the enamel-adhesive interface
directly has the side effect of concentrating stress in the
underlying enamel.17 Therefore, the delaminating tech-
nique used in this study where sharp debonding pliers
were used to apply a slow squeezing force directly be-
tween the bracket and enamel to cause bond failure
may have concentrated higher stresses in the enamel
and resulted in higher levels of iatrogenic damage. The
tensile strength of enamel parallel (24.7 6 9.6 to
42.2 6 12.0 MPa)18,19 or perpendicular to the prisms
(11.4 6 6.3 and 11.5 6 4.7 MPa)18,19 is much lower
than its compressive strength (372 MPa)20; therefore
passing tensile stress onto the enamel should be avoided.
Failure at the enamel-adhesive14 and bracket-
adhesive interfaces21 have both been suggested to be
favorable. Given the high incidence of enamel damage
noted in this study, failure at the bracket-adhesive inter-
face seems preferable to avoid passing tensile stress onto
the enamel. The disadvantage of this mode of failure is
that more adhesive remains on the tooth surface. These
remnants require removal that can cause damage and
increase the time required for cleanup. If the adhesive
removal technique applies predominantly compressive
forces to the enamel, then it can better withstand the
trauma compared with tensile forces that can generate
cracks and tearouts. This study confirmed that as more
bonding material was found on the bracket (eg, failure
at the enamel- adhesive interface), there was more
enamel on the bonding material (Table II). This corrob-
orates the findings of Pont et al,4 who only examined
metal brackets. Therefore, failure at the bracket-
adhesive interface, despite taking longer to clean up,
would seem preferable to avoiding the creation of cracks
and tearouts in the enamel. The long-term conse-
quences of these cracks and tearouts have not been
well studied.
Another logical approach to reduce force transmis-
sion through to enamel, and thereby reduce enamel
damage, is to use a bonding material that is weaker
cohesively or has reduced bond strength to enamel.13,22
The ceramic brackets bonded with RMGIC did exhibit
less enamel damage than the other 2 ceramic bracket
September 2017  Vol 152  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Cochrane et al
groups (P 5 0.047). In addition, the maximum
amount of enamel tearout (represented as percentage
of bracket base covered by enamel) was also
substantially lower in the CGIC group compared with
the other ceramic groups (CGIC, 5.4%; CEC, 31.3%;
CSEP, 46.1%). Since the clinical failure rates of RMGIC
compare favorably with composite resin, the reduced
incidence of iatrogenic damage shown in this study
would favor its use over composite resin.23 An additional
benefit is that the remnant RMGIC has also been re-
ported to be easier to remove than composite resin.24
The range of enamel damage expressed as percentage
of the bracket covered with enamel was broad (about 0%
to 46.1%), but only a few patients had a high percentage
of enamel coverage. These results suggest that the resul-
tant damage may not only be due to the bracket type,
bonding material type, removal technique, and operator
variation, but also to the quality of the enamel surface
to which the bracket has been bonded. Defects that could
reduce the cohesive strength of enamel would include
noncavitated carious lesions and developmental hypo-
mineralized lesions.25 The finding of greater damage to
lateral incisors has also been found by other authors.13
It is speculated that this may be due demineralization
on these teeth since anecdotally these teeth are often dis-
placed palatally and may be difficult to clean. Demineral-
ized or developmentally hypomineralized enamel may be
more susceptible to damage at bracket removal. This may
be an indication for avoiding resin tag formation and
instead using RMGIC to chemically bond to the enamel
and reduce the risk of enamel tear outs.
This study showed that enamel damage due to the
debonding process occurs commonly (1 in 4 brackets ex-
hibiting enamel damage), although often only a small
amount of enamel was present. Enamel was more
commonly found on ceramic brackets, presumably due
to their higher bond strength and increased rigidity
and brittleness compared with metal brackets. Therefore,
to minimize iatrogenic damage at debond, our results
would indicate that the clinician can choose metal
brackets over ceramic, use RMGIC instead of composite
resin for ceramic brackets, and take extra care when de-
bonding lateral incisors, since these appear particularly
susceptible to damage. When offering the use of ceramic
brackets, the clinician should consider advising the pa-
tient as part of the informed consent process of the
increased risk of enamel damage when debonding.
There are limitations of this study. It is possible that
small amounts of adhesive may have fractured away
from the bracket base during the debonding process
and that any enamel on these fragments may not have
been accounted for. This was a retrospective study, but
a standardized debonding technique was used in each
Cochrane et al
practice, and this was accounted for in the inclusion
criteria. No volumetric measurements were done, but
even shallow enamel loss is best avoided, because the
entire bonding and debonding processes cause cumula-
tive enamel loss.
CONCLUSIONS
The following conclusions can be made from this
study:
1. Enamel damage regularly occurs during debonding
and can be quite severe, although major damage is
limited to a relatively few patients.
2. Damage occurs more frequently with removal of
ceramic brackets than with metal brackets.
3. Ceramic brackets attached with RMGIC showed less
damage (frequency and amount) than ceramic
brackets attached with composite resin.
