ORIGINAL ARTICLE

Exposure to the oral environment

enhances the corrosion of metal
orthodontic appliances caused by
fluoride-containing products:
Cytotoxicity, metal ion release, and
surface roughness
Pintu-on Chantarawaratit and Tipanan Yanisarapan
Bangkok, Thailand

Introduction: This study aimed to evaluate the metal ion release, cytotoxicity, and surface roughness of clini-
cally used metal orthodontic appliances after immersion in different fluoride product solutions compared with
those of new appliances. Methods: Used fixed appliances were debonded from 36 patients after their treatment-
was done. New appliances were as-received. Each used and new group comprised 36sets of 20 brackets and 4
tubes that were divided into 3 groups by archwire type; stainless steel, nickel-titanium, andbeta-titanium. The
samples in each group weredivided into 3 subgroups and immersed in solutionsof fluoride toothpaste, 1.23%
acidulated phosphate fluoride,or artificial saliva without fluoride as a control group. The immersion times were
estimated from the recommended time for using each fluoride product for 3 months. The samples were then
immersed in Dulbecco’s Modified Eagle’s Medium for 7 days. The cytotoxicity test was evaluated by 3-(4,5-
dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay using primary gingival fibroblasts. Chromium,
nickel, and iron ion release were detected using inductively coupled plasma mass spectroscopy. The surface
roughness of the brackets and wires was measured by a scanning electron microscope and a noncontact
optical 3-dimensional surface characterization and roughness measuring device. The data were analyzed
using the paired t test and 2-way analysis of variance. Results: Used brackets demonstrated a significantly
higher ion release, surface roughness, and cytotoxicity than the new brackets. Acidulated phosphate fluoride
significantly increased the ion release and surface roughness; however, it significantly decreased cell viability,
especially in the titanium molybdenum subgroup. Conclusions: Used brackets were significantly prone to
further corrosion. Acidulated phosphate fluoride gel should not be used in orthodontic patients with fixed metal
appliances. (Am J Orthod Dentofacial Orthop 2021;160:101-12)

O
rthodontic fixed appliances composed of metal particularly corrosive because of its varying temperature,
alloys are commonly used to treat malocclusions. acidity from food and drink, bacterial products, and
These appliances are maintained in the oral cav- enzyme activity.1-3 Therefore, orthodontic appliance
ity for several years. However, the oral environment is corrosion has become a major concern. Research
investigating this topic has been focused on 2
principal issues: the effects on mechanical properties
Department of Orthodontics, Faculty of Dentistry, Chulalongkorn University, of the materials and toxicity on the surrounding tissue
Bangkok, Thailand. and patient’s health.1-4
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
Previous studies have reported that corrosion com-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Pintu-on Chantarawaratit, Department of Ortho- promises the mechanical properties of metal alloys by
dontics, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand increasing the surface roughness of the appliance,
10330; e-mail, pintuon@gmail.com.
increasing the friction between the archwire and
Submitted, December 2019; revised, February 2020; accepted, March 2020.
0889-5406/$36.00 brackets, and decreasing mechanical strength.1,4-6
Ó 2021 by the American Association of Orthodontists. All rights reserved. Biologically, metal ions released by orthodontic
https://doi.org/10.1016/j.ajodo.2020.03.035

101
102 Chantarawaratit and Yanisarapan

appliances from corrosion cause both local and systemic and to compare the results with those of as-received
adverse effects. A previous study reported that stainless brackets.
steel (SS) brackets incubated in a cell culture medium
MATERIAL AND METHODS
for 30 days released a high concentration of titanium,
chromium (Cr), manganese, nickel (Ni), and The study protocol was approved by the Human
molybdenum ions.7 These ions affect the surrounding Research Ethics Committee of the Faculty of Dentistry,
oral tissues by decreasing enzyme or mitochondrial ac- Chulalongkorn University, Thailand (HREC-DCU 2016-
tivity, carcinogenicity, and mutagenicity.7-9 Moreover, 102, 2019-052).
metal ions are ingested into the gastrointestinal The experimental flow and protocol are shown in
system. Some ions, such as Cr and Ni ions, have the Figure 1. The sample size was calculated from previous
potential to induce type IV hypersensitivity,10,11 which studies.6,28 The new appliance group had 36 sets of
can be severe in some patients.12 Orthodontic patients as-received brackets and tubes. Each set comprised 20
have been reported to have a higher prevalence of Ni brackets and 4 tubes (Tomy International, Tokyo, Japan)
hypersensitivity compared with nonorthodontic with a slot size of 0.018-in. Used appliances (Tomy In-
patients.10,11 ternational) were obtained from 36 nonextraction or-
Fluoride toothpaste (TP) has been universally rec- thodontic patients (10 males and 16 females, aged
ommended for daily tooth brushing. In addition, other between 15-24 years) in the Department of Orthodon-
professional fluoride products, such as fluoride gel or tics, Faculty of Dentistry, Chulalongkorn University,
fluoride varnish, have been used as a standard protocol Thailand. Each patient had 24 fully erupted teeth from
for dental caries control (CON), especially in high-risk the central incisors to the first molars that were bonded
caries patients, such as those undergoing orthodontic with 20 brackets and 4 molar tubes. During treatment,
treatment.13-16 However, sodium fluoride (NaF) from the patients repeatedly received oral hygiene instruction
fluoride-containing products reacts with the hydrogen and motivation. They were directed to brush their teeth
ions from bacterial products, resulting in the formation with a fluoride TP at least twice a day. No other anticar-
of hydrofluoric acid (HF).3,17 This acid dissolves the cinogenic product was recommended to the patients.
protective oxide layer on the surface of the metal in The appliances were removed from the patients’ teeth
the oral cavity, allowing corrosion to occur.3,17 The after their treatment was completed. The average treat-
fluoride product-induced corrosion of titanium and ment duration was 23 6 4 months. After debonding
other dental alloys used as restorations or dental from the enamel surfaces, the brackets and tubes were
implants has become a concern.18-20 The metal washed with deionized water. To avoid the corrosive ef-
orthodontic bracket and wires corrosion caused by fect of typical sterilization techniques, the used appli-
fluoride has been investigated.6,21-23 Their results ances were sterilized in a hot air oven (180oC,
demonstrated increased surface roughness and 60 minutes; Memmert, Schwabach, Germany) instead
friction between brackets and archwires, affecting the of using an autoclave or disinfectant.29
efficiency of orthodontic treatment.24-26 Surface The new and used brackets and archwires were
roughness induces plaque accumulation on the immersed in deionized water and cleaned in an ultra-
appliances and adjacent tooth surfaces, leading to sonic cleaner (Biosonic UC300; Coltene, Altst€atten,
caries and gingivitis.27 Switzerland) at 40 kHz for 15 minutes. Each set of
The previous studies concerning metal orthodontic brackets and tubes were ligated with two 0.016-
appliance corrosion from fluoride have used as- in 3 0.022-in preformed archwires to simulate full
received appliances.6,21-26 Currently, there is no report fixed orthodontic appliances from both dental arches.
on the effect of corrosion on used brackets that have The samples in the used and unused groups were
been exposed to the environment in orthodontic divided into 3 groups (n 5 12) by 3 metal types of arch-
patients’ oral cavity for several years. Therefore, the wires SS, NT, and TMA (Ormco; Accord, Orange, Calif).
purpose of our study was to evaluate the metal ion The compositions of the archwires are shown in
release, cytotoxicity, surface morphology, and surface Table I.30 The archwires were ligated to the brackets
roughness of debonded SS brackets after clinical use with 0.010-in ligature wires (Ormco; Accord). Each set
and 3 different types of archwires; SS, nickel-titanium of samples was weighed on a semimicro analytical bal-
(NT), and titanium molybdenum (TMA) exposed to a ance (New Classic MS-S; Mettler Toledo, Greifensee,
fluoride TP or acidulated phosphate fluoride (APF) gel Switzerland).

