ORIGINAL ARTICLE

In vivo effect of a resin-modified glass

ionomer cement on enamel demineralization
around orthodontic brackets
Renata Corrêa Pascotto, DDS, MS, PhD,a Maria Fidela de Lima Navarro, DDS, PhD,b
Leopoldino Capelozza Filho, DDS, MS, PhD,c and Jaime Aparecido Cury, DDS, MS, PhDd
Maringá, PR, Bauru, SP, and Piracicaba, SP, Brazil

Because the risk of dental caries increases with the use of orthodontic appliances and its control cannot
depend only on the patient’s self-care, this study evaluated the effect of a glass ionomer cement on reducing
enamel demineralization around orthodontic brackets. Fourteen orthodontic patients were randomly divided
into 2 groups of 7; they received 23 brackets fitted to their premolars, bonded with either Concise (3M Dental
Products, St Paul, Minn), a composite resin (control group), or Fuji Ortho LC (GC America, Chicago, Ill), a
resin-modified glass ionomer cement (experimental group). The volunteers lived in a city that has fluoridated
water, but they did not use fluoridated dentifrices during the study. After 30 days, the teeth were extracted
and longitudinally sectioned; in the enamel around the brackets, demineralization was assessed by
cross-sectional microhardness. The determinations were made at the bracket edge cementing limits, and at
occlusal and cervical points 100 and 200 ␮m away from them. In all of these positions, indentations were
made at depths from 10 to 90 ␮m from enamel surface. Analysis of variance showed statistically significant
effects for position, material, depth, and their interactions (P ⬍ .05). The Tukey test showed that the glass
ionomer cement was statistically more efficient than the control, reducing enamel demineralization in all
analyses (P ⬍ .05). The use of glass ionomer cement for bonding can be encouraged because it decreases
the development of caries around orthodontic brackets. (Am J Orthod Dentofacial Orthop 2004;125:36-41)

O
rthodontic therapy with fixed intraoral appli-
ances frequently makes the patient’s habitual
oral hygiene more difficult. The accumulation
of dental plaque adjacent to the brackets and bands
increases the patient’s risk of caries, and white spot
lesions at the end of corrective therapy are frequent.1-4
The incidence of enamel demineralization after the use
of a fixed orthodontic appliance can occur in up to 50%
of patients.1,5 Although the combination of fluoride
methods, eg, dentifrice and mouthrinse, is efficient for
reducing caries progression in this clinical situation, the
patient’s cooperation is essential.1,6-9 Thus, other mea-
sures to reduce caries activity around the orthodontic
brackets should be implemented.
a
Enamel demineralization is recognized as a possible
side effect of bonding orthodontic brackets with com-
posite resins. Fluoride-releasing sealant materials have
been shown to inhibit tooth demineralization.7,10,11
However, when brackets are bonded and debonded
with this technique, there is enamel loss and risk of
enamel cracks and scratches.12
Conventional glass ionomer cement has been eval-
uated for bonding orthodontic brackets due to its
anticariogenic property,13-15 which has been attributed
to the release of fluoride.15,16 However, the low adhe-
sive strength of this material has been a limitation of its
clinical use.17,18
Resin-modified glass ionomer cements have greater