4. Ceramic bracket fracture was greatest with 2-step
etch-and-bond with composite resin, and there
was no significant difference between the brackets
attached with RMGIC or SEP and composite resin.
5. Bonds often had a mixed mode of failure, with the
most common site being the bracket-bonding ma-
terial interface.
6. There was a relationship between the amount of
bonding material and the amount of enamel on
the bracket.
7. Maxillary lateral incisors were at greater risk of dam-
age at debond than maxillary central incisors and
canines.
ACKNOWLEDGMENT
We thank Roger Curtain at the Bio21 Institute and
Emily Szycman and David Thomas at the Melbourne
Dental School.
REFERENCES
1. Campbell PM. Enamel surfaces after orthodontic bracket debond-
ing. Angle Orthod 1995;65:103-10.
2. Gwinnett AJ, Gorelick L. Microscopic evaluation of enamel af-
ter debonding—clinical application. Am J Orthod 1977;71:
651-65.
3. 
Artun J. A post-treatment evaluation of multibonded ceramic
brackets in orthodontics. Eur J Orthod 1997;19:219-28.
4. Pont HB, Ozcan M, Bagis B, Ren Y. Loss of surface enamel after
bracket debonding: an in-vivo and ex-vivo evaluation. Am J Or-
thod Dentofacial Orthop 2010;138:387.e1-9: discussion, 87-9.
American Journal of Orthodontics and Dentofacial Orthopedics
319
5. Boyde A. Enamel loss from iatrogenic demineralization proced-
ures. In: Kawasaki K, Clement JG, editors. International tooth
enamel symposium—demineralization and remineralization. To-
kyo, Japan: Wakaba Publishing; 2008. p. 77-88.
6. Cochrane NJ, Ratneser S, Reynolds EC. Effect of different ortho-
dontic adhesive removal techniques on sound, demineralized
and remineralized enamel. Aust Dent J 2012;57:365-72.
7. Brantley WA, Eliades T. Orthodontic materials: scientific and clin-
ical aspects. Stuttgart, Germany: Georg Thieme; 2001.
8. Reynolds IR. A review of direct orthodontic bonding. Br J Orthod
1975;2:171-8.
9. Powers JM, Kim HB, Turner DS. Orthodontic adhesives and bond
strength testing. Semin Orthod 1997;3:147-56.
10. 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 2001;119:36-42.
11. Rajagopal R, Padmanabhan S, Gnanamani J. A comparison of
shear bond strength and debonding characteristics of conven-
tional, moisture-insensitive, and self-etching primers in vitro.
Angle Orthod 2004;74:264-8.
12. Joseph VP, Rossouw E. The shear bond strengths of stainless
steel and ceramic brackets used with chemically and light-
activated composite resins. Am J Orthod Dentofacial Orthop
1990;97:121-5.
13. Bishara SE, Fehr DE. Ceramic brackets: something old, something
new, a review. Semin Orthod 1997;3:178-88.
14. Toledano M, Osorio R, Osorio E, Romeo A, de la Higuera B, Garcia-
Godoy F. Bond strength of orthodontic brackets using different
light and self-curing cements. Angle Orthod 2003;73:56-63.
15. Redd TB, Shivapuja PK. Debonding ceramic brackets: effects on
enamel. J Clin Orthod 1991;25:475-81.
16. Kitahara-Ceia FM, Mucha JN, Marques dos Santos PA. Assessment
of enamel damage after removal of ceramic brackets. Am J Orthod
Dentofacial Orthop 2008;134:548-55.
17. Bennett CG, Shen C, Waldron J. The effects of debonding on the
enamel surface. J Clin Orthod 1984;18:330-4.
18. Giannini M, Soares CJ, de Carvalho RM. Ultimate tensile strength
of tooth structures. Dent Mater 2004;20:322-9.
19. Carvalho RM, Santiago SL, Suh B, Fernandes CA, Pashley DH. Ef-
fects of prism orientation on tensile strength of enamel. J Adhes
Dent 2000;2:251-7.
20. Craig RG, Peyton FA, Johnson DW. Compressive properties of
enamel, dental cements, and gold. J Dent Res 1961;40:
936-45.
21. Proffit WR, Sarver DM. Contemporary orthodontic appliances. In:
Proffit WR, Fields HW, Sarver DM, editors. Contemporary ortho-
dontics. 5th ed. St Louis: Elsevier Mosby; 2013. p. 367.
22. Pickett KL, Sadowsky PL, Jacobson A, Lacefield W. Orthodontic
in vivo bond strength: comparison with in vitro results. Angle Or-
thod 2001;71:141-8.
23. Fricker JP, Dip G. A new self-curing resin-modified glass-ionomer
cementfor the direct bonding of orthodontic brackets in vivo. Am J
Orthod Dentofacial Orthop 1998;113:384-6.
24. Øgaard B, Fjeld M. The enamel surface and bonding in orthodon-
tics. Semin Orthod 2010;16:37-48.
25. Mahoney EK, Rohanizadeh R, Ismail F, Kilpatrick N, Swain M. Me-
chanical properties and microstructure of hypomineralised enamel
of permanent teeth. Biomaterials 2004;25:5091-100.
September 2017  Vol 152  Issue 3