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Chantarawaratit and Yanisarapan 103

Fig 1. Sample preparation and experimental flow; x and y indicate the areas of brackets and wires
scanned by SEM.

The 12 sets of samples in each archwire group were mimicking the recommended APF gel application
divided into 3 media subgroups (n 5 4); artificial saliva time (ie, 4 minutes per time, once every
(Table II) as the CON group and solutions of TP or APF 3-6 months).15
gel. The volume of the CON medium, 1 mL per 0.2 g
The samples were washed with deionized water and
of the weight of the set, was calculated from
cleaned in an ultrasonic cleaner at 40 kHz for 15 minutes.
ISO10993-5.31 The TP medium was a mixture of TP con-
Each set of samples was then immersed in 10 mL cell cul-
taining 1000 ppm of NaF (Colgate Total; Colgate-
ture medium (Dulbecco’s Modified Eagle’s Medium
Palmolive, Thailand) and artificial saliva at a 1:4 (w/v)
[DMEM]; Gibco; Thermo Fisher Scientific, Waltham,
ratio. The APF medium was prepared by mixing 1.23%
Mass) at 5oC for 7 days.6 The DMEM was divided into
APF gel (Pascal International, Bellevue, WA) and artifi-
2 parts for metal ion measurement and cytotoxicity
cial saliva at a 1:1.4 (v/v) ratio.
testing.
The samples were immersed in their respective media
Next, 15 mL plastic centrifuge tubes (Corning;
in an incubator shaker at 37oC and 80 rpm. The immer-
Sigma-Aldrich, St. Louis, Mo) were cleaned by soaking
sion period was estimated from the recommended time
in 10% nitric acid overnight and rinsed with deionized
that each fluoride product would be clinically used for
water. A total of 3 mL of culture media from each sub-
3 months, as described in a previous study.6
group was dispensed into a tube. Ni, Cr, and iron (Fe)
1. CON groups: 12 samples were immersed in artificial ions were measured using inductively coupled plasma
saliva without fluoride for 5 hours 36 minutes, mass spectroscopy (ICP-MS) (iCAP RQ ICP-MS; Thermo
calculated as in no. 2. Fisher Scientific, Waltham, Mass). Standard solutions
2. TP groups: 12 samples were immersed in TP solu- (50, 100, and 200 mg/L) of each metal were prepared
tion for 5 hours 36 minutes, simulating the total in DMEM for calibration. DMEM alone was used as a
recommended tooth brushing time for 3 months negative CON. The mean of 3 values was calculated in
(ie, 2 minutes per time, twice per day).15 mg/L.
3. APF groups: 12 samples were immersed in APF Primary human gingival fibroblasts were isolated
solution for 4 minutes and dried for 30 minutes, from the healthy gingiva over impacted third molars of

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104 Chantarawaratit and Yanisarapan

