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Surface modification for bonding
between amalgam and orthodontic
brackets
Wittawat Wongsamut, Sirichom Satrawaha and Kornchanok Wayakanon1
Website:
www.jorthodsci.org
Abstract:
DOI:
10.4103/jos.JOS_25_17 OBJECTIVE: Testing of methods to enhance the shear bond strength (SBS) between orthodontic
metal brackets and amalgam by sandblasting and different primers.
MATERIALS AND METHODS: Three hundred samples of amalgam restorations (KerrAlloy®) were
prepared in self‑cured acrylic blocks, polished, and divided into two groups: nonsandblasted and
sandblasted. Each group was divided into five subgroups with different primers used in surface
treatment methods, with a control group of bonded brackets on human mandibular incisors. Following
the surface treatments, mandibular incisor brackets (Unitek®) were bonded on the amalgam with
adhesive resin  (Transbond XT®). The SBS of the samples was tested. The adhesive remnant
index (ARI) and failure modes were then determined under a stereo‑microscope. Two‑way analysis
of variance, Chi‑square, and Kruskal–Wallis tests were performed to calculate the correlations
between and among the SBS and ARI values, the failure modes, and surface roughness results.
RESULTS: There were statistically significant differences of SBS among the different adhesive
primers and sandblasting methods (P < 0.05). The sandblasted amalgam with Assure Plus® showed
the highest SBS (P < 0.001). Samples mainly showed an ARI score = 1 and mix‑mode failure. There
was a statistically significant difference of surface roughness between nonsandblasted amalgam and
sandblasted amalgam (P < 0.05), but no significant differences among priming agents (P > 0.05).
CONCLUSIONS: Using adhesive primers with sandblasting together effectively enhances the
SBS between orthodontic metal brackets and amalgam. The two primers with the ingredient
methacryloxydecyl dihydrogen phosphate (MDP) monomer, Alloy Primer® and Assure Plus®, were the
most effective. Including sandblasting in the treatment is essential to achieve the bonding strength
required.
Keywords:
Amalgam, orthodontic brackets, primers, shear bond strength, surface roughness

Introduction and complexities are commonly found

on mandibular molars, with treatments

Departments of Preventive
Dentistry and 1Restorative
O rthodontic treatment for both clinical
and cosmetic purposes has long been
a popular dental treatment for teenagers,
varying from small restorations on the
buccal pit to restorations of the entire
buccal surface of the tooth. At least one
Dentistry, Faculty of
but in recent times, middle‑aged patients amalgam restoration was found in 50–85%
Dentistry, Naresuan
University, Phitsanulok,
and seniors have also sought orthodontic of the population.[1,2] These restorations are
Thailand treatment in greater numbers than regularly in clinically acceptable condition
previously. These patients, in earlier dental and there is no necessity to replace them
Address for treatments, have commonly received when orthodontic treatments are sought.
correspondence: amalgam or metal restorations. The However, orthodontists frequently
Dr. Kornchanok
Wayakanon,
amalgam restorations of various sizes encounter bonding problems of orthodontic
Department of brackets on amalgam. Replacement of
Restorative Dentistry, This is an open access article distributed under the terms of the
Faculty of Dentistry, Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
Naresuan University, License, which allows others to remix, tweak, and build upon the
H o w t o c i t e t h i s a r t i c l e : Wo n g s a m u t W,
Phitsanulok - 65000, work non‑commercially, as long as the author is credited and the
Satrawaha S, Wayakanon K. Surface modification for
Thailand. new creations are licensed under the identical terms.
bonding between amalgam and orthodontic brackets.
E‑mail: wkornchanok@ J Orthodont Sci 2017;6:129-35.
hotmail.com For reprints contact: reprints@medknow.com

