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222]

Original Article

An in vitro comparison of shear bond strength using

different bonding techniques in amelogenesis imperfecta
cases
ABSTRACT
Introduction: The objective of this study is to assess and compare shear bond strength (SBS) using different bonding techniques in
amelogenesis imperfecta (AI) cases.
Materials and Methods: Totally 30 extracted premolars from AI cases and 10 premolars from normal cases were obtained. The first
group of (10) normal samples was treated with 37% orthophosphoric acid (H3PO4), second group (10) of AI cases was treated with conventional
technique (37% H3PO4), third group (10) with sodium hypochlorite (5% NaOCl), and fourth group (10) with 2% sodium fluoride (2% NaF). Brackets
were bonded using Transbond XT light curing adhesive and SBS was measured using the Instron universal testing machine.
Results: Statistically highly significant difference observed between the strengths of all four groups (P < 0.01) with the mean highest for control
group followed by NaF conditioning and NaOCl conditioning and least for conventional bonding procedure in AI cases. On pairwise comparison
using Tukey’s post hoc test, statistically highly significant difference was observed between the mean SBS for control group versus Group 2,
Group 3, and Group 4, Group 2 versus Group 3, and Group 2 versus Group 4.
Conclusion: Brackets bonded by conventional technique showed lower SBS as compared to NaOCl and NaF in AI cases. The application
of 2% NaF gel for 4 min before acid etching of hypomineralized tooth surface shows significantly higher SBS as compared to conventional and
NaOCl group in AI cases.

Keywords: Amelogenesis imperfecta, shear bond strength, sodium fluoride, sodium hypochlorite

INTRODUCTION practice. Enamel is the outermost layer of the crown which

does not have the capacity to regenerate or repair. It is
The success or failure of an orthodontic treatment can be composed predominantly of inorganic structure, making up
greatly determined by the bonding of orthodontic attachments.
The principle of bonding attachments to the enamel is based Megha Shankar Chougule,
on micromechanical interlocking of the adhesive resin with Rajesh Bajranglal Kuril,
the enamel. High failure rates of resin bonding using the Jyotirmayee Batkishor Dalai1,
current conventional technique are reported in amelogenesis Sanjeet Bechanram Maurya
Departments of Orthodontics and Dentofacial Orthopedic and
imperfecta (AI) cases wherein the enamel is reduced or may
1
Paedodontics and Preventive Dentistry, YMT Dental College
even be completely absent. This study has given us an insight
and Research Institute, Mumbai, Maharashtra, India
into different bonding techniques in such cases which might
bring down the failure rates associated with bonding and thus Address for correspondence: Dr. Rajesh Bajranglal Kuril,
Department of Orthodontics and Dentofacial Orthopedic,
the cost associated with maintenance.
YMT Dental Hospital, Sector 4, Kharghar, Mumbai ‑ 410 210,
Maharashtra, India.
Bonding of orthodontic attachments using orthodontic E‑mail: rajeshlibran3@[Link]

adhesives is one of the important procedures in orthodontic

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How to cite this article: Chougule MS, Kuril RB, Dalai JB, Maurya SB.
DOI:
An in vitro comparison of shear bond strength using different bonding
10.4103/ijor.ijor_47_17 techniques in amelogenesis imperfecta cases. Int J Orthod Rehabil
2018;9:64-71.

64 © 2018 International Journal of Orthodontic Rehabilitation | Published by Wolters Kluwer ‑ Medknow

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Chougule, et al.: An in vitro comparison of shear bond strength using different bonding techniques in amelogenesis imperfecta cases

to 96% by weight and the remaining 4% by organic structure The hypocalcified type shows pigmented, softened,
and plasma.[1,2] and easily detachable enamel. Radiographically, enamel
thickness is normal, but its density is even less than that
The fundamental principle of bonding to dental hard tissues of the dentin. In the hypoplastic type, the enamel is well
is based on micromechanical interlocking of the adhesive mineralized, but its amount is reduced. Clinically, grooves
resin with the enamel and dentin.[3] and pits will be realized on the surface of the fine enamel.
The rough pattern of hypoplastic type exhibits thin‑, hard‑,
While bonding to enamel depends on the micromechanical and rough‑surfaced enamel. The tooth is tapered toward
retention to the etched substrate,[4] bonding to dentin relies the incisal/occlusal face and has open contact points.
on hybridization with the exposed collagen mesh.[5] Radiographs exhibit a thin peripheral outline of radiodense
enamel and low or absent cusps.[7,11] Clinical and radiographic
A significant number of patients seeking orthodontic appearances of the teeth of our cases were harmonious with
treatment have local or generalized hypomineralized areas in hypomaturation‑type AI.
one or more teeth due to hereditary or environmental factors.
Enamel hypomineralization may be a result of incipient caries In this study, diagnosis of hypomaturation‑type AI is based
or may be due to a systemic condition known as molar incisor on the family history, clinical observation, and meticulous
hypomineralization.[6] recording which form the backbone of diagnosis.