3 young adult donors, 2 men and 1 woman, after obtain- were randomly chosen from each experimental group.
ing informed consent. The average donor age was The as-received and untreated brackets and wires were
18 years 9 months (standard deviation, 1.7 years). The used as a negative CON. The samples were cleaned in de-
isolated tissue was washed several times with DMEM ionized water in an ultrasonic cleaner at 40 kHz for
and cut into 1-2 mm3 pieces. Five explant pieces were 15 minutes, wiped and left until dry and scanned by
placed into a 35-mm 3 10-mm cell culture dish (SPL scanning electron microscope (SEM) (FEI, Eindhoven,
Life Sciences, Gyeonggi-do, Korea) and incubated with Netherlands) at 20 kV and 50003 magnification. The
a growth medium (DMEM supplemented with 10% fetal bracket area near the slot was scanned at position x,
bovine serum, 10,000 IU/mL penicillin G sodium, and the middle area of the wires was scanned at point
100,000 mg/mL streptomycin sulfate, 25 mg/mL ampho- y, which was adjacent to x (Fig 1, A).
tericin B, and 1% L-glutamine) at 37 C in a 5% CO2 at- The approximately 400 3 400 mm2 area at position x
mosphere. When the outgrown cells reached 80% and y (Fig 1, A) on the bracket and wire surfaces were
confluence, the cells were subcultured using 0.25% scanned by a noncontact optical 3-dimensional surface
trypsin- ethylenediaminetetraacetic acid solution at a characterization and roughness measuring device (Infin-
12.5:1 ratio. All experiments were performed using cells ite focus SL, Alicona, Graz, Austria) to evaluate the sur-
from the third to the fifth passage. All media supple- face roughness of the samples at 50x magnification.
ments were purchased from Gibco. Each sample was scanned 3 times. The data was
The gingival fibroblasts were seeded in 24-well plates analyzed by IF-MeasureSuite software (Alicona, Graz,
at a concentration of 40,000 cells per well, incubated as Austria).
above for 24 hours (approximately 80% confluent),
washed twice with phosphate-buffered saline, and the Statistical analysis
wells were divided into 2 CON groups and 9 experi- The data were analyzed by the SPSS program
mental groups and treated for 3 days as follows: for Windows (version 22.0; SPSS, Chicago, IL). The
1. Positive CON: cells incubated with 1 mL 20% 1-sample Kolmogorov-Smirnov and Levene tests were
ethanol in DMEM per well.6,32 used to test the normal distribution and homogeneity
2. Negative CON: cells incubated with 1 mL DMEM per of variance, respectively. The differences between new
well. and used appliances were evaluated by the paired t
3. Experimental groups: cells incubated with 1 mL cul- test. Two-way analysis and Tamhane’s T2 post-hoc
ture media immersed with samples (SS-CON, NT- analysis were used to analyze the differences in metal
CON, TMA-CON; SS-TP, NT-TP, TMA-TP; SS-APF, ion release, cell viability, and surface roughness between
NT-APF, and TMA-APF). the groups. Values of P \0.05 were considered statisti-
cally significant.
Subsequently, an MTT (3-[4, 5-dimethylthiazol-2-
yl]-2, 5-diphenyltetrazolium bromide) assay was per-
RESULTS
formed for cytotoxicity testing as previously described.33
Briefly, the medium was removed, the cells were washed The mean and standard deviation values for the
twice with phosphate-buffered saline and incubated metal ion release, cell viability, and surface roughness
with 250 mL 1 mg/mL MTT solution (Molecular Probes, of the brackets and wires are presented in Table III.
Eugene, OR) in DMEM without phenol red for 10 mi- In the new and used bracket groups with all types of
nutes. The MTT solution was removed, and the precipi- wires, the highest amount of Cr ions was in the APF
tated formazan crystals were dissolved in 500 mL groups. The maximum concentration of Cr was found
dimethyl sulfoxide. The optical density was determined in the used SS-APF groups (166.32 6 19.58 mg/L,
by measuring the light absorbance at 570 nm using an Table III, Fig 2, A and B). Among the used bracket
Epoch Microplate Spectrophotometer (BioTek Instru- groups, significant differences in Cr were detected in
ment, Winooski, Vermont). The background absorbance the TP and APF solutions in all archwire types compared
of dimethyl sulfoxide was subtracted from the sample with their CON groups. However, in the new bracket
absorbance, and the experiments were performed 3 groups, only the APF groups had a significantly higher
times. The percent cell viability was calculated using amount of Cr ions than the CON groups (P \0.05, Fig
the following formula: 2, A). Among the wire types, the highest levels of Cr
Cell viability (%) 5 (OD of the experimental group/ were found in the new and used SS groups immersed
OD of the negative CON) 3 100 in all solutions, except in the new bracket groups in
Four maxillary central incisor brackets and pieces of the CON solution, in which the Cr in the TMA group
the archwire that were in contact with the brackets was slightly higher than those in the SS group

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Chantarawaratit and Yanisarapan 105

only the SS wire presented a significant difference in Cr

Table I. Archwire alloy compositions
between the new and used groups (P \0.05, Fig 2, A
Wire and B).
alloy Composition (wt %) The highest level of Fe ions was found in the used SS-
SS 17-20 Cr, 8-12 Ni, 0.15 C, and balance mainly Fe APF groups (2236.09 6 487.50 mg/L, Table III, Fig 2, C
NT 55 Ni and 45 Ti (approximate and may contain small
amounts of Cu or other elements)
and D). In the new and used bracket groups, significantly
T-Mo 77.8 Ti, 11.3 Mo, 6.6 Zr. and 4.3 Sn higher amounts of Fe were released in all groups of arch-
wire types immersed in APF solutions; however, the dif-
C, carbon; Ti, titanium; Cu, copper; Mo, molybdenum; Zr, zirco-
ference was not significant between the immersed in TP
nium; Sn, Tin.
solution groups compared with their CON groups
(P \0.05, Fig 2, C). In the used bracket groups, SS
released the highest level of Fe in all solutions, compared
Table II. Composition of the artificial saliva used as with NT and TMA. In contrast, in the new bracket
CON groups, SS presented a significantly higher amount of
Fe only in the APF solution (P \0.05, Fig 2, D). In addi-
Ingredients Amount (g)
Potassium chloride 0.75
tion, in every solution, the SS wires with used brackets
Magnesium chloride 0.07 released significantly more Fe ions than those with
Calcium chloride 0.199 new brackets. In contrast, for the NT and TMA wires,
Dipotassium hydrogen phosphate 0.965 only the APF solutions generated significant differences
Potassium dihydrogen phosphate 0.439 in Fe between the new and used bracket groups
Sodium carboxymethylcellulose 6
Sodium benzoate 2.4
(P \0.05, Fig 2, C and D).
Deionized water 1200 (mL) APF significantly induced Ni ion release in all exper-
imental conditions compared with their CON groups;
however, TP significantly increased the Ni release only
(P \0.05, Fig 2, B). Comparing the new and used in the used TMA group (P\0.05, Fig 2, E). APF also pro-
brackets, the used APF groups with all archwire types moted significant differences in Ni between archwire
showed a significantly higher amount of ions than those types when using both new and used brackets
of the new APF groups. Significantly higher amounts of (P \0.05, Fig 2, F). Moreover, all used bracket groups
Cr ions were also found in the used TP groups with SS released significantly higher amounts of Ni than the
and NT wires compared with the new TP groups. How- new bracket groups in the same condition (P \0.05,
ever, among wire types immersed in the CON solutions, Fig 2, C and D). The maximum amount of Ni was found

