Haewon Lee
5th year, group 14Effect of various residual adhesive removal methods
on enamel surface after bracket debonding:
a Systematic Review
Master’s Thesis
Supervisor
PhD, Julija Urbonė
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
ODONTOLOGY FACULTY THE CLINIC OF ORTHODONTICS
Effect of various residual adhesive removal methods on enamel surface after bracket debonding:
a Systematic Review
Master’s Thesis
The thesis was done
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EVALUATION TABLE OF THE MASTER’S THESIS
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No. MT parts MT evaluation aspects
Compliance with MT requirements and evaluation Yes Partially No 1 Summary (0.5 point)
Is summary informative and in compliance with the
thesis content and requirements?
0.3 0.1 0
2 Are keywords in compliance with the thesis
essence? 0.2 0.1 0
3 Introduc- tion, aim and tasks (1 point)
Are the novelty, relevance and significance of the
work justified in the introduction of the thesis? 0.4 0.2 0
4 Are the problem, hypothesis, aim and tasks
formed
clearly and properly?
0.4 0.2 0
5 Are the aim and tasks interrelated? 0.2 0.1 0
6 Selection criteria of the studies, search methods and strategy (3.4 points)
Is the protocol of systemic review present? 0.6 0.3 0
7
Were the eligibility criteria of articles for the selected protocol determined (e.g., year, language,
publication condition, etc.)
0.4 0.2 0
8
Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) described and is the last
search day indicated?
0.2 0.1 0
9
Is the electronic search strategy described in such a way that it could be repeated (year of search, the last search day; keywords and their combinations; number of found and selected articles according to
the combinations of keywords)?
0.4 0.1 0
10
Is the selection process of studies (screening, eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?
0.4 0.2 0
11
Is the data extraction method from the articles (types of investigations, participants,
interventions, analysed factors, indexes) described?
12
Are all the variables (for which data were sought and any assumptions and simplifications made) listed and defined?
0.4 0.2 0
13
Are the methods, which were used to evaluate the risk of bias of individual studies and how this information is to be used in data synthesis, described?
0.2 0.1 0
14 Were the principal summary measures (risk ratio,
difference in means) stated? 0.4 0.2 0
15 Systemiza - tion and analysis of data (2.2 points)
Is the number of studies screened: included upon assessment for eligibility and excluded upon giving the reasons in each stage of exclusion presented?
0.6 0.3 0
16
Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents) presented?
0.6 0.3 0
17
Are the evaluations of beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)
0.4 0.2 0
18
Are the extracted and systemized data from studies presented in the tables according to individual tasks? 0.6 0.3 0 19 Discussio n (1.4 points)
Are the main findings summarized and is their
relevance indicated? 0.4 0.2 0
20 Are the limitations of the performed systemic
review discussed? 0.4 0.2 0
21 Does author present the interpretation of the
results? 0.4 0.2 0
22
Conclusion s (0.5 points)
Do the conclusions reflect the topic, aim and tasks
of the Master’s thesis? 0.2 0.1 0
23 Are the conclusions based on the analysed
material?
0.2 0.1 0
24 Are the conclusions clear and laconic? 0.1 0.1 0
25
Reference s (1 point)
Is the references list formed according to the
requirements? 0.4 0.2 0
26
Are the links of the references to the text correct? Are the literature sources cited correctly and precisely?
0.2 0.1 0
27 Is the scientific level of references suitable for Master’s thesis? 0.2 0.1 0
28
Do the cited sources not older than 10 years old form at least 70% of sources, and the not older than
5 years – at least 40%?
0.2 0.1 0
Additional sections, which may increase the collected number of points 29 Annexes Do the presented annexes help to understand the
*Remark: the amount of collected points may exceed 10 points.
30
Practical recomme ndations
Are the practical recommendations suggested
and are they related to the received results? +0.4 +0.2 0
31
Were additional methods of data analysis and their results used and described (sensitivity analyses, meta-regression)?
+1 +0.5 0
32
Was meta-analysis applied? Are the
selected statistical methods indicated? Are the results of
each meta-analysis presented?
