A Cross-Sectional Study of Different Orthodontic Brackets Debonding Techniques Used in the Arab Region
Citation: Alfaqeeh SA, et al. A Cross-Sectional Study of Different Orthodontic Brackets Debonding Techniques Used In the Arab Region. Ann Med Health Sci Res. 2021;11:1262-1266.
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Objective: This study aims to create statistical and analytical data describing different orthodontic brackets debonding techniques used in the Arab region, stating the most commonly used methods, instruments and the outcome of each method to provide sufficient information for future guidelines to improve its performance.
Materials and Methods: An online survey was sent to members of four orthodontic societies in the Arab region (Saudi, Jordanian, Egyptian and, Lebanese), the survey included five demographic data questions: (sex, age, nationality, years of experience and job description) and six epidemiological questions about bracket debonding techniques and instruments used.
Results: A total of 252 responses were received,39% of the participants did not report any enamel changes after the debonding procedure, while 61% found some enamel damage. The majority of bracket type used was metal (86%), and the bracket remover plier was the most commonly used plier to remove the brackets (74.6%), followed by a light wire cutter (9.5%). Rotary instruments were the method of choice for eliminating residual adhesive from enamel (90.1%); tungsten carbide burs were the most common (24.6%) specifically with low-speed hand piece (24.2%) while prophylaxis paste is the most used method for polishing. The respondents (61%) found enamel esthetic changes between treated and untreated teeth while 39% did not see any changes.
Conclusion: This study results showed the similarity between Arab orthodontists with their approach and used armamentarium of debonding and polishing. This study has also drawn a picture of the current debonding, finishing and polishing techniques used in the Arab region in comparison with the Italian study from which this study survey was adopted.
Debonding; Brackets; Orthodontics; Orthodontists; Arab; Finishing; Polishing
Orthodontics had witnessed many developments, including the application of new adhesives, new brackets materials, curing methods and more efficient primers.  Bonding of the orthodontic brackets to the tooth enamel had become an accepted clinical practice in 1970.  After that, the focus of the orthodontic research was directed towards the mechanical and physical properties of the adhesive materials including the adhesive strength and enamel surface during and after the orthodontic treatment, inaddition to evaluating the effect of variables to prevent any possible side effects in clinical situations.  The goal of the debonding procedure towards the end of fixed orthodontic treatment is to remove the brackets and the bonding material restoring the enamel to its original condition.  That is usually carried out by two steps: the first is brackets debonding, which could be done by multiple techniques including mechanical methods, chemical solvents, ultrasonic scalers and lasers. [5-7] The next step is removing the adhesive resin which could be done by various methods including hand instruments, i.e., scalers and pliers, and rotary instruments, i.e., sandpaper discs, diamond burs, stainless steel burs, rubbers, tungsten carbide burs at high and low speed, fiber-reinforced composite burs, kinetic removal of adhesive remnants by intraoral sandblasting with aluminum oxide and ultrasonic clean-up. [8,9]
During debonding, many clinicians faced difficulty distinguishing between the enamel and the residual resin due to similarities in the color especially when the tooth surface is wet, and their method of choice is mechanical devices. [10,11] The implementation of the debonding procedure should be effective and careful, as there is a high risk that enamel damage might occur if the procedure is done improbably due to the micromechanical bond between the adhesive material and the enamel. [12-14] These damages include loss of enamel structure, cracks and enamel surface damage, which can occur during brackets removal and adhesive clean up.  Similarly, the remaining adhesive material following the debonding procedure results in a rough enamel surface hence, causing plaque biofilm accumulation facilitating the development of white spot lesions and periodontal problems. [16,17]
Researchers had suggested various methods for resin adhesive material removal and enamel polishing;  emphasizing on the most crucial goal of removing the adhesive material from the tooth structure, which is to leave the enamel in its normal status.  Moreover, avoiding any iatrogenic damages as it might be troubling to the clinicians to prove the damages that happened is not a result of the orthodontic treatment.  It is noticed that most studies have mainly focused on adhesives, enamel preparation and methods of curing. On the other hand, there are not enough studies on debonding techniques. This study aims to create statistical and analytical data describing different orthodontic brackets debonding techniques used in the Arab region, stating the most commonly used methods, instruments and the outcome of each technique; to provide sufficient information for a future guideline to improve the clinical performance.