Table III. Mean and standard deviation of metal ion release and cell viability
Cr (mg/L) Fe (mg/L) Ni (mg/L) Cytotoxicity(%)

Groups New Used New Used New Used New Used

SS
CON 0.84 6 0.10 35.32 6 21.70 255.13 6 11.0 756.02 6 254 5.36 6 0.07 84.02 6 11.38 90.28 6 7.19 70.29 6 5.50
TP 0.60 6 0.04 134.45 6 22.62 281.99 6 2.95 1327.1 6 251.1 5.86 6 0.41 148.37 6 62.13 83.53 6 6.09 53.71 6 9.02
APF 112.01 6 10.88 166.3 6 19.58 641.36 6 36.14 2236.1 6 487.5 62.81 6 5.85 845.32 6 138.3 67.23 6 7.08 53.71 6 5.99
( ) 0.07 6 0.02 0.07 6 0.02 233.84 6 6.00 233.84 6 6.00 0.83 6 0.10 0.83 6 0.10 97.19 6 1.8 96.4 6 2.32
(1) - - - - - - 1.91 6 0.33 1.83 6 0.38
NT
CON 0.48 6 0.02 26.60 6 13.24 271.82 6 12.61 270.61 6 16.16 7.17 6 0.42 121.02 6 138.3 81.60 6 4.32 65.97 6 7.75
TP 0.54 6 0.05 64.04 6 8.66 264.37 6 12.51 406.53 6 293.5 8.38 6 0.36 145.80 6 42.82 70.51 6 4.66 49.77 6 8.04
APF 44.38 6 4.40 105.46 6 13.53 562.02 6 26.7 1795.7 6 69.86 265.64 6 27.89 1844.8 6 249.6 53.71 6 5.99 30.54 6 6.63
( ) 0.12 6 0.07 0.12 6 0.07 243.78 6 4.53 243.78 6 4.53 0.67 6 0.09 0.67 6 0.09 100.26 6 5.94 101.19 6 4.48
(1) - - - - - - 1.50 6 0.37 1.36 6 0.49
TMA
CON 1.01 6 0.12 3.64 6 2.57 256.49 6 20.42 290.51 6 4.29 6.27 6 0.10 115.81 6 34.86 73.51 6 4.87 63.51 6 6.27
TP 0.21 6 0.02 13.45 6 10.41 297.83 6 18.83 377.6 6 164.2 3.82 6 0.35 300.02 6 78.98 53.88 6 13.56 41.38 6 8.47
APF 34.22 6 3.12 98.25 6 8.12 383.03 6 30.21 1240.0 6 111.5 121.65 6 9.69 402.79 6 80.50 9.62 6 3.76 2.77 6 0.88
( ) 0.12 6 0.02 0.12 6 0.02 237.06 6 8.90 237.06 6 8.90 0.74 6 0.04 0.74 6 0.04 96.6 6 3.95 99.4 6 2.05
(1) - - - - - - 1.63 6 0.51 1.62 6 0.53
(1) positive CON; ( ): negative CON.

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106 Chantarawaratit and Yanisarapan

Fig 2. Metal ion concentrations: A, C, and E, ion release according to the type of wire; B, D, and F, ion
release according to immersion media. An asterisk (*) indicates a significant difference between new
and used groups. Different letters indicate a significant difference between groups; P \0.05, n 5 4.

in the NT-APF group (1844.81 6 249.63 mg/L, Table III, groups. In all experiment conditions, the used groups
Fig 2, E and F). had significantly lower viability than the new groups
APF significantly reduced cell viability in the new and (Fig 3, A and B).
used brackets ligated with all types of archwire The SEM images revealed that the used bracket sur-
compared with their CON groups. Moreover, TP also faces with all archwire types were rougher than those
significantly decreased viability in all archwire types, in the new groups (Fig 4, A-H). Most of the new bracket
except for the new SS group (P \0.05, Fig 3, A). The surfaces showed a corrosion pattern with pits on their
highest and lowest viability among the 3 types of arch- surfaces (Fig 4, A, C, E, and G), whereas crevices and
wires were found in the SS and TMA groups, respectively cracks were present on the used bracket groups (Fig 4,
(Fig 3, B). The lowest cell viability, as toxic as the positive C, D, F, and H). The APF groups of the new and used
CON, was found in the used TMA-APF group, whereas groups demonstrate more pits, fissures, and cracks
the highest cell viability was shown in new SS-CON compared with their untreated groups (Fig 4, A-H).

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Chantarawaratit and Yanisarapan 107

Fig 3. Cell viability: A, viability according to the type of wire; B, viability according to immersion media.
An asterisk (*) indicates a significant difference between new and used groups. Different letters indicate
a significant difference among groups. (1), positive CON; ( ), negative CON; P \0.05, n 5 4.