© 2017 Journal of Orthodontic Science Published by Wolters Kluwer - Medknow 129

 Wongsamut, et al.: Improved bonding of metal brackets to amalgam restorations

amalgam with resin composite is a common solution in 1  month. They must have the normal morphological
small‑sized restorations. Replacing an amalgam filling feature, no cavities, and no restorations. Calculus and
with resin composite may produce mercury vapor, which soft tissues were removed. All teeth were then submerged
is toxic, during the amalgam removal and inevitably in fresh 10% formalin solution for 2 weeks and stored in
results in greater destruction of the tooth structure.[1] 0.1% thymol solution. Thirty teeth were used as a control
group to be bonded with brackets without sandblasting or
Cementing an orthodontic band is preferred for a tooth primers. Three hundred amalgam samples (KerrAlloy®;
which has a large amalgam restoration. Traditionally, Kerr, CA, USA) were prepared in box‑like cavities of size
orthodontic bands have been used, being anchored on 6 × 7 × 2 mm3 in self‑cured acrylic blocks.[12] After the
teeth throughout the often‑lengthy treatment period. amalgams were completely set, they were polished with
The use of these devices often caused the accumulation 1200‑grit sand paper and then the amalgam samples were
of dental plaque, increasing the risk of dental caries, submerged in distilled water at 37°C for 24 h.[12]
gingivitis, and periodontal disease, and often resulted
in interdental spaces after de‑banding. More recently, The amalgam samples were divided into either a
a buccal tube, using a dental adhesive, has become nonsandblasted or a sandblasted group. The surface of
the preferred, and common, method for anchoring an the latter group was treated by sandblasting with 50 µm
orthodontic device to the teeth. aluminum oxide powder for 3 s, at a 10‑mm distance
and with 7  kg/cm 2 air pressure [12]  (Micro‑abrasive
An acid‑etching technique was introduced by sandblaster; Parkell Inc., New York, USA). Each group
Buonocore, [3] which creates micro‑porosities on was divided into five subgroups with different surface
enamel surfaces, allowing the use of resin adhesives treatment methods, as shown in Table  1. In group  1,
in multidisciplinary dentistry, including orthodontic mandibular incisor stainless steel brackets  (Unitek®;
treatment. Unfortunately, the bond strength of dental 3M Unitek, CA, USA) were bonded with Transbond
adhesives for bonding orthodontic devices to amalgam XT® primer and adhesive (Transbond XT®; 3M Unitek,
using this acid‑etching technique provides a significantly CA, USA) on the enamel surfaces of lower mandibular
lower bond strength (3.0–5.0 MPa) when compared with incisors  (control group). In groups  2–5, amalgam
bonding directly to tooth substrates  (6.0–18.0 MPa).[4] restorations were coated with different adhesive
There have been many literatures published addressing primers as shown in Table  1  [Monobond N®  (MN),
this problem.[5‑17] Adhesive systems have been developed Metal primer®  (MP), Alloy Primer®  (AP), and Assure
which use chemical primers to prepare the substrate Plus® (As)] according to manufacturer’s instructions.
surface to improve the bonding strength of resin‑based
materials between amalgam and buccal tubes. However, The brackets were bonded immediately with Transbond
these have not been shown to be completely effective. XT® primer and adhesive on each group, except the
As group where the brackets were bonded without
The purpose of our study was to develop a new method Transbond XT® primer.
to increase the bond strength between orthodontic
brackets and amalgam restorations reducing the risk of The light curing machine  (Mini L.E.D. wavelength
bond failure. 420–480 nm; Acteon, Merignac, France) was held 3‑mm
from the bracket for 20 s on each interproximal side to
Materials and Methods cure the adhesive.