+2 +1 0
General requirements, non-compliance with which reduce the number of points 33
Gener al requir ements
Is the thesis volume sufficient (excluding annexes)? 15-20 pages (-2 points) <15 pages (-5 points)
34 Is the thesis volume increased
artificially? -2 points -1 point
35 Does the thesis structure satisfy the requirements of Master’s thesis? -1 point -2 points
36 Is the thesis written in correct language,
scientifically, logically and laconically? -0.5 point -1 points
37 Are there any grammatical, style or
computer literacy-related mistakes? -2 points -1 points
38 Is text consistent, integral, and are the
volumes of its structural parts balanced? -0.2 point -0.5 points
39 Amount of plagiarism in the thesis. >20%
(not evaluated) 40
Is the content (names of sections and sub- sections and enumeration of pages) in compliance with the thesis structure and
aims?
-0.2 point -0.5 points
41
Are the names of the thesis parts in compliance with the text? Are the titles of sections and sub-sections
distinguished
logically and correctly?
-0.2 point -0.5 points
42 Are there explanations of the key terms
and abbreviations (if needed)? -0.2 point -0.5 points
43
Is the quality of the thesis typography (quality of printing, visual aids, binding) good?
-0.2 point -0.5 points
Reviewer’s comments: _____________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
０
TABLE OF CONTENTS
SUMMARY... 1
INTRODUCTION... 2
SELECTION CRITERIA OF THE STUDIES. SEARCH METHODS AND STRATEGY... 4
1 SYSTEMATIZATION AND ANALYSIS OF DATA... 8
1.1 Study characteristics... 11
DISCUSSION... 18
CONCLUSIONS... 20
１
SUMMARY
Objectives: The purpose of the present study is (1) to assess the effect of adhesive removal method
on enamel surface and (2) recommend the best method for adhesive remnant clean up.
Material and Methods: In this systematic review, identification of relevant literature has been
proceeded by PubMed and ScienceDirect electronic databases which searched the data published from 1st of February 2008 up to 28th of February 2018 with these searching keywords: Orthodontic brackets, debonding, adhesive removal, enamel surface, enamel damage.
Results: A total 193 scientific articles were identified which were related to keywords. Finally, 10
articles were selected. The present data included 454 extracted teeth that majority of them are premolars. No meta-analysis could be performed due to the heterogeneity of quantitative result which caused by different enamel surface assessment instruments Our tasks are to review and to analyze efficiency of available adhesive removal methods on extracted human teeth to minimize enamel damage after debonding fixed appliance. The result in the present systematic review shows that the most destructive tools are diamond bur, ultrasonic scaler, adhesive removing plier, and laser which cause irreversible iatrogenic damage on enamel. In all studies showed that tungsten carbide burs are faster but produced rougher enamel surface especially at high speed than the other methods mentioned in this study.
Conclusions: Sof-Lex disk, composite bur, fiberglass bur, glass air-abrasion, adhesive residue
remover and one step finisher and polisher shown remarkable less enamel surface roughness than tungsten carbide bur but taken longer time for adhesive remnant removal. So that, considered in the aspects of enamel damage, required time for adhesive removal and cost, a combination of methods could be recommended. Further studies should be performed to find out adhesive removal method for perfect adhesive clean up and combination among them which can minimize enamel loss and gain a smooth surface.
２
INTRODUCTION
At the end of the orthodontic treatment with a fixed appliance, the last important task is to turn the enamel surface back to its original condition with minimal enamel loss and to return its original roughness by removing the bonded brackets and residual adhesive [1,2].
Enamel loss has been investigated using methods which can be classified as qualitative, semi-quantitative or semi-quantitative. Qualitative methods such as scanning electron microscopy consist of subjective observations of surfaces following debonding. Semi-quantitative methods are similar but make use of an index for measurement. Quantitative methods can measure the actual depth of removed enamel surface, spot, line, the surface rugosity or the mean depth of enamel loss by analysis of a three dimensional (3D) scan of the resultant surface. Quantitative methods can be surface roughness tester, profilometry, laser scanning devices, atomic force microscope and optical coherence tomography. Scanning electron microscopy requires subjective inspection, and cannot be used for comparative assessments alone. Alternatively, quantitative techniques can provide more reliable comparisons of different cleanup processes [1,3-5].