AI is a heterogeneous group of hereditary disorders that may I n t h i s s t u d y, t w o c h e m i c a l s o l u t i o n s ( s o d i u m

affect the enamel of some or all teeth in the primary and/or hypochlorite [NaOCl] and sodium fluoride [NaF]) were used
permanent dentition. to improve bond strength in AI cases.

AI has been reported as an isolated finding with an autosomal Mechanism of action of sodium hypochlo rite
dominant, autosomal recessive, or X‑linked mode of • According to De‑Deus et al., NaOCl eliminates the organic
inheritance.[7,8] matter present on the enamel surface by dissolving it.
• When enamel is deproteinized with NaOCl, more Types 1
Incidence and 2 patterns of conditioning were found, while without
The estimated frequency of AI in the population varies NaOCl, more Type 3 patterns were found. According
between 1:718 and 1:14.000 in the western population. AI to Silverstone et al. (1975), the more retentive etching
affects 1 of 14,000–16,000 children in the United States.[9] patterns are Types 1 and 2 because the porous surface
offers more retentive areas of greater size and depth.
Witkop (1957) classified AI based primarily on the • NaOCl as a deproteinizing agent is a possible strategy
phenotype.[9] Five types were as follows: to optimize adhesion by removing organic elements of
1. Hypoplastic the enamel structure before acid etching.
2. Hypocalcification • NaOCl has an antibacterial effect. Its mechanism of action
3. Hypomaturation has been explained by Solera and Silva‑Herzog.[12]
4. Pigmented hypomaturation • pH similar to calcium hydroxide (CaOH2)
5. Local hypoplasia. • N aOCl + HO → NaOH (sodium hydroxide) +
HClO (hypochlorous acid). NaOH acts on fatty acids
The diagnosis of AI frequently presents with sensitive and forming soap (saponification), which reduces surface
discolored teeth. Poor dental esthetics is the result of surface tension. The HClO etches and neutralizes amino
roughness, staining, and abnormal crown shapes from enamel acids
loss. Clinical management is considered to improve the poor • The chlorine ion acts on cell metabolism inhibiting
appearance and function of the affected teeth using bonded its enzymatic action
restorations.[10] • The hydroxyl ion binds to calcium ions denaturalizing
protein formation of CaOH2.
Clinical presentation of AI varies according to its type.
In the hypomaturation type, the affected teeth exhibit Mechanism of action of sodium fluoride
mottled, opaque white‑brown yellow‑discolored enamel, The mechanism of action of fluoride gel is considered to
which is softer than normal. In radiographs, the thickness result from its local action on the tooth plaque interface
of enamel is normal, but its density is the same as that of through promoting remineralization and by reducing tooth
the dentin. enamel solubility.[13]
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Chougule, et al.: An in vitro comparison of shear bond strength using different bonding techniques in amelogenesis imperfecta cases

Enamel demineralization is markedly inhibited if fluoride Frequent bracket debonding in AI or hypomineralized