The study was approved by Naresuan University All bonded bracket samples were stored in distilled
Institution Review Board: IRB No. 320/58. water at 37°C for 24  h followed by thermocycling at
5–50°C for 15 s in each bath and 10 s for traveling between
Sample preparation two baths at room temperature[12] for 2000 cycles.
The extracted human mandibular incisors of above
20  years old patients for periodontal treatment were After being thermocycled, each bracket was outlined
collected in 10% formaldehyde solution, no longer than on a sample tooth with a permanent marker. When

Table 1: Priming products used

Product name Monomer Manufacturer
Monobond N® (MN) Silane methacrylate, phosphoric methacrylate, and sulfide methacrylate Ivoclar Vivadent AG (Schaan, Liechtenstein)
Metal primer® (MP) MMA, 4‑META Reliance orthodontic products (IL, USA)
Alloy Primer® (AP) 10‑MDP, VBATDT Kuraray Medical (Tokyo, Japan)
Assure Plus® (As) HEMA, MDP, TEGDMA, Bis‑GMA Reliance orthodontic products (IL, USA)
Transbond XT primer® TEGDMA, Bis‑GMA 3M Unitek (CA, USA)

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 Wongsamut, et al.: Improved bonding of metal brackets to amalgam restorations

mounting brackets onto the tooth, the base of the bracket As illustrated in Table 3, the groups where the brackets
was set parallel to the direction of force to be applied were bonded to teeth  (24.59 MPa) had significantly
in the bond shear tests. Using a Universal Testing higher SBS than all groups in which the brackets were
Machine  (Instron 8872; Instron Corp, Bucks, UK), bonded to amalgam (P < 0.0001). Bonding to a tooth is
50‑kg load force was applied at a crosshead speed of obviously preferable to bonding to amalgam.
1 mm/minute.
Preparing the surface of the amalgam samples by
After debonding, the tooth surface, amalgam sandblasting (4.96 MPa) provided a significantly higher
surface, and bracket base were observed under a SBS than the amalgam samples which had not been
stereomicroscope with  ×25 magnification, and the sandblasted  (3.20 MPa). Sandblasting is an effective
percentage of surface area with adhesive remnants was preparation method.
determined for each by ImageJ software (Rasband, W.S.
National Institutes of Health, Bethesda, MD, USA) In all cases sandblasting prior to bonding with a primer
and classified according to the adhesive remnant provided a stronger bond, which was significantly
index (ARI) scores: different to the primer only (P < 0.04) and sandblasted only
0 = no adhesive left on the samples (amalgam or tooth) (P < 0.0001) samples. That is, sandblasting with primer is
1 = <50% of the adhesive left on the samples better than primer or sandblasting only. The table also
2 = >50% of the adhesive left on the samples illustrates that there is a difference between the sandblasted
3 = 100% of the adhesive left on the samples. only and the AP primer group with no sandblasting, but
this was not statistically significantly different.
The debonded surfaces were also categorized into three
failure modes: cohesive failure, adhesive failure, and In the nonsandblasted group, the AP group had the
mixed‑mode failure. highest SBS  (4.59 MPa) which was not significantly
different from the MP (3.62 MPa) and the As (4.06 MPa)
Determination of surface characteristics and groups (P > 0.05). In the sandblasted primer group, the
surface roughness As group had the highest SBS (7.41 MPa), which was not
After the surface treatment, the surfaces of the samples statistically different from the AP group (6.70 MPa). The
in each group were observed under scanning electron SBS of the MP and MN groups was significantly lower
microscopy  (SEM) at 500×  and 1000×  magnification. than that of the As group. This demonstrates that specific
The surface roughness was analyzed by atomic force types of primers strengthen the SBS of metal brackets
micrographs  (AFM)  (Flex‑Axiom; Nanosurf, Liestal, bonded on sandblasted amalgam.
Switzerland). The probe  (Tab190AI‑G; Budgetsensors,
Sofia, Bulgaria) had a nominal spring constant of Adhesive remnant index scores and failure modes
48 N/m, 190 kHz resonance frequency, and 50 × 50 µm2 Both ARI scores and failure modes showed statistically
surface area. significant differences between tooth and amalgam