The quantitative roughness results confirmed that

APF significantly increased brackets surface roughness
in the new and used bracket groups compared with their
CON groups (Table IV). All experimental conditions ex-
hibited that the used bracket groups had a significantly
higher bracket surface roughness than the new bracket
groups (P \0.05, Fig 5, A and B). TP significantly
increased the surface roughness in the used bracket
groups coupled with NT and TMA wires. However, in
the SS groups, only the APF groups had a significantly
higher surface roughness than their CON group
(P \0.05, Fig 5, A). In addition, the SS groups showed
the lowest bracket surface roughness in all solutions;
however, there was no significant difference between
the used SS and NT groups in the CON solutions in the
used bracket groups (P \0.05, Fig 5, B). Among the
new bracket groups, the NT groups exhibited the signif-
icantly highest surface roughness in every solution
(P \0.05). In contrast, among the used groups, the
TMA groups had the significantly highest surface rough-
ness in the CON and TP solutions; however, the bracket
surface roughness in the NT group was slightly higher
compared with the TMA group in the APF solution
(P \0.05, Fig 5, B).
The SEM images of the wire surfaces showed that the
highest and lowest surface roughness was found in the
TMA and SS groups, respectively (Fig 6, A-I). The SS
and TMA group surfaces demonstrated corrosive
grooves and fissures, including the CON groups, whereas
the corrosion on the NT surfaces was presented as poros-
ities (Fig 6, A-I). The surface roughness of all archwire
types noticeably increased after APF immersion (Fig 6,
D-I). Furthermore, after treatment with APF, cracks
were seen across the surface of the TMA wire coupled
Fig 4. Bracket surfaces scanned by SEM: A, as-received with used brackets (Fig 6, F). In all experimental condi-
brackets; B, untreated used brackets; C, new SS-APF; tions, the archwires combined with used brackets had
D, used SS-APF; E, new NT-APF; F, used NT-APF; more pits and grooves than those with new brackets
G, new TMA-APF; H, used TMA-APF. (Fig 6, A-I).

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108 Chantarawaratit and Yanisarapan

Table IV. Mean and standard deviation of bracket and wire surface roughness
Bracket surface roughness(nm) Wire surface roughness(nm)

Groups New Used New Used

SS
CON 119.94 6 5.39 352.26 6 27.26 83.62 6 3.67 96.92 6 8.884
TP 134.87 6 1.74 415.88 6 45.33 84.18 6 5.56 107.90 6 3.67
APF 157.01 6 5.74 648.06 6 36.02 94.52 6 2.97 132.36 6 10.09
( ) 113.31 6 9.38 282.21 6 25.55 67.97 6 3.79 67.97 6 3.79
NT
CON 157.18 6 4.94 366.71 6 22.80 149.53 6 6.27 163.22 6 9.44
TP 166.17 6 7.20 470.72 6 27.79 146.00 6 4.84 181.42 6 17.47
APF 183.31 6 7.55 831.77 6 45.48 163.27 6 4.02 315.18 6 17.77
( ) 113.31 6 9.38 282.21 6 25.55 140.84 6 2.95 140.84 6 2.95
TMA
CON 144.05 6 4.94 436.31 6 22.80 215.57 6 7.38 268.72 6 19.61
TP 158.93 6 7.20 561.45 6 27.79 236.61 6 4.61 308.31 6 27.89
APF 177.68 6 7.55 811.35 6 45.48 264.53 6 6.07 476.14 6 21.49
( ) 113.31 6 9.38 282.21 6 25.55 183.25 6 3.39 183.25 6 3.39

( ), negative CON.

APF significantly enhanced the surface roughness of the TMA groups coupled with new and used brackets
all archwires in the new and used bracket groups, whereas compared with their CON groups (P \0.05, Fig 5, C). In
TP significantly increased the surface roughness only in all solutions, the highest and lowest surface roughness

Fig 5. Bracket and wire surface roughness from various media: A, and B, bracket surface roughness
according to wire type and immersion media, respectively. C, and D, wire surface roughness according
to wire type and immersion media, respectively. An asterisk (*) indicates a significant difference be-
tween new and used groups. Different letters indicate a significant difference between groups;
P \0.05, n 5 4.

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Chantarawaratit and Yanisarapan 109

Fig 6. Wire surfaces scanned by SEM: A, untreated SS wire; B, new SS-APF; C, used SS-APF;
D, untreated NT wire; E, new NT-APF; F, used NT-APF; G, untreated TMA wire; H, new TMA-APF;
I, used TMA-APF.

was found in the TMA and SS groups, respectively. Signif- TiO2), respectively. The corrosive effect of fluoride prod-
icant differences between archwire types were found in ucts on metal orthodontic appliances has been previ-
every solution (P \0.05, Fig 5, D). In all experimental ously reported to be due to the chemical reaction
conditions, the used bracket groups presented a signifi- between NaF and the protective oxide layers on the
cantly higher wire surface roughness compared with the metal surface.34 The NaF from fluoride products reacts
new bracket groups (P \0.05, Fig 5, C and D). with the hydrogen ions (H1) from bacterial products
and acidic food or drink, generating HF.34
NaF 1 H1 / HF 1 Na1
DISCUSSION HF is one of the strongest inorganic acids and attacks
The present study evaluated the potential of fluoride- the protective oxide layers on the stainless steel and
containing solutions to corrode metal orthodontic appli- titanium-based alloys. The chemical reactions are shown
ances by comparing new and used brackets coupled with in equation (a) and equations (b-d), respectively.3,17,34,35
3 orthodontic archwire types: SS, NT, and TMA after im- Cr2O3 1 6HF / 2CrF3 1 3H2O (a)
mersion in TP and APF solutions, using artificial saliva as Ti2O3 1 6HF / 2TiF4 1 3H2O (b)
a negative CON group. The new brackets were used as- TiO2 1 4HF / TiF4 1 2H2O (c)
received, whereas the used brackets were obtained TiO2 1 2HF / TiF2 1 H2O (d)
from orthodontic patients after their clinical treatment In both new and used bracket groups, the highest
was completed. We found that used brackets were prone levels of the 3 ions and surface roughness were found
to corrode much more compared with new brackets, on in the samples immersed in APF. A possible explanation
the basis of ion release, cytotoxicity, and surface rough- is that the acidity of phosphoric acid (H3PO4) in APF is a
ness, especially after immersion in APF. key factor in enhancing the corrosion of metal appli-
The corrosive resistance of SS and titanium-based al- ances.19,20,36 Consequently, compared with TP, a higher
loys is based on their protective oxide layers, which are amount of HF is produced, as shown by the following
chromium oxide (Cr2O3) and titanium oxide (Ti2O3 and equation.17

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110 Chantarawaratit and Yanisarapan