To restore enamel surface after orthodontic treatment requires two main steps, bracket debonding and clearing the residual adhesive from the tooth surface. The first step is brackets removing, various methods are using such as mechanical methods, chemical solvents, ultrasonic scalers and, lasers. The mechanical removal method is universally used in clinical practice among those methods and different bracket debonding forces are used in combination with mechanical removal methods. Following procedure is removing adhesive resin, many researchers have introduced different techniques for resin removal and subsequent enamel polishing without causing iatrogenic damage [1,6]. So far, to obtain clear enamel appearance after debracketing, diverse tools have been proposed to remove adhesive remnants such as various burs, Sof-Lex discs, ultrasonic devices and air abrasion units. Although there are different opinions in the literature regarding this matter,tungsten carbide bur at low speed is one of the most common and conventional methods of removing residual adhesive from the enamel surface. Nowadays various new and more conservative multiple and one-step systems for cleaning enamel surface have been developed and gained popularity among orthodontists [6,7].
３ Apparently, the effect of the mechanical removal of remaining adhesives after bracket debonding seemed destructive to enamel surface, causing a significant amount of enamel loss and irreversible enamel damage. Although scarring on the enamel surface during adhesive removal can’t be avoided, the damage can be significantly reduced if selecting a proper technique. Therefore, there is a great need for choosing effective removal techniques to cause the least damages to the patient at the end of treatment and, whenever possible, preserve the original tooth condition [6,7].
This study aimed to determine the most efficient method for removing adhesive remnant on enamel surface after bracket debonding which causes the least damage to enamel and to suggest a proper method.
Our tasks are to review and to analyze efficiency of available adhesive removal methods on extracted human teeth to minimize enamel damage after debonding fixed appliance.
4
SELECTION CRITERIA OF THE STUDIES.
SEARCH METHODS AND STRATEGY
This systematic review was organized according to the protocol of the following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines [8].
The search for relevant articles was conducted by PubMed/MEDLINE and ScienceDirect electronic databases. The Key terms that were used in the search are: “orthodontic brackets,” “debonding,” “adhesive removal,” “enamel surface” and “enamel damage.”
The Studies included evaluation of articles from dental journals which published between 1st of February 2008 and 28th of February 2018 in English language, able to read in full version and studies were specified into performed only on human category with the keywords that were selected.
Total 193 publications were identified, titles and abstracts of all the studies were screened impartially without bias about the names of the authors or the publication dates and finally, full reports were obtained for all the studies that were deemed eligible for inclusion in this paper (Figure 1).
Data was collected independently extracted from reports in the form of variables according to the aim and themes of present review as listed on words. The following data were obtained from the included articles: Author(s), year of publication, investigated extracted teeth, adhesive removal, enamel surface assessment method, quantitative analysis, qualitative analysis.
In this systematic review, the focus question was advanced according to population, intervention, comparison, and outcome(PICO) (Table 1).
Table 1. PICO question table
Population (P) Extracted teeth which underwent bracket attachment with adhesive materials and then debonding process.
Intervention (I) Various adhesive removal methods.
5 Outcome (O) Comparing the difference in enamel roughness or enamel loss depends on
adhesive removal method by quantitative and qualitative analysis.
Focus question What kind of method is the most efficient to remove adhesive remnant on enamel surface with leading the least damage to enamel and can be suggested?
The resulting articles were independently subjected to clarify inclusion and exclusion criteria.
Inclusion and exclusion criteria
Inclusion criteria for the selection were;
• Comparison between at least 2 of adhesive removal or polishing methods. • In vitro studies in measuring enamel damage.
• Studies with metal brackets or buccal metal tubes.
• Studies about remineralized, demineralized enamel were included only if experiments on
sound enamel were carried out under same intervention. • Studies include tungsten carbide bur as a comparator.
Exclusion criteria for the selection were: • Non-human studies.
• Studies which is showing single case reports, literature reviews, commentaries. • Studies with ceramic brackets.
• Assessing and evaluating the enamel surface only by qualitative or semi-quantitative methods.
• Studies does not include tungsten carbide burs as a comparator.
6
Risk of bias assessment
The risk of bias was included in the extraction procedure with The Cochrane Risk of Bias Tool [9] that include six processes: Random sequence generation, allocation concealment, blinding of participant’s and personnel, blinding of outcomes assessment, incomplete outcome data selective reporting, other bias. The risk of bias that indicated within these studies is collected and organized in Table 2.
Risk of bias quality assessment within studies
The quality assessment of the selected articles showed an unknown risk of bias for all of the included articles because they were unclearly described and high risk of other bias in most of the articles because the population of studies was controlled.