Statistical analysis Table 2: Analysis of variance for SBS (two‑way

Shear bond strength  (SBS) data were analyzed by ANOVA)
two‑way analysis of variance  (ANOVA) with least Degrees of Sum of Mean F Sig.
square difference post‑hoc test at P < 0.05. The ARI data freedom squares square
and failure modes were analyzed by Chi‑square test Sandblast 1 423.80 423.80 204.14 0.00*
Primer 4 111.50 27.87 13.43 0.00*
at P <  0.05. Root mean squared roughness  (Rq) was
Sandblast* primer 4 25.65 6.41 3.09 0.02*
analyzed by the Kruskal–Wallis and the Mann–Whitney
*Statistically significant difference (P<0.05)
U‑tests at P < 0.05.
Table 3: Standard descriptive statistics of SBS (MPa)
Results
No sandblast Sandblast
Tooth 24.59±3.03* ‑
Shear bond strength
Amalgam‑No primer 3.20±0.75a 4.96±0.85A,c
SBS showed statistically significant differences among all
Amalgam‑Alloy Primer (AP) 4.59±0.14b,c 6.70±1.90B,C
variables: sample types, sandblast technique, and types
Amalgam‑Metal primer (MP) 3.62±0.76a,b 6.35±1.28C,D
of primers. SBS of sandblasted groups were significantly Amalgam‑Monobond N (MN) 3.78±0.79a,d 5.72±1.44D
higher than nonsandblasted groups (P < 0.05). Types of Amalgam‑Assure Plus (As) 4.06±0.80b,d 7.41±1.60B
primers also had significant influence on SBS (P < 0.05). *Statistically significant difference (P<0.05). Superscript lower case characters
SBS had a significant effect on the interaction between (a,b,c,d) represent statistically significant differences of SBS when compared
within a nonsandblasted group. Superscript upper case characters (A,B,C,D)
the sandblast technique and the types of primers on SBS represent statistically significant differences of SBS when compared within a
on amalgam surfaces (P = 0.02) [Table 2]. sandblasted group

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 Wongsamut, et al.: Improved bonding of metal brackets to amalgam restorations

samples (P  <  0.05) and between nonsandblasted mechanical creation of surface roughness (sandblasting,
and sandblasted amalgam groups (P  <  0.05) grinding with dental burs, or using a laser) and a chemical
[Figures 1 and 2, Table 4]. surface treatment (using metal primers or intermediate
resin).[5‑17] When comparing all techniques for their
Scanning electron microscope analysis
The SEM analysis of the polished amalgam showed ability to promote surface roughness, the sandblasting
scratch lines on the amalgam surfaces. The treated and no technique has the highest potential to increase the bond
treated enamel surfaces with 37% phosphoric acid were strength.[5,10]
used as controls [Figure 3]. For the sandblasted amalgam,
the surfaces of samples were much rougher. When Table 4: Comparison between group of ARI scores
primers were applied on both the polished amalgam and failure modes (Chi‑square test)
and sandblasted amalgam, the surface appearances were Group ARI scores Failure
modes
unchanged, except for the surfaces primed with As. For
χ2 Sig. χ2 Sig.
all the samples primed with As, the surfaces looked
Tooth‑amalgam 47.79 0.00* 35.01 0.00*
smooth and seemed to have film covering the whole
Nonsandblasted‑sandblasted amalgam 38.16 0.00* 35.67 0.00*
surface [Figure 4].
Within nonsandblasted group 2.77 0.60 2.77 0.60
Within sandblasted group 4.37 0.36 3.24 0.52
Atomic force micrographs and root mean square *Statistical significance (P<0.05)
roughness
Figure 4 shows the surface characteristics of the polished Table 5: Surface roughness analysis (Mann‑Whitney
amalgam and the sandblasted amalgam, with and U‑test)
without primers, as shown in three‑dimensional  (3D) No sandblast/ Sandblast/acid
AFM. unetching etching
Tooth 83.97±20.3 427.95±63.0**
The mean average surface roughness of the amalgam Amalgam‑No primer 243.13±60.2aADF 586.57±77.1bB
and the tooth samples are shown in Table 5. Amalgam‑Alloy Primer (AP) 224.10±37.8aADF 441.79±31.0bB
Amalgam‑Metal primer (MP) 106.20±10.1aAF 441.72±99.6bBDE
The surface roughness of the amalgam showed statistically Amalgam‑Monobond N (MN) 185.72±35.0aAF 419.13±56.9bBE
significant differences between the sandblasted and Amalgam‑Assure Plus (As) 229.75±62.4aCEF 353.92±127.8bCF
nonsandblasted groups  (P  <  0.001) except after being Statistically significant difference (P<0.05). **Statistically significantly higher
than unetched enamel. Lower cases represent statistically significant
coated with Assure Plus (P = 0.117) (data not shown). differences of surface roughness within columns. Upper cases represent
However, there was no statistically significant difference statistically significant differences of surface roughness in rows