Materials and Methods
Members of the Saudi Orthodontic Society (SOS) (1954 members), the Jordanian Orthodontic Society (JOS) (174 members), the Lebanese Orthodontic Society (151 members) and the Egyptian Orthodontic Society (EOS) (424 members) were reached out by a WhatsApp message whenever a mobile phone number is available and an electronic mail (e-mail) whenever an e-mail address is available containing the aim of the study and its significance to the field and a link which redirects the participant to a web-based questionnaire prepared using the Survey Monkey software. The survey that included five demographic data questions, i.e., sex (male or female), age, nationality, professional experience (years of experience) and job description (general practitioner, post-graduate student, specialist and, consultant), and six epidemiological questions with a possibility to add personal considerations [Figure 1].  Besides, part of the participants was personally interviewed by the authors at the 13th Annual Conference of the Saudi Orthodontic Society and the 14th Arab Orthodontic Conference held in Jeddah in 2019 and other areas when applicable.
The protocol for this study was approved by the Institutional Review Board of King Saud University (E-18-3281). Data were collected to an excel sheet (Microsoft Office 2017) and analyzed using Statistical Package for the Social Sciences version 24.0 (SPSS, Chicago, IL, USA) to calculate the descriptive statistics.
A total of 252 dentists took an interest in this study of various nationalities: (65.1%) were Saudis, (15.5%) Syrians, (5.6%) Jordanians, (3.6%) Egyptians, (3.2%) Lebanese, (1.6%) Yemenis, (1.6%) Kuwaitis, (1.2%) Bahrainis and (2.8%) were non- Arabs. As for the sex of the participants: 61.5% of them were male and 38.5% were female. The age of the participants had a mean of 39 years old who were mostly specialists (42.1%) and consultants (32.9%). Post-graduate students and board residents (16.7%) were followed by general practitioners (8.3%). More than half (53.5%) of the dentists hadan experience of more than 10 years in the dental field.
Percentage of enamel damages after debonding
A total of 38.9% of dentists did not report any enamel changes after the debonding procedure, while 61.1% found enamel damage, mostly in percentages below 10% as shown in Figure 2.
Types of brackets used
The most commonly used brackets in the clinical practice were metal brackets (86%) followed by ceramic (13%), while only 1% were using polycarbonate brackets as shown in Figure 3.
Pliers used for brackets removal
The bracket removing plier was the most commonly used instrument by dentists to remove the brackets(74.6%) followed by cutter (9.5%) while 4.7% reported the use of bracket removing plier in combination with different pliers and techniques. Different pliers are shown in Table 1.
|Types of pliers||Subjects (%)|
|Bracket removal pliers||188 (74.6%)|
|Did not specify||14 (5.6%)|
Table 1. Pliers used during bracket removal in clinical practice.
Methods of adhesive removal
The majority of the dentists (90.1%) used rotary instruments to remove residual adhesives after debonding, 6.7% used ultrasound while only 3.2% used hand instruments. More specifically, tungsten carbide burs with either high or low-speed hand piece were the most commonly used instruments for the removal of remaining adhesive. Different instruments were reported and are listed in Table 2.
|Methods and instruments||Subjects (%)|
|Tungsten carbide burs||62 (24.6%)|
|Low-speed tungsten carbide burs||61 (24.2%)|
|High-speed tungsten carbide burs||18 (7.1%)|
|Polishing burs||10 (4%)|
|Refer to hygienist||10 (4%)|
|Did not specify||49 (19.5%)|
Table 2: Instruments used for removing residual adhesive from enamel after debonding.
Methods of polishing the enamel after debonding
Prophylaxis paste was the most used method by dentists to polish the enamel after.
Enamel esthetic changes
A total of 61% of the dentists found enamel esthetic changes between treated and untreated teeth, where 39% did not report any esthetic changes as shown in Figure 4.
The questionnaire used in the present study was adapted from a previous European study that aimed to conduct an epidemiological survey of the orthodontic debonding techniques in Italy and describes the most commonly used methods to remove the brackets and adhesive material from the tooth surface.  A total of 252(≈9.5%) out of 2703 members of the four different Arab Orthodontic Societies participated in the present study. A similar response rate (≈11.28%) was noted recently in Turkey when the aim to evaluate the compliance of orthodontists to infection control procedures was investigated.  Both illustrate the difficulty in obtaining a high response rate solely from orthodontic societies. However, despite the quite low response rate; the sample according to the descriptive statistics has composed mainly of specialists and consultants which overloads the gathered data.
A total of 38.9% of the dentistsdid not report any enamel damages after debonding while 61.1% found some enamel damages, among those 68.3% found significant enamel damage of more than 5% after debonding, which is way more than what Sfondrini et al.  and Campbell  found: ≈32.17% and 46.78%, respectively. Metal brackets were found to be the most commonly used brackets in clinical practice (85.7%), which is in agreement with the findings from a previous study (89.14%).  The popularity of metal brackets could be due to the many properties, most importantly its low cost, greater strength, higher modulus of elasticity, good formability and high corrosion resistance in the mouth. 