is present at the time of acid challenge because fluoride cases is a common shortcoming in clinical orthodontics
diffuses with the acid from plaque into the enamel and and might delay treatment completion and increase the
acts at the crystal surface to reduce mineral loss. When costs relative to the maintenance of fixed orthodontic
pH rises following demineralization, fluoride can combine appliances.
with dissolved calcium and phosphate ions to precipitate or
grow fluorapatite‑like crystalline material within the tooth. Hence, the purpose of this study is to assess and compare
Fluoride enhances this mineral gain and provides a material SBS using different bonding techniques in AI cases.
that is more resistant to subsequent acid attack.[14]
MATERIALS AND METHODS
Schmidlin et al. reported that fluoride‑treated, acid‑etched
demineralized enamel allowed good penetration of a 1. Extracted teeth: Total 40
bonding agent. The low microleakage scores observed in • 3 0 e x t r a c t e d p r e m o l a r t e e t h f r o m A I
the hypomineralized/NaF group may be related to adequate cases (hypomaturation type) and 10 extracted
resin adhesion and high bond strength. The precipitation premolar teeth from normal cases stored in distilled
of calcium fluoride (CaF2) on the surface of NaF‑treated water [Figure 1a and b].
hypomineralized enamel may have a great inhibitory effect 2. Solutions used [Figure 2]
on microleakage.[15,16] • 5% NaOCl
• 2% NaF
Hicks and Silverstone reported that fluoride treatment • Distilled water
followed by acid etching of demineralized enamel produced 3. Bonding kit – 37% phosphoric acid, Transbond XT primer,
the highest shear bond strength (SBS) in teeth with Transbond XT adhesive, applicator tip, and light‑emitting
demineralized enamel. Previous studies found that fluoride diode (LED) [Figure 3].
treatment followed by acid etching of caries‑like lesions 4. Universal testing machine (UTM) [Figure 4].
provided etching patterns that were suitable for adhesive
placement, while creating a rapid supply of fluoride for Methods
remineralization that reharden the enamel.[17] The same has Sample unit
been reported by Shahabi et al. who found that application of A sample of 30 extracted premolar teeth from
2% NaF before acid etching of demineralized enamel caused a hypomaturation‑type AI cases and 10 extracted premolar
significant increase in bond strength of orthodontic brackets. teeth from normal cases who were undergoing orthodontic
treatment.
It has also been demonstrated that fluoride treatment
followed by acid etching of hypomineralized enamel can Allocation
produce etching patterns similar to those observed in etched The groups were divided as follows: Group I (10 teeth):
sound enamel, while restoring the mineral lost during lesion Control. And 30 teeth were randomly and equally allocated
formation.[17] into the following three groups:
• Group II (10): Conventional bonding procedure
The essence of adhesion depends on achieving the best acid • Group III (10): NaOCl conditioning
etching, with a generalized retentive morphological condition • Group IV (10): NaF conditioning.
over the enamel and the dentine surface. High failure rate
of resin bonding using the current conventional technique is 37% orthophosphoric acid was applied to the tooth surface
reported in AI cases wherein the enamel is reduced resulting and left for a period of 15 s. The tooth was then washed
in hypersensitivity (Ohsawa, 1972; Van Meerbeek et al., 2001). and air‑dried until a dull frosty appearance was seen. The
procedure was done for all the test specimens to be bonded
Topical fluoride is especially important in such AI patients with three different bonding techniques to be evaluated.
because of their high risk of caries and it may also reduce
hypersensitivity to a significant extent and improve this effect Group 1 (control): Teeth surfaces were etched with a 37%
when associated with the occlusion of the dentin tubules.[18] phosphoric acid gel for 15 s. The tooth was rinsed with a
copious amount of water and dried with an oil‑free air spray.
Studies by Rada and Hasiakos, Seow, and Saroğlu et al. Then, a thin coat of Transbond XT primer (3M Unitek) was
have reported high failure rates in resin‑dentin bonding to applied on the surface and the bracket was placed in the center
AI‑affected teeth.[19‑21] of the crown with the use of Transbond XT adhesive (3MUnitek).
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Chougule, et al.: An in vitro comparison of shear bond strength using different bonding techniques in amelogenesis imperfecta cases

a b
Figure 1: (a) Extracted premolars of normal cases. (b) Extracted premolars
of amelogenesis imperfecta cases