H3PO4 1 3NaF / Na3PO4 1 3HF in all archwire types coupled with either new or used
In contrast to APF, TP was rarely seen to generate bracket groups was significantly decreased than those
significantly higher amounts of metal ions than the immersed in DMEM. These findings confirmed the re-
CON group. Although a previous study found that sults of previous studies that APF significantly decreased
neutral fluoride products with a high fluoride concentra- the cell viability of a human osteosarcoma cell line and
tion can produce biological effects from metal corro- gingival fibroblasts.6,28 In addition, the viability of the
sion,37 in our study, the fluoride concentration in TP TMA group immersed in APF was lower than 30%, which
was not enough to markedly induce ion release and sur- is considered cytotoxic according to ISO10993-5, the
face roughness. These results correspond to previous biological evaluation of medical devices.31 Therefore,
studies that reported that a low concentration of fluoride APF gel should not be recommended for use by an or-
in a neutral environment did not induce galvanic corro- thodontic patient with fixed metal appliances, especially
sion or increase the surface roughness of dental al- when using TMA archwires.
loys.20,26 Therefore, APF, which has both a high Surface roughness is a parameter of metal surface
concentration of fluoride and a low pH, created greater corrosion.5 The SEM images illustrated that the brackets
corrosive effects on metal orthodontic appliances and wires exposed to APF were markedly rougher than
compared with TP.26,38 the untreated samples. These results correspond with
On the basis of a previous study, the amount of ions those of a previous study using 1.1% neutral and acidu-
released in our study were measured from DMEM after lated fluoride gel.25 Furthermore, the NT and TMA wires
incubation with treated appliances for 7 days.6 There- that initially had more surface roughness than the SS
fore, to compare with daily dietary intake, the results wires exhibited more corrosive pits and grooves after im-
should be divided by 7. In the present study, the esti- mersion in APF.25 The explanation for this finding is that
mated daily release of Cr and Fe ions in every experi- the rougher surfaces of the NT and TMA wires are more
mental condition was lower than the recommended susceptible to pitting and crevice corrosion than the SS
daily dietary intake (35 mg and 8 mg, respectively).39 wire.3 Although the surface of SS wires did not notice-
However, the ions released from the brackets and wires ably change after being immersed in fluoride solutions,
would likely accumulate in the gingival fibroblast cells the amount of metal ions released significantly
and induced DNA damage.40 Cr was reported as a poten- increased, especially in the used bracket groups. These
tial marker for carcinogenic substances. Moreover, free results might be a consequence of a uniform attack:
Fe ions induce cell apoptosis by increasing lipid peroxi- corrosion that occurs uniformly over the entire exposed
dation that can damage the mitochondrial function and surface of a metal. The uniform attack is not typically
cell organelles.41,42 detectable by SEM before large amounts of metal have
We found that Ni ion levels were higher than the rec- dissolved.3 This type of corrosion also occurs on NT
ommended daily maximum dietary intake (162 mg) in the and TMA surfaces; however, the surface morphologies
used bracket NT-APF groups (1844.81 6 249.63 mg/L); of pitting and crevices are more noticeable.3
however, the levels were still lower than the Ni toxic dose We observed that the used bracket groups presented
(60 mg/kg).39,43 Ni atoms are weakly bonded to form more grooves and porosities than the new bracket
intermetallic compounds in alloys; thus, they gradually groups in the same conditions. The surfaces of the un-
release from an orthodontic appliance into the patient’s treated used brackets also exhibited more cracks and
oral cavity.3 Our results confirmed that, including when roughness than did the as-received bracket group. Inter-
immersed in artificial saliva, the Ni released in the used estingly, the as-received archwires coupled with used
bracket groups was significantly higher than those in brackets presented more pits and crevices than those
the new groups. A previous study reported that urinary treated with new brackets, especially after immersion
Ni levels significantly increased after 2 months of ortho- in the APF solution. This outcome revealed that used
dontic treatment using fixed metal appliances.44 This brackets had a higher ability to induce new archwire
implies that Ni ingested into the gastrointestinal system corrosion than new brackets. Moreover, ICP-MS demon-
might impact other organs and systems in a patient’s strated that the concentrations of Cr, Fe, and Ni ions
body. Ni has been reported to cause dermatitis and con- were dramatically higher in the used bracket groups
tact stomatitis.11,45 In addition, long term exposure to than the new bracket groups in the same condition.
Ni-containing orthodontic appliances was reported to Increased surface roughness impacts several mechan-
induce Ni hypersensitivity.11 ical properties of orthodontic appliances. With high
In this study, the groups with used brackets exhibited corrosion, and thus, high surface roughness, friction be-
significantly lower cell viability than their negative CON tween the brackets and archwires increases and compli-
groups. Moreover, after immersion in APF, the viability cates the orthodontic mechanics, especially when using

July 2021  Vol 160  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Chantarawaratit and Yanisarapan 111