The most commonly used pliers for brackets debonding were found to be the bracket removing pliers (74.6%), followed by cutters (9.5%), as illustrated in Table 1. The opposite was found by Sfondrini et al.  cutters (37.08%) were more frequently used, and bracket removing pliers (34.83%) came after. Few variability’s have been noticed in the response as there is a lack of guidelines and many opt to use combinations of pliers as shown in Table 1. Using pliers to apply a shear or tensile force to the bracket is the most clinically convenient method of debonding.  Debonding instruments that use tensile force likeLift-Off Debonding Instrument and bracket removing pliers with shear–peel force through squeezing bracket wings can result in bond failure at the bracket-adhesive interface causing fewer enamel damages. On the other hand, ligature cutter which applies shear force at bracket base, How and Weingart pliers, by applying pressure force at the bracket base, are claimed to lead bond failure at the enamel-adhesive interface with more enamel damages such as cracks, fracture, and splits which are irreversible. 
Rotary instruments were the method of choice for removing residual adhesive from enamel, used by 90.1%, and the most used instruments, as shown in Table 2, were tungsten carbide burs (24.6%) followed by low-speed tungsten carbide burs (24.2%). This finding is consistent with the results from a previous study  as 40.77% of the respondents were reported to use tungsten carbide burs at low speed for removing adhesive residue. Boncuk et al.  said that the use of tungsten carbide burs produces minimal damage to the enamel during the removal of adhesive residue. Also, Sigiliao et al.  found that the longer time spent on removing remaining adhesive resin reduces the roughness left on the enamel surface. Zachrisson and Artun  recommended using tungsten carbide burs at low speed claiming that it produces a fine scratch pattern with less enamel damage. In contrast, most enamel damages were reported to occur after the use of high-speed tungsten carbide burs or ultrasonic scalers.  Ultra-fine diamond burs were reported to be efficient in the removal of composite remnants, yet it was also reported to produce the roughest finished enamel surface which could be the reason behind its minimal use, 3.2% in the present study. 
When it came to the methods of polishing the enamel after debonding, results shown in Table 3, prophylaxis paste (31.7%) was the most commonly used method among respondents, followed by rubber cup (25.8%). Plenty of combinations between different instruments and methods were reported, whereas few orthodontists (4%), did not perform any polishing of the enamel and believe that it is sufficient to only refer the patient to the hygienist. Scarring of the enamel surface after the debonding procedure is inevitable, but it can be minimized by choosing the right protocol. Further studies are required where finishing techniques can be evaluated in the clinical setting.  A total of 60.7%of the respondents found enamel esthetic changes between treated and untreated teeth; on the other hand, 39.3% did not see this change. During adhesive removal, two aspects of enamel damage should be put into consideration: first enamel loss from etching, grinding during finishing, and the followed polishing, second is increased enamel roughness by scratching. 
|Prophylaxis paste||80 (31.7%)|
|Rubber cup||65 (25.8%)|
|Abrasive disks||20 (7.9%)|
Table 3: The instruments used for polishing the enamel after debonding.
Direct comparison with the study from which the survey has been adapted  was made along with the results of the present study. The use of the same questionnaire adds to the validity of the questions asked. The findings of Sfondrini et al.  were as quoted “This survey showed the high variability of different methods for bracket debonding, adhesive removal and tooth polishing. The collected answers indicate that most orthodontists have developed their armamentarium of debonding and polishing, basing their method on trials and errors”. There are some questions regarding the attitude of debonding between the Italian Orthodontic Society and the Arab Orthodonticthat were answered similarly at times. The same cause was investigated in two different contents,andwearrived ata slightly different conclusion.
This study can be considered the first step in the advancement of knowledge of different orthodontic brackets debonding techniques used in the Arab region.We hope that it will help in creating the foundation for understanding the research problem and establishing clear guidelines to minimize damages to the enamel after bracket debonding.
The limitations in this investigation include the low response rate; also, most of the samples are members of the Saudi orthodontic society, but unfortunately, the other Arab societies included had a lower response. Although the response rate was lower than expected, consultants with longer experience composed most of the sample which is a point of strength. Future studies should explore additional samples to advance the present study’s findings.
This study has drawn the picture of the current debonding, finishing and polishing techniques used in the Arab region. The findings of our present study revealed that the majority of Arab orthodontists had similar approach regarding the orthodontic brackets debonding techniques with some variability, although there was a lack of clear guidelines supporting their used methods. Furthermore, this data is aiming to help in establishing a future clear protocol in respect of brackets de-bonding techniques.
The authors declare that they have no competing interests. All the listed authors contributed significantly to the conception and design of study, acquisition, analysis, and interpretation of data and drafting of the manuscript, to justify authorship.
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