in the surface roughness within both the sandblasted and

nonsandblasted amalgam groups [Table 6]. Table 6: Surface roughness analysis (Kruskal‑Wallis
test)
Discussion Degrees of Chi‑square Sig.
freedom
Bonding orthodontic brackets on amalgam restorations Between nonsandblasted and 11 36.79 0.000*
sandblasted amalgam
is challenging for orthodontists. Additional surface
Within nonsandblasted amalgam 5 10.85 0.054
treatments have been introduced to enhance the bond
Within sandblasted amalgam 5 5.14 0.399
strength on different substrates by various mechanisms; *Statistically significant (P<0.05)

Figure 1: Frequency of ARI scores Figure 2: Frequency of failure modes

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 Wongsamut, et al.: Improved bonding of metal brackets to amalgam restorations

Figure 3: Three-dimensional AFM of human incisor. Unetched enamel (left) and etched enamel with 37% phosphoric acid (right)

Figure 4: Scanning electron micrographs (×1000 magnifications) and 3D AFM of treated amalgam surfaces. The polished amalgam surfaces followed by each type of primers
(left) and the sandblasted amalgam surfaces followed by different types of primers (right)

In 2015, the International Standards Organization (ISO)[18] thermocycling of 2000  cycles, 5–50°C, 15 s immersion
recommended the protocol for thermocycling: 500 cycles, time, and 10 s traveling time. The figure of 2000 cycles is
5–50°C, 20 s immersion time, 5–10 s traveling time at room closer to intraoral situations in real life.[18] Furthermore,
temperature.[12,14] However, in our study, we performed the 500  cycles recommended in the ISO standard
Journal of Orthodontic Science - Volume 6, Issue 4, October-December 2017 133
 Wongsamut, et al.: Improved bonding of metal brackets to amalgam restorations