sliding mechanics.5,34 Previous studies exhibited that recommended during orthodontic treatment with fixed
fluoride-containing products significantly elevated the metal orthodontic appliances, especially with the long
friction between brackets and archwires.24,34 Further- clinical duration that brackets are commonly used. In
more, fluoride was reported to decrease the unloading contrast, fluoride TP is safer for orthodontic patients
force of superelasticity and shape-memory alloys, such with lower adverse effects on the biocompatibility and
as NT and copper-NT archwires. Thus, the ability of mechanical properties of their metal appliances.
the wires to return to their original shape decreased.
Clinically, this unloading force generates orthodontic CREDIT AUTHORSHIP CONTRIBUTION STATEMENT
tooth movement. Therefore, the degree of tooth Pintu-on Chantarawaratit: Conceptualization,
displacement was consequently decreased.25 Moreover, Methodology, Validation, Formal analysis, Investigation,
rougher orthodontic appliances results in increased pla- Resources, Data curation, Writing - original draft,
que accumulation that complicates the oral hygiene Writing - review & editing, Supervision, Project admin-
control in orthodontic patients.27 istration, Funding acquisition. Tipanan Yanisarapan:
The oral environment is believed to have a high po- Methodology, Validation, Formal analysis, Investigation,
tential to enhance the corrosion of metals and alloys Data curation.
used in dental treatment; thus, several methods have
been employed to mimic this condition in the laboratory. ACKNOWLEDGMENTS
Thermocycling and heat treatment were performed in
previous studies to evaluate the corrosion of used ortho- This work was supported by the Faculty of Dentistry,
dontic brackets.46,47 In the present study, the used Chulalongkorn University (Lecturer Funding). We appre-
brackets in our study were exposed to the oral environ- ciate Tomy International, Tokyo, Japan and Ormco,
ment for several years; therefore, they had been corroded Accord, Calif for providing the brackets and archwires,
by genuine temperature changes, acidity, bacterial prod- respectively. In addition, the authors thank Dr Kevin
ucts, enzyme activity, cell and tissue reactions, and fluo- Tompkins for his valuable suggestions.
ride treatments in the oral cavity, which is a strength of
REFERENCES
our study.3 However, in vitro experiments cannot repre-
sent the entire corrosion process that occurs in the oral 1. House K, Sernetz F, Dymock D, Sandy JR, Ireland AJ. Corrosion of
environment.3 Saliva clearance reduces the concentra- orthodontic appliances—should we care? Am J Orthod Dentofacial
Orthop 2008;133:584-92.
tion of the metal ions released from orthodontic appli- 2. Widu F, Drescher D, Junker R, Bourauel C. Corrosion and biocom-
ances. Consequently, the concentrations of these ions patibility of orthodontic wires. J Mater Sci Mater Med 1999;10:
in orthodontic patients’ oral cavity are probably lower 275-81.
than those reported in the present study. In addition, 3. Eliades T, Athanasiou AE. In vivo aging of orthodontic alloys: im-
the cell and tissue reactions from metal orthodontic plications for corrosion potential, nickel release, and biocompati-
bility. Angle Orthod 2002;72:222-37.
appliance corrosion could not be replicated, which are 4. Chaturvedi TP, Upadhayay SN. An overview of orthodontic
limitations in the present study.3 Previous in vivo studies material degradation in oral cavity. Indian J Dent Res 2010;21:
using buccal mucosa cells found that orthodontic treat- 275-84.
ment with fixed metal orthodontic appliances decreased 5. Nanjundan K, Vimala G. Evaluation of frictional resistance and
cell viability, induced DNA damage, and increased metal surface characteristics after immersion of orthodontic brackets
and wire in different chemical solutions: a comparative in vitro
ion concentration in the cells.9,40 However, there is no study. Indian J Dent Res 2016;27:513-20.
in vivo study reporting the biological effects caused by 6. Yanisarapan T, Thunyakitpisal P, Chantarawaratit P. Corrosion of
the corrosion of metal orthodontic appliances from metal orthodontic brackets and archwires caused by fluoride-
fluoride-containing products. Therefore, future clinical containing products: cytotoxicity, metal ion release and surface
studies are needed to resolve these issues. roughness. Orthod Waves 2018;77:79-89.
7. Ortiz AJ, Fernandez E, Vicente A, Calvo JL, Ortiz C. Metallic ions
released from stainless steel, nickel-free, and titanium orthodontic
alloys: toxicity and DNA damage. Am J Orthod Dentofacial Orthop
CONCLUSIONS
2011;140:e115-22.
Used brackets were more susceptible to corrosion 8. Costa MT, Lenza MA, Gosch CS, Costa I, Ribeiro-Dias F. In vitro
from fluoride-containing products compared with as- evaluation of corrosion and cytotoxicity of orthodontic brackets.
J Dent Res 2007;86:441-5.
received brackets. In the present study, APF gel was
9. Hafez HS, Selim EM, Kamel Eid FH, Tawfik WA, Al-Ashkar EA,
the most corrosive agent that significantly increased Mostafa YA. Cytotoxicity, genotoxicity, and metal release in pa-
metal ion release, surface roughness, and decreased tients with fixed orthodontic appliances: a longitudinal in-vivo
cell viability. Therefore, APF gel application is not study. Am J Orthod Dentofacial Orthop 2011;140:298-308.

American Journal of Orthodontics and Dentofacial Orthopedics July 2021  Vol 160  Issue 1
112 Chantarawaratit and Yanisarapan