Figure 2: Chemical solutions

Figure 3: Bonding kit

The excess composite was removed from the periphery of the

base with a dental explorer and the bracket was light cured
Figure 4: Universal testing machine (Instron)
for 40 s from occlusal, gingival, mesial, and distal directions
using Bluephase LED as shown in Figure 5.
soluble reaction products, which if not removed can interfere
with etching process affecting bond strength. Then, the teeth
Group 2 (conventional): The bonding procedure was the same
were etched with 37% phosphoric acid gel, then rinsed with
as the control group (Group 1), but brackets were bonded
water, and air‑dried. Then, a thin coat of Transbond XT primer
on hypomineralized enamel (hypomaturation AI) as shown
was applied on the surface and the bracket was placed on
in Figure 6.
center of crown with the use of Transbond XT adhesive and
then light cured with Bluephase LED as shown in Figure 8.
Group 3 (NaOCl): Teeth surfaces were etched with a 37%
orthophosphoric gel (H3PO4) for 15 s, then rinsed with
All the bonded teeth were kept in distilled water at 37°C for
copious amount of water, and dried with an oil‑free air spray. 24 h and then mounted in dental stone so that the buccal
A 5% NaOCl solution was applied on the enamel surface for surface of the tooth was parallel to the direction of the
1 min, then rinsed with water, and air‑dried. Again, teeth debonding force [Figure 9].
surfaces were etched with a 37% phosphoric acid gel for 15 s.
The tooth was rinsed with a copious amount of water and Evaluation of bond strength
dried with an oil‑free air spray. Then, a thin coat of Transbond SBS was measured using the Instron UTM. A parallel knife
XT primer was applied on the surface and the bracket was edge shearing device was aligned 0.05 mm from the bonded
placed on crown with the use of Transbond XT adhesive and interface and force was applied to cause debonding using
then light cured with Bluephase LED as shown in Figure 7. a crosshead speed of 1 mm/min. The stress value was
recorded [Figure 10].
Group 4 (NaF): In this group, a 2% neutral NaF gel was applied
on the enamel surface for 4 min. Subsequently, the teeth RESULTS
were rinsed with water for two consecutive periods of 5 min
each after application of NaF for 4 min to remove any readily Table 1 explains the numerical values of the SBS of the ten
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Chougule, et al.: An in vitro comparison of shear bond strength using different bonding techniques in amelogenesis imperfecta cases

Figure 6: Bonding procedure by conventional technique in amelogenesis

imperfecta
Figure 5: Bonding procedure by conventional technique in normal cases

Figure 8: Bonding procedure by sodium fluoride conditioning in

amelogenesis imperfecta

Table 3 presents the results of the post hoc test wherein each
Figure 7: Bonding procedure by 5% sodium hypochlorite conditioning in
amelogenesis imperfecta group’s mean SBS has been compared with the mean of the
other three groups.
samples examined in each group. Lowest SBS was recorded in
Group 2 at 5.02 MPa and the highest in Group 1 at 13.78 MPa. There was a statistically highly significant difference between
the strengths between the following pairs
Statistical analysis • Control versus Group 2, Group 3, and Group 4
Data obtained were compiled on a MS Office Excel • Group 2 versus Group 3, Group 2 versus Group 4.
Sheet (v 2010). Data were subject to statistical analysis
using the Statistical Package for the Social Sciences (SPSS However, there was a nonsignificant difference between
Group 3 and Group 4 (P > 0.05).
v 21.0, IBM, Armonk, New York, The United States of
America).
Inference
MPa values are statistically similar/not different for Group 3
Intergroup comparison of mean SBS (between the groups)
and Group 4.
was done using one‑way ANOVA followed by pairwise
comparison using post hoc Tukey’s test. Table 4 describes the results of the one‑way ANOVA test
between the four groups and within the groups. The
For all the statistical tests, P < 0.05 was considered to be difference between the four groups was found to be
statistically significant, keeping α error at 5% and β error at statistically significant.
20%, thus giving a power to the study as 80%.
There was a statistically highly significant difference between
Table 2 describes the mean SBS of the four groups with the the strengths of all four groups (P < 0.01) with the mean
respective standard deviation. The lowest mean SBS was highest for control group followed by NaF conditioning
recorded in Group 2 at 5.48 and the highest in Group 1 at and NaOCl conditioning and least for conventional bonding
11.505 followed by Group 4 at 7.651and Group 3 at 6.659. procedure.
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Chougule, et al.: An in vitro comparison of shear bond strength using different bonding techniques in amelogenesis imperfecta cases