Synthesis of results
Relevant data of interest on the previously stated variables (Author, year of publication, investigated extracted teeth, and adhesive removal, enamel surface assessment method, outcome) were collected and organized into a table 3 and 4.
Statistical analysis
No meta-analysis could be performed due to the heterogeneity between studies. Various assessment methods and outcome variables are made it difficult to establish a comparison between the studies. Parametric data were expressed as mean enamel loss or enamel surface roughness.
7
Table 2. Risk of bias assessment
Study Random sequence generation Allocation conceal-ment Blinding of participa nt’s and personnel Blinding of outcomes assessment Incompl ete outcome data Selective reporting Oth er bias Banerje e et al. [4] ? ? + + + + - Sigilião et al. [6] ? ? + + + + - Ahrari et al. [7] ? ? + + + + - Taha et al. [10] ? ? + + + + - Karan et al. [11] ? ? + + + + - Mohebi et al. [12] ? ? + + + + ? Özer et al. [13] ? ? + + + + - Cardos o et al. [14] ? ? + + + + - Cochra ne et al. [15] ? ? + + + + - Janisze wska-Olszow ska et al. [16] ? ? + + + + -
8
1. SYSTEMIZATION AND ANALYSIS OF DATA
Collected articles were screened according to PRISMA flowchart (Figure 1). The initial search identified a total of 193 articles and 18 articles were fully reviewed. According to the title relevance and exclusion of duplicated articles, 26 potentially relevant articles were identified. Following 8 articles were rejected due to lack of information and not relevant result. Among remaining 18 articles during eligibility stage, 8 articles were excluded. Finally, ten articles were included, in which have had evaluated a total of 454 extracted teeth. Exclusion of articles during eligibility stage are as followed: articles that included in exclusion area such as enamel surface assessed after adhesive clearance by only qualitative or semi-quantitative method [17-20], tungsten carbide bur is not included as a comparator [1,3] and study comparing polishing methods under using only one adhesive removal tool [21,22].
9
10
11
1.1 STUDY CHARACTERISTICS
Total 10 studies finally selected in this systematic review were in vitro studies. Table 4 indicates regarding quantitative analysis based on an instrumental evaluation of enamel surface roughness or volumetric enamel loss after adhesive removal and qualitative analysis based on visual inspection.
It can be seen in table 3 that various tools were used for adhesive removal, among those adhesive removal methods tungsten carbide burs were described in all studies. So articles included in this systematic review have tungsten carbide bur as a comparator.
Özer et al. [13] reported that low-speed Sof-Lex disks restored the enamel most successful that Sof-Lex disks and intact enamel surface have no statistically significant difference at 0.05 significance level. Disks combined with high-speed tungsten carbide bur, fiberglass burs and fiberglass burs combined with low and high-speed tungsten carbide bur are as followed and their enamel roughness had not statistically significant difference. The author suggests using fiberglass burs combined with low and high-speed tungsten carbide burs instead of Sof-lex disks due to its uncomfortable working area visibility.
Adhesive remnant removed faster with high-speed tungsten carbide bur than the other methods, but visual inspection and volumetric enamel roughness parameter demonstrated that it is more destructive to enamel surface compared with other methods combinations. Also, study concludes that low-speed tungsten carbide bur proved to be unsuitable for adhesive removal. Therefore, high and low-speed tungsten carbide bur cannot be used alone and polishing must be followed. Low-speed tungsten carbide bur produced higher surface roughness than with high-speed tungsten carbide bur and author described that this outcome might be related to the pressure applied when adhesive removal with low-speed tungsten carbide bur. The author recommended using Sof-Lex disk and fiberglass burs due to their efficiency even though they took longer time than high and low-speed tungsten carbide bur [13].
A similar study was done by Cardoso et al. [14], they also concluded Sof-Lex disks produced the least enamel roughness followed by fiberglass burs and high-speed tungsten carbide burs. However, the study found that ultrasonic scaler and adhesive removing pliers shown significantly increased enamel roughness that even ultrasonic scaler cause unacceptable surfaces with large and deep scratches.