correspond to intraoral temperature variations over a bond provided from 4‑META was less thanfrom10‑MDP
period of <2 months,[19] which is a too short time period when exposed to fluid over a period of time.[28] This might
for our testing. Perhaps because of the large number of explain the higher SBS from Alloy Primer® compared with
thermocycles in our study, the SBS results which were that from Metal primer® and Monobond N®.
achieved were lower than that in previous studies.[5‑17]
Furthermore, the present study also showed no statistical
We selected Transbond XT® as it is commonly used in difference in the SBS between the Assure Plus® and the other
SBS evaluation in orthodontics due to its high SBS.[8,20‑24] primers in the non‑sandblasted groups. The composition
Furthermore, it has the benefit of rapid polymerization of Assure Plus® is different from other primers. Assure
under a light‑cure system, which allows a more accurate Plus® comprises HEMA, MDP and Bis‑GMA, which is a
bracket position.[25] large polymer with molecular weight of 512 g/mol. Other
primers in this study contain methylmethacrylate which
The amalgams coated with primers had lower surface has a molecular weight of 100 g/mol. This might create
roughness, but they showed higher SBS than that of the the Assure Plus® viscosity which resulted in the film‑like
nonprimer‑coated groups, both nonsandblasted and characteristic covering of the amalgam surfaces. HEMA
sandblasted. This implies that the primers are effective is an hydrophilic material, and it is able to decrease the
in promoting chemical bonds between the amalgam and surface tension of materials.[29] In 2009, the effectiveness of
the adhesive resin. a suitable amount of HEMA in glass ionomer cement (GI)
was observed with SBS on both precious alloys and
In the sandblasted group, the rough surface of the non‑precious alloys. The SBS continuously increased with
amalgam samples  (both with and without primers the increase in the amount of HEMA. The peak of the SBS
applied) showed under SEM and AFM.[26,27] However, occurred with HEMA at 40% for non‑precious metal and
when the amalgam was coated with Assure Plus, the 30% for precious metals.[30] Our observations were that
surfaces of this group looked smoothly covered with the SBSs of the sandblasted amalgam were high with both
film in the same way as the nonsandblasted group. When Assure Plus® and Alloy Primer®, with little difference
compared with other sandblasted groups, the Assure between them. Both primers have MDP as a functional
Plus coated group had higher SBS, even though the monomer. MDP manifests chemical interaction with
surface roughness was similar. Assure Plus, therefore, hydroxyapatite and has chemical bonds with phosphate
seems to provide better chemical bonds with amalgam groups on nonprecious metal.[31,32] Previous studies found
that do other primers. that the MDP bonds have more hydrolytic stability than
other functional monomers.[28,33] These observations might
We found that the SBS of the amalgam samples enhanced explain the high SBS in Assure Plus® and Alloy Primer®
with the primer still had a lower SBS than the tooth in the sandblasted groups.
samples of the control group. However, all the primers
enhanced the bond strength between brackets and When comparing SBS between the sandblasted and
amalgam. These findings agree with the published the nonsandblasted groups for each primer, SBS of the
research.[4,9‑12,14] sandblasted groups significantly increased in all types
of primers, clearly indicating that the sandblasting
The highest SBS of the amalgam samples without technique enhances SBS of resin on amalgam surfaces.
sandblasting was shown in the groups bonded
with Alloy Primer ® (4.59 MPa), which contains Several studies reported that bonding failure occurred
10‑methacryloyloxydecyl dihydrogen phosphate most often between the amalgam surfaces and the
(10‑MDP). This is a popular monomer used as a component adhesive when using conventional orthodontic bonding
in resin cement, including amalgam bonds for operative techniques: ARI score = 0.[8,11–14,16] In the present study,
dentistry.[17] 10‑MDP is a phosphate functional monomer adhesive failure most often occurred in mixed‑mode
which is effective in chemically bonding to non‑noble failures: ARI score  =  1. The number of samples that
metals. Apparently, amalgam is this type of metal. experienced ARI failure mode  =  0, increased in the
nonsandblasted group. This indicates that sandblasting
There was no statistically significant difference between the and adhesive primers do enhance bond strength, which is
Metal primer® and theMonobond N® (in Asia).The active supported by the ARI score = 2 in the sandblasted groups,
composition in Metal primer® is 4‑META, which provides which showed the highest SBS. This demonstrates that
chemical bonding to non‑noble metals by phosphate the ARI score is positively correlated with the SBS.
functional monomer. Monobond N® is a universal primer,
since its components are silane, phosphate functional Reynolds’s in vitro study suggested that the SBS for
monomer and sulfide functional monomer, which perform clinical success in orthodontic treatment should be
chemical bonds between resin and silica, non‑noble metals between 5.9 and 7.9 MPa.[33] The present study showed
or noble metals. However, the stability of the chemical that the highest SBS of nonsandblasted amalgam samples
134 Journal of Orthodontic Science - Volume 6, Issue 4, October-December 2017
 Wongsamut, et al.: Improved bonding of metal brackets to amalgam restorations

was the Alloy Primer® group  (4.59 MPa), which was 12. Sperber RL, Watson PA, Rossouw P, Sectakof PA. Adhesion of
lower than the orthodontic clinical acceptable value. bonded orthodontic attachments to dental amalgam: In vitro
study. Am J Orthod Dentofacial Orthop 1999;116:506‑13.
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