a b
Figure 9: (a) Bonded normal tooth mounted on dental stone. (b) Bonded Figure 10: Shear bond strength test using universal testing machine
amelogenesis imperfecta tooth mounted on dental stone
extent of hypomineralization, which influences the bonding
Table 1: Shear bond strength values performances.[22]
Number of Shear bond strength (MPa)
samples Group 1 Group 2 Group 3 Group 4 Hiraishi et al. in their study showed that bonding could not
(control) (conventional) (NaOCl) (NaF)
be improved by increasing etching time in AI cases. Keeping
1 10.21 5.24 6.28 8.89
this finding in mind, the etching time was kept similar in all
2 12.00 6.00 7.12 6.20
3 10.09 5.02 7.24 7.29 three groups.[10]
4 10.44 5.19 7.14 7.68
5 13.34 5.81 6.20 8.34 A reduction in mineral content and an increase in protein
6 12.67 5.16 6.12 7.22 content pose great challenges to bonding to teeth with AI
7 10.22 5.08 7.16 7.09 using adhesive restorative materials.
8 11.87 6.03 6.22 8.24
9 10.43 5.09 7.02 7.32 The action of H3PO4 on the enamel occurs mostly on the
10 13.78 6.18 6.09 8.24
mineralized tissue (inorganic matter). Moreover, H3PO4 does
NaOCl: Sodium hypochlorite, NaF: Sodium fluoride
not eliminate the organic matter. In AI cases, outer organic
layer prevents the conventional 37% H3PO4 from effectively
Table 2: Overall descriptives of numerical data
etching the surface resulting in inconsistent pattern and an
Groups n Mean SD SE
unreliable enamel surface for bonding. Thus, it is necessary
Control 10 11.505 1.410 0.445
to remove the organic matter from the enamel surface to
Conventional bonding procedure 10 5.480 0.464 0.146
NaOCl conditioning 10 6.659 0.5081 0.160 enhance the quality of etching pattern, which gave rise to
NaF conditioning 10 7.651 0.785 0.248 the concept of deproteinization.
Total 40 7.823 2.439 0.385
SD: Standard deviation, SE: Standard error, NaOCl: Sodium hypochlorite, NaF: Sodium Venezie et al. reported in their study that pretreating enamel
fluoride affected by AI with NaOCl would make the enamel crystals
more accessible to the etching solution, resulting in a
Graph 1 presents graphical interpretation of mean SBS values clinically more favorable etched surface.[23]
of the four groups with the Group 1 (control group) showing
highest SBS at 11.505 followed by Group 4, Group 3, and Few studies have evaluated the adhesion of adhesive
Group 2 in decreasing order of bond strength. resin to hypomineralized enamel and suggested some
methods to improve the bonding interface. Pretreatment of
DISCUSSION hypomineralized enamel with 5% NaOCl has been recommended
to remove excess enamel proteins (deproteinization), thus
Major concern associated with AI cases is altered quality improving the bond strength.[21,23]
and quantity of enamel, which can make the attachment
and retention of fixed brace problematic. The chemical William et al. recommended initial etching of the
composition and mechanical properties also vary with the hypomineralized defect with 37% phosphoric acid, applying
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Chougule, et al.: An in vitro comparison of shear bond strength using different bonding techniques in amelogenesis imperfecta cases

Table 3: Presents the results of the post hoc test wherein each group’s mean shear bond strength has been compared with the
mean of the other three groups
(I) Groups (J) Groups Mean difference (I‑J) Std. error Sig. 95% confidence interval
Lower bound Upper bound
1 2 6.0250000 0.3923762 0.000** 4.968242 7.081758
3 4.8460000 0.3923762 0.000** 3.789242 5.902758
4 3.8540000 0.3923762 0.000** 2.797242 4.910758
2 1 ‑6.0250000 0.3923762 0.000** ‑7.081758 ‑4.968242
3 ‑1.1790000 0.3923762 0.024* ‑2.235758 ‑0.122242
4 ‑2.1710000 0.3923762 0.000** ‑3.227758 ‑1.114242
3 1 ‑4.8460000 0.3923762 0.000** ‑5.902758 ‑3.789242
2 1.1790000 0.3923762 0.024* 0.122242 2.235758
4 ‑0.9920000 0.3923762 0.072* ‑2.048758 0.064758
4 1 ‑3.8540000 0.3923762 0.000** ‑4.910758 ‑2.797242
2 2.1710000 0.3923762 0.000** 1.114242 3.227758
3 0.9920000 0.3923762 0.072* ‑0.064758 2.048758
*The mean difference is significant at the 0.05 level.