12 In the study of Cochrane et al. [15], low-speed aluminum oxide polishing disc and low-speed tungsten carbide bur produced significantly less enamel damaging depth than high-speed tungsten carbide bur that the results are contrasted to Özer et al. [13] due to the operator's different pressure applying for adhesive removal. In this study, authors stated that this is because high-speed tungsten carbide bur produce high blade torque with less operator handpiece pressure and this makes burs are less sensitive to density difference in enamel.
On the contrary, with low-speed tungsten carbide bur removal has low torque with higher operator handpiece pressure resulting in minimal damage to enamel because of increased hardness of burs and high modulus of elasticity. The greatest mean depth of damage was obtained by high-speed bur and ultrasonic scaler and they showed similar enamel lesion depth [15].
Banerjee et al. [4] in their study concluded that 45S5 bioactive-glass air-abrasion produced less mechanical damage to enamel surface than low-speed tungsten carbide bur and Alumina air abrasion caused more enamel loss than the tungsten carbide bur. Taha et al. [10] reinforced this result which published more recently and reported both glass air-abrasion method(45S5 and QMAT3) showed less damage than tungsten carbide bur on enamel surface and QMAT3 produced the lowest enamel roughness among them regardless of the adhesive material used. They described this new experimental fluoride-containing bioactive glass powder (QMAT3) makes it possible to clean up the residual adhesive selectively without inducing damage on enamel surface due to the characteristic that it has lower hardness value than enamel surface. However, glass air-abrasion took about twice longer time than tungsten carbide bur.
In Mohebi et al. [12], in their atomic force microscopy studies, reported that white stone burs produced a smoother surface than tungsten carbide bur under loupe magnification while tungsten carbide bur showed the roughest surface but there is no statistically significant difference. Duration of adhesive removal with white stone bur took more prolonged time(56.6s) than tungsten carbide bur(34,2s) and tungsten carbide bur under loupe magnification(33.6s). The mean time difference between the tungsten carbide bur and tungsten carbide bur under loupe magnification was not statistically significant(P>0.05).
The author mentioned that despite the white stone bur and tungsten carbide bur showed similar enamel surface roughness after resin removal, the time required for adhesive removal showed significant differences among the methods mainly due to differences in the cutting efficiency of the instruments which determined by the speed of rotation, bur type, and a number of blades
13 [12]. Karan et al. [11] obtained a similar conclusion about the relationship between
time-consuming for adhesive removal and characteristic of bur. Result showed statistically significantly difference between tungsten carbide bur and composite bur, with the tungsten carbide bur produced higher average maximum roughness depth (P<0.001). But tungsten carbide bur required shorter time(40s) than composite bur(84.2S) for adhesive removal and the reason for this is due to cutting efficiency of instruments that carbide burs have an aggressive cutting with the sharp blades and composite burs have no blade. Composite burs peeled off by dividing of fibers into fragments during abrasion and a new part of glass fiber was revealed. The study considered that time-consuming method could not be preferred despite better efficiency to the clinician so that tungsten carbide bur used first to remove heavy residual remnant and composite bur can be used for the last removal of the last adhesive layer close to the enamel.
Ahrari et al. [7] found that cleaning adhesive remnant with low-speed tungsten carbide bur showed the least surface roughness values and also surface irregularity was not significantly different between adhesive removal and finishing stage. High-speed tungsten carbide bur showed a minimal degree of irreversible enamel damage compare to ultrafine diamond bur and Er: YAG laser which causes a significant and irreversible increase in the enamel surface irregularity while ultrafine diamond bur showed a much less roughened surface than the Er: YAG laser.
In the study of Sigilião et al. [6] reported that the smooth surface was obtained by 30-blade tungsten carbide bur in low speed, DU10CA ORTHO polisher, Renew finishing system and Diagloss polisher. 12-blade tungsten carbide bur in low and high-speed handpieces showed no significant differences in mean enamel surface roughness before bonding and after debonding. However, in the evaluation of the average maximum peak to valley height, high speed 12-blade tungsten carbide bur only shown increased enamel roughness among adhesive removal methods. Low speed 30-blade tungsten carbide bur and Diagloss polisher required a longer time than other methods.
Janiszewska-Olszowska et al. [16], in their 3D laser microscope studies, the result of enamel roughness parameter showed Adhesive Residue Remover as the smoothest and most repeatable enamel surface(lowest variance) and followed by one step polisher and finisher. Tungsten carbide bur showed the roughest surfaces and the highest amount of enamel removing.