10. Kolokitha OE, Kaklamanos EG, Papadopoulos MA. Prevalence of 28. Kao C-T, Ding S-J, He H, Chou MY, Huang T-H. Cytotoxicity of or-
nickel hypersensitivity in orthodontic patients: a meta-analysis. thodontic wire corroded in fluoride solution in vitro. Angle Orthod
Am J Orthod Dentofacial Orthop 2008;134:722.e1-12; discussion 2007;77:349-54.
722-3. 29. Mayhew MJ, Kusy RP. Effects of sterilization on the mechanical
11. Bass JK, Fine H, Cisneros GJ. Nickel hypersensitivity in the properties and the surface topography of nickel-titanium arch
orthodontic patient. Am J Orthod Dentofacial Orthop 1993;103: wires. Am J Orthod Dentofacial Orthop 1988;93:232-6.
280-5. 30. Brantley WA, Eliades T. Orthodontic materials: scientific and clin-
12. Kolokitha OE, Chatzistavrou E. A severe reaction to Ni-containing ical aspects. New York: Thieme Verlag; 2001.
orthodontic appliances. Angle Orthod 2009;79:186-92. 31. ISO. Biological evaluation of medical devices-Part 5: Tests for
13. Maguire A. ADA clinical recommendations on topical fluoride for in vitro cytotoxicity. (ISO. Swiss Confederation: International or-
caries prevention. Evid Based Dent 2014;15:38-9. ganization for standardization; 2009, p. 10993-5:2009).
14. Karadas M, Cantekin K, Celikoglu M. Effects of orthodontic treat- 32. Tapani E, Taavitsainen M, Lindros K, Vehmas T, Lehtonen E.
ment with a fixed appliance on the caries experience of patients Toxicity of ethanol in low concentrations. Experimental evaluation
with high and low risk of caries. J Dent Sci 2011;6:195-9. in cell culture. Acta Radiol 1996;37:923-6.
15. American Dental Association Council on Scientific Affairs. Profes- 33. Mosmann T. Rapid colorimetric assay for cellular growth and sur-
sionally applied topical fluoride: evidence-based clinical recom- vival: application to proliferation and cytotoxicity assays. J Immu-
mendations. J Am Dent Assoc 2006;137:1151-9. nol Methods 1983;65:55-63.
16. American Dental Association Council on Scientific Affairs. Profes- 34. Alavi S, Farahi A. Effect of fluoride on friction between bracket and
sionally applied topical fluoride: evidence-based clinical recom- wire. Dent Res J (Isfahan) 2011;8(Suppl 1):S37-42.
mendations. J Dent Educ 2007;71:393-402. 35. Kim H, Johnson JW. Corrosion of stainless steel, nickel-titanium,
17. Castro SM, Ponces MJ, Lopes JD, Vasconcelos M, Pollmann MCF. coated nickel-titanium, and titanium orthodontic wires. Angle Or-
Orthodontic wires and its corrosion—the specific case of stainless thod 1999;69:39-44.
steel and beta-titanium. J Dent Sci 2015;10:1-7. 36. Kuhta M, Pavlin D, Slaj M, Varga S, Lapter-Varga M, Slaj M. Type
18. Nakagawa M, Matsuya S, Shiraishi T, Ohta M. Effect of fluoride of archwire and level of acidity: effects on the release of metal ions
concentration and pH on corrosion behavior of titanium for dental from orthodontic appliances. Angle Orthod 2009;79:102-10.
use. J Dent Res 1999;78:1568-72. 37. Jeng JH, Hsieh CC, Lan WH, Chang MC, Lin SK, Hahn LJ, et al.
19. Schiff N, Grosgogeat B, Lissac M, Dalard F. Influence of fluoride Cytotoxicity of sodium fluoride on human oral mucosal fibroblasts
content and pH on the corrosion resistance of titanium and its al- and its mechanisms. Cell Biol Toxicol 1998;14:383-9.
loys. Biomaterials 2002;23:1995-2002. 38. Watanabe I, Watanabe E. Surface changes induced by fluoride pro-
20. Reclaru L, Meyer JM. Effects of fluorides on titanium and other phylactic agents on titanium-based orthodontic wires. Am J Or-
dental alloys in dentistry. Biomaterials 1998;19:85-92. thod Dentofacial Orthop 2003;123:653-6.
21. Mirjalili M, Momeni M, Ebrahimi N, Moayed MH. Comparative 39. National Academy of Sciences. Nutrient recommendations: dietary
study on corrosion behaviour of Nitinol and stainless steel ortho- reference intakes (DRI). United States of America: National Acad-
dontic wires in simulated saliva solution in presence of fluoride emies Press; 2011.
ions. Mater Sci Eng C Mater Biol Appl 2013;33:2084-93. 40. Faccioni F, Franceschetti P, Cerpelloni M, Fracasso ME. In vivo
22. Pulikkottil VJ, Chidambaram S, Bejoy PU, Femin PK, Paul P, study on metal release from fixed orthodontic appliances and
Rishad M. Corrosion resistance of stainless steel, nickel-titanium, DNA damage in oral mucosa cells. Am J Orthod Dentofacial Orthop
titanium molybdenum alloy, and ion-implanted titanium molyb- 2003;124:687-93; discussion 693-4.
denum alloy archwires in acidic fluoride-containing artificial 41. Chen F, Vallyathan V, Castranova V, Shi X. Cell apoptosis induced
saliva: an in vitro study. J Pharm Bioallied Sci 2016;8(Suppl 1): by carcinogenic metals. Mol Cell Biochem 2001;222:183-8.
S96-9. 42. Fraga CG, Oteiza PI. Iron toxicity and antioxidant nutrients. Toxi-
23. Tahmasbi S, Ghorbani M, Masudrad M. Galvanic corrosion of and cology 2002;180:23-32.
ion release from various orthodontic brackets and wires in a 43. Agency for Toxic Substances and Disease Registry. ToxGuide. At-
fluoride-containing mouthwash. J Dent Res Dent Clin Dent Pros- lanta: Department of health and human services; 2015.
pects 2015;9:159-65. 44. Menezes LM, Quint~ao CA, Bolognese AM. Urinary excretion levels
24. Kao CT, Ding SJ, Wang CK, He H, Chou MY, Huang TH. Compar- of nickel in orthodontic patients. Am J Orthod Dentofacial Orthop
ison of frictional resistance after immersion of metal brackets and 2007;131:635-8.
orthodontic wires in a fluoride-containing prophylactic agent. Am 45. Genelhu MC, Marigo M, Alves-Oliveira LF, Malaquias LC,
J Orthod Dentofacial Orthop 2006;130:568.e1-9. Gomez RS. Characterization of nickel-induced allergic contact sto-
25. Walker MP, White RJ, Kula KS. Effect of fluoride prophylactic matitis associated with fixed orthodontic appliances. Am J Orthod
agents on the mechanical properties of nickel-titanium-based or- Dentofacial Orthop 2005;128:378-81.
thodontic wires. Am J Orthod Dentofacial Orthop 2005;127: 46. Huang TH, Yen CC, Kao CT. Comparison of ion release from new
662-9. and recycled orthodontic brackets. Am J Orthod Dentofacial Or-
26. Huang H-H. Variation in surface topography of different NiTi or- thop 2001;120:68-75.
thodontic archwires in various commercial fluoride-containing en- 47. Behroozi Z, Momeni Danaei S, Sardarian AR, Moshkelghosha V,
vironments. Dent Mater 2007;23:24-33. Sardarian AR. Evaluation of the corrosion of five different
27. Marques IS, Ara ujo AM, Gurgel JA, Normando D. Debris, rough- bracket-archwire combination: an in-vitro analysis using induc-
ness and friction of stainless steel archwires following clinical tively coupled plasma mass spectrometry. J Dent (Shiraz) 2016;
use. Angle Orthod 2010;80:521-7. 17(3 Suppl):262-7.

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