Table 4: ANOVA 12
Sum of df Mean F Significant
10
squares square
Between groups 204.313 3 68.104 88.470 0.000 8
Within groups 27.713 36 0.770
Total 232.025 39 6

4
5% NaOCl and then re‑etching the enamel surface before
2
resin placement. This technique provides better bonding and
reduces the amount of microleakage.[24] These findings are in 0
line with the results of present study, which also shows an Group 1 (control) Group 2 Group 3 (NaOCl) Group 4 (NaF)
(conventional)
increase in SBS in samples treated with NaOCl.
Graph 1: Graphical presentation of intergroup comparison

Some authors believe that self‑etching adhesives bond better

falls. Thus, gels deliver fluoride to the surface of enamel and
to hypomineralized enamel than total‑etch systems. However,
Adebayo et al. detected that the bond strength of self‑etch to the subsurface hypomineralized lesions, where it forms
adhesives was not influenced by enamel hardness.[25] deposits of CaF2 and provides a reservoir of fluoride ions,
and the amount of fluoride deposition in the subsurface
In general, there are a limited number of studies that have lesion is greater after topical applications with such
evaluated effect of fluoride treatment in AI cases. Fluoride high‑concentration fluoride applications.[27]
treatment before acid etching of enamel can restore the
mineral lost during lesion formation while providing There is no clinical equivalency on the effectiveness of 1 min
etching patterns that are suitable for composite placement. fluoride gel applications, but there are considerable data on
Schmidlin et al. reported that fluoride‑treated, acid‑etched remineralization and caries prevention for professionally
demineralized enamel allowed good penetration of bonding applied topical fluoride of 4 min.[28,29]
agent. This also can be attributed to increased SBS.[15]
A limitation of the present study was that it determined
Few more studies have also predicted that the bond strength the short‑term effects of different surface treatments in AI
of resin placed over fluoride treated caries‑like lesions would cases, while in clinical conditions, brackets are generally left
be comparable to that of the normal enamel. Although in the oral cavity for nearly 2 years or even more. Hence,
they did not measure SBS, Scanning Electron Microscope further research is required in this field to find more suitable
(SEM) revealed suitable etching patterns.[17,26] protocols to be followed while bonding brackets in AI cases.

With higher concentration topical fluoride vehicles (such as CONCLUSION

NaF gels), CaF2 is precipitated on the enamel surface. This
CaF2 acts as a fluoride reservoir that is released when pH The following conclusions were drawn from the study:
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Chougule, et al.: An in vitro comparison of shear bond strength using different bonding techniques in amelogenesis imperfecta cases

1. Brackets bonded by conventional technique showed AME 2006;6 Suppl 4:22‑9.

13. Featherstone JD, Ten Cate JM. Physicochemical aspects of fluoride‑enamel
lower SBS as compared to NaOCl and NaF in AI cases.
interactions. In: Ekstrand J, Fejerskov O, Silverstone LM, editors.
2. The application of 2% NaF gel for 4 min before acid Fluoride in Dentistry. Copenhagen: Munksgaard; 1988. p. 125‑49.
etching of hypomineralized tooth surface shows 14. Ten Cate JM. Current concepts on the theories of the mechanism of
significantly higher SBS as compared to conventional action of fluoride. Acta Odontol Scand 1999;57:325‑9.
15. Schmidlin PR, Zehnder M, Pasqualetti T, Imfeld T, Besek MJ.
and NaOCl group in AI cases.
Penetration of a bonding agent into De‑ and remineralized enamel
in vitro. J Adhes Dent 2004;6:111‑5.
Financial support and sponsorship 16. Shahabi M, Moosavi H, Gholami A, Ahrari F. In vitro effects of several
Nil. surface preparation methods on shear bond strength of orthodontic
brackets to caries‑like lesions of enamel. Eur J Paediatr Dent
2012;13:197‑202.
Conflicts of interest 17. Hicks MJ, Silverstone LM. The effect of acid‑etching on caries‑like
There are no conflicts of interest. lesions treated with stannous fluoride. J Dent Res 1983;62:783‑8.
18. Petersson LG. The role of fluoride in the preventive management
of dentin hypersensitivity and root caries. Clin Oral Investig
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