14
Table 4. Evidence table arranged enamel damage by assessment methods Authors
and Year
Qualitative or
Semi quantitative assessment
Quantifiable assessment (Mean (± SD))
Mean time(±SD) in seconds for adhesive
resin removal
Banerjee et al. [4]
2008
Enamel surface under 250xSEM magnification Group 1(8-bladed tungsten carbide bur at low speed): lined up with the long axis of the bur. Seen most severely damaged surface Group 2(Alumina air-abrasion): the rough enamel surface has sharp peaks that were closely placed
Group 3 (Bioactive glass air-abrasion): the rough enamel surface had peaks that were placed further apart and were more rounded than those created by the alumina air-abrasion,resulting in a less rough appearance Enamel loss (mm3) Group 1: 0.285(±0.075) Group 2: 0.386(±0.254) Group 3: 0.135(±0.033) - Sigilião et
al. [6] 2015 Enamel surface under 500xSEM magnification
Group 1 (12-blade tungsten carbide bur at low speed): scratches Group 2 (12-blade tungsten carbide bur at high speed): deeper scratches than group 1
Group 3 (30-blade tungsten carbide bur at low speed): surface more similar to the original tooth
Group 4 (DU10CA ORTHO polisher) & Group 5 (Renew Finishing System): loss of perikymata with fine scratches Group 6 (Diagloss polisher) : well-marked and deep fine scratches caused by the diamond particles embedded in rubber
Initial and final enamel roughness(µm) Group 1: 6.03(±3.04) /5.48 (±0.59) Group 2: 8.16(±2.16) / 8.66(±1.75) Group 3: 7.90(±2.33) / 5.16(±1.77) Group 4: 6.25(±2.31) / 5.82(±1.62) Group 5: 6.04 (±1.50) /4.65(±1.00) Group 6: 8.07 (±2.47) /5.35(±1.06) Group 1: 34.0 (±5.73) Group 2: 23.5 (±5.01) Group 3: 57.5 (±19.9) Group 4: 31.8 (±4.56) Group 5: 31.9 (±5.85) Group 6: 63.5 (±13.8) Ahrari et al. [7] 2013 -
Roughness depth in the adhesive removal stage and finishing stage (µ) Low-speed tungsten carbide bur : 2.21(±0.53) / 1.64(±0.72)
High-speed tungsten carbide bur : 3.76(±1.16) / 2.98(±1.23)
Daimond bur: 5.81(±0.72) /
15 4.19(±1.10) Er:YAG laser:10.25(±3.01) /7.51(±2.15) Taha et al. [10] 2018
Enamel surface under 250xSEM magnification
Group 1 (Low speed tungsten carbide bur): roughened and pitted surface
Group 2 (45S5-air-abrasion): some area has microscopic roughness
Group 3 (QMAT3-air-abrasion): uniformly smooth surface
Enamel surface roughness(µm) Bracket bonding using
composite resin (Transbond XTTM) / Resin modified glass ionomer cement (Fuji Ortho LCTM)
Group 1: 2.93 (±0.06) / 2.57 (± 0.05) Group 2: 1.89 (±0.04) / 1.59 (± 0.02) Group 3: 0.58 (± 0.02) / 0.51 (± 0.04)
Bracket bonding using composite resin / Resin modified glass ionomer cement Group 1: 23.20(±4.99)/22.90 (±4.41) Group 2: 40.71(±2.89)/38.42(±4. 29) Group 3: 42.51(±3.51)/40.32(±3. 36) Karan et al. [11] 2010
3D views were obtained by AFM scans
Low speed 8-bladed tungsten carbide bur showed significantly rougher surfaces than low speed composite bur
Enamel surface roughness(nm) in prebond and resin removal stage Low speed tungsten carbide bur : 324.40( ±115.87) /587.37 (±143.46) Composite bur:
394.38(±149.97)/297.23(±124.72)
Tungsten carbide bur :40 (min.: 31, max.: 57) Composite bur: 84.2 (min.:61, max.:122) Mohebi et al. [12] 2017 -
Average enamel roughness(nm) Low speed 12-bladed tungsten carbide bur ≈ 550.00
White stone≈ 390.00
Low speed 12-bladed tungsten carbide bur with loupe camera ≈ 420.00
Tungsten carbide bur: 34.2 (±5.12)
White stone bur: 56.5 (±10.66)
Tungsten carbide bur under loupe
magnification: 33.6 (±7.24) Özer et al.
[13] 2008
Enamel surface under 750xSEM magnification
Group 1(High speed tungsten carbide bur): scratched surface with
Enamel surface roughness(µm) Intact enamel :2.04 (±1.16)
Group 1: 6.22(±1.08) Goup 2: 13.02(±2.96)
16 deep grooves
Group 2(Low speed tungsten carbide bur): the most worst case, punctured,scratched and scarred surface with protuberances and grooves
Group 3 (Sof-Lex disks): the most even roughened surface Group (1+3): smooth, scratched surface
Group (2+3) & group (1+4): scarred surface
Group (2+4) & group 4(Fiberglass bur) : some scarring but shallow than group 1,(2+3) and (1+4)
Group 1: 8.23 (±2.77) Goup 2: 7.54 (±3.42) Group 3: 2.42 (±1.89) Group 1+3: 4.56 (±2.13) Group 2+3: 6.93 (±3.76) Group 4: 4.67 (±1.17) Group 1+4: 5.54 (±2.41) Group 2+4: 5.34 (±3.72) Group 3: 24.63(±6.22) Group 1+3: 25.76 (±4.03) Group 2+3: 30.82(±5.68) Group 4: 23.62(±4.24) Group 1+4: 26.19 (±3.78) Group 2+4: 31.64 (±4.57) Cardoso et al. [14] 2014
Mean ESI (kruskal-wallis analysis) in adhesive removal stage and polishing stage
Group 1(High speed tungsten carbide bur): 2.3 / 2.5
Group 2(Sof-Lex discs): 1.5 / 1.3
Group 3(Adhesive removing plier): 1.6 / 1.3 Group 4(Ultrasonic scaler):3.2 / 2.8
Group 5(Fiberglass burs): 1.6 / 1
Enamel surface roughness in the adhesive removal stage and polishing
stage (µm) Group 1: 0.8291 (±0.2983) / 1.0151 (±0.3226) Group 2: 0.4701 (±0.0674) / 0.4401(±0.1977) Group 3: 1.7401 (±0.0339) / 2.0909 (±0.7268) Group 4: 2.2601 (±0.5544) / 1.9793 (±0.5369) Group 5: 0.7456 (±0.2319)/ 0.7362 (±0.1647) - Cochrane et al. [15] 2012
Enamel surface under 3000xSEM magnification Group 1(Low speed 16-fluted tungsten carbide bur with water coolant) & Group 2(High speed 12-fluted tungsten carbide bur with water coolant): Well demarcated horizontal scratches (scratches were more well defined in group 1)
Group 3(Low speed aluminum oxide polishing disc without coolant): smooth surface with few minor scratches
Group 4(ultrasonic scaler with coolant) : highly irregular
Enamel damage depth (µm) Group 1: 7 (±2) Group 2: 18 (±7) Group 3: 16 (±6) Group 4: 4 (±1) Group 1: 23 (±2) Group 2: 16 (±2) Group 3: 102(±22) Group 4: 16 (±1)
17 SD= standard deviation ; ESI= enamel surface index; SEM = scanning electron microscopy; AFM = atomic force microscopy
*Indices aiding visual enamel evaluation [14]: Enamel surface index(ESI) by Zachrisson and Arthun’s criteria; 0 – perfect surface with no scratches and distinct intact perikymata, 1 – satisfactory surface with fine scratches and some perikymata, 2 – acceptable surface with several marked and some deeper scratches, no perikymata, 3 – imperfect surface with several distinct deep and coarse scratches, no perikymata
damaged surface Janiszewsk a-Olszowska et al. [16] 2016 -
Height of enamel surface roughness (µm)
Intact enamel: 1,8902 (± 0.3575) Tungsten carbide bur: 1,0911 (± 0,3257)
Shofu One Gloss: 0,8601 (± 0,3397) Adhesive residue remover: 0.7521 (± 0,1744)
18
DISCUSSION
Our focused question was what kind of method is the most efficient for adhesive removal on enamel surface which causes the least damage to enamel. According to total 10 articles with 454 extracted teeth which were experimented with various interventions, each study showed consistent result based on quantitative analysis. Tungsten carbide burs were compared with other methods in all articles and each study concluded that tungsten carbide showed less time consuming on adhesive removal especially at high-speed handpiece but more destructive than other methods such as a Sof-Lex disk, composite bur, fiberglass bur, glass air-abrasion, adhesive residue remover and one step polisher and finisher. From the angle of efficiency, time requirement or cost, it is recommended to use those methods in combination. For example, high or low-speed tungsten carbide bur can be used first for the visible adhesive removal on enamel surface and then other methods mentioned above can be used as followed for removing last adhesive layer intimate to enamel. Diamond bur, ultrasonic scaler, adhesive removing pliers and laser cause significant irreversible enamel damage so that should not be used.
The studies in the present systematic review showed heterogeneity because of the high diversity of enamel surface assessment instruments. All ten studies presented results of enamel surface irregularity or enamel surface loss in different amounts (volume or surface depth) assessed with various quantitative instrumental methods. Among ten articles, four had only average roughness which indicates the arithmetic mean of all absolute distances of the surface roughness from the center line within the measuring length. Some studies assert that this parameter has limitation for surface profile registration. According to Sagiliao et al. [6], many studies use the average roughness value as the only indicator of surface smoothness. However, this universally accepted parameter has limitations when used alone because it can not discover the profile of irregularities and distinguish between scarred surface’s peaks from valleys. In case of average maximum roughness height, it enabled us to recognize vertical profile. Similarly, according to Mohebi et al. [12], to find the precise profile, to have a better view of surface irregularity, we should use not only average roughness value but also root mean square roughness and average maximum peak to valley height parameters. Different methodology results in this difference in this systematic review and this could have been avoided if more standardized methodological approaches had been adopted by the original studies.
Seven articles included in this systematic review showed also qualitative analysis add on to quantitative analysis, 6 with scanning electron microscopy and 1 with atomic forces microscopy scans, which indicate visual information of enamel surface by scanning a focused electron beam
19 over a surface to create an image. Few articles which were using scanning electron microscopy alone on evaluating enamel surface were excluded from this review during assessing eligibility stage in PRSMA flowchart [8]. It is because many studies reporting that qualitative analysis which has only subjective information can be used only as a supportive tool for quantitative evaluation methods.
Not consensus about the efficiency of polishing after adhesive removal but Janiszewska-Olszowska et al. [16] asserts that enamel roughness caused by adhesive removing tools cannot be smoothened by polishing. Similarly, Ahari et al. [7] stated that final polishing could not restore enamel roughness to its original roughness values before treatment. And Cardoso et al. [14] also reported pumice paste polishing was optional because according to quantitative results, by comparing mean enamel roughness before and after polishing, polishing does not affect significantly on mean enamel roughness and it could not restore enamel to initial state. Therefore, it should be cautiously focused to choose the adhesive removal method to minimize enamel damage.
The study of Cochrane et al. [15] assessed and compared effect of adhesive removal methods all on sound, remineralized and demineralized enamel surface. Discs showed least destructive on both demineralized and remineralized enamel. Low-speed tungsten carbide bur and ultrasonic scaler should not be used on both of them. Remineralization of enamel leads to a reduction in depth and area of lesion whether which adhesive removal method is used. This result provides evidence to support remineralization of white spot lesions before adhesive removal to prevent iatrogenic damage.
Only in vitro studies on extracted human teeth were included in this review. However, the experimental conditions such as good illumination, moisture control, and an optimal viewing angle may differ from an in vivo condition thus highlighting the necessity for future clinical trials intraorally when estimating the intervention effect.
20
CONCLUSIONS
Obviously removing adhesive remnant increased surface roughness and could not be restored in its original enamel condition. The result shown in total 10 articles, tungsten carbide bur required less time consuming for adhesive removal than other methods but showed rougher enamel surface than Sof-Lex disk, fiberglass bur, composite bur, glass air-abrasion, residual adhesive remover and one step polisher and finisher. However, in aspects of efficiency, time requirement or cost, it is recommended to use those methods in combination. Diamond bur, laser, adhesive removing plier and ultrasonic scaler can cause irreversible iatrogenic damage to enamel so that should not be used for adhesive removal. The results can be different according to different enamel surface assessment methods and clinical conditions so further researches should be performed in order to discover adhesive removal method for perfect adhesive clean up and combination among them which can minimize enamel loss and preserve the original tooth state as much as possible.
21
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