b
Department of Dentistry, State University of Maringá, Maringá, PR. adhesive strength than conventional ones19-21 and the
Faculty of Dentistry of Bauru, USP, Bauru, SP.
c
Faculty of Dentistry of Bauru and Hospital for the Rehabilitation of Cranial-
advantage of not promoting changes on the tooth
Facial Anomalies, USP, Bauru, SP. surface after debonding.22 In addition, in vitro studies
d
Faculty of Dentistry of Piracicaba, UNICAMP, Piracicaba, SP, Brazil. have shown that this ionomeric material can control
This work was based on a thesis submitted by the first author to the Faculty of
Dentistry of Bauru, University of São Paulo, Brazil, in partial fulfillment of the caries around orthodontic appliances.23-26 However,
requirements for the Doctor Degree in Dentistry. resin-modified glass ionomer cement for orthodontic
Reprint requests to: Renata Corrêa Pascotto, State University of Maringá,
Dentistry Department, Av Mandacarú, 1550, Bloco S-08, CEP: 87.030-120,
use has not been sufficiently evaluated in clinical
Maringá PR, Brazil; e-mail, rpascotto@uol.com.br. conditions. The few in vitro evaluations of this material
Submitted, September 2002; revised and accepted, December 2002. in reducing dental caries were more qualitative than
0889-5406/$30.00
Copyright © 2004 by the American Association of Orthodontists. quantitative.10,11
doi:10.1016/S0889-5406(03)00571-7 Thus, the aim of this study was to evaluate in vivo
36
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 125, Number 1
the effect of a glass ionomer cement in reducing dental
caries; enamel demineralization around the orthodontic
brackets was determined quantitatively.
MATERIAL AND METHODS
This study was conducted at the Foundation for the
Study and Treatment of Cranium-Facial Deformities,
University of São Paulo, Bauru, after the approval by a
local research and ethics committee.
Fourteen orthodontic patients, 12-17 years of age,
scheduled to have premolars extracted for orthodontic
reasons were randomly divided into 2 groups of 7 each.
The patients had prior clinical and radiographic exam-
inations. Salivary flow rate and buffer capacity were
also determined. The criteria for including patients
were no active caries lesions, and normal salivary flow
rate (⬎1.0 mL/min) and buffer capacity (final pH
between 6.0 and 7.0). The 2 groups, equivalent with
regard to the caries risk parameters, received brackets
(S2C-03Z, Dental Morelli, Sorocaba, SP, Brazil)
bonded with either Fuji Ortho LC (GC America,
Chicago, Ill), a resin-modified glass ionomer cement
(experimental group), or Concise (3M Dental Products,
St Paul, Minn), a composite resin (control group). The
manufacturers’ recommendations were followed, in-
cluding conventional acid etching before bonding with
Concise, but, for the resin-modified glass-ionomer ce-
ment, no acid etching was used, and partial drying was
done before bonding. Excessive adhesive around the
bracket and between bracket base and tooth was re-
moved with a clinical probe at bonding.
Twenty-three brackets were cemented for each
group (14 maxillary and 9 mandibular first premolars in
the experimental group, 16 maxillary and 7 mandibular
first premolars in the control group). After 30 days, the
teeth were extracted and stored in a refrigerator in
flasks containing gauze dampened with 2% formalde-
hyde, pH 7.0, until the analysis. Dental caries in enamel
around the brackets was evaluated by cross-sectional
microhardness. During the experimental period and 3
weeks before it started, the subjects brushed their teeth
with a nonfluoridated dentifrice, but they drank fluori-
dated water. They received no instructions regarding
oral hygiene, kept their usual habits, and were in-
structed not to use any antibacterial substance.
The extracted teeth were longitudinally sectioned
into halves, in the buccal-palatal direction, through the
center of the orthodontic bracket, with a water-cooled,
double-faced diamond disk. The half crown sections
were embedded in acrylic resin and polished with 3
grades of abrasive paper discs (320, 600, and 1200
grit); final polishing was done with a 1-␮m diamond
spray and a polishing cloth disc. A microhardness tester
Pascotto et al 37
(HMV-2000, Shimadzu, Kyoto, Japan) with a Knoop
diamond under a 50-g load for 5 seconds was used for
the microhardness analysis. Forty-eight indentations
were made in each half crown, in 8 positions, according
to the diagram in the Figure 1. On the buccal surface,
indentations were made under the bracket. In the
occlusal and cervical regions, indentations were made
at the edge (0) of the bracket and at 100 and 200 ␮m
away from it. Indentations were also made in the
middle third of the lingual surface of each half crown,
as another control. In all these positions, 6 indentations
were made at 10, 20, 30, 50, 70, and 90 ␮m from the
external surface of the enamel. The values of Knoop
hardness numbers found in the 2 half crowns were
averaged. Cross-sectional microhardness was used to
evaluate caries, because there is a good correlation
(0.91) between enamel microhardness and percentage
of mineral in caries lesions.27
Throughout the study, brackets were lost for differ-
ent reasons: debonding, during extraction procedures,
or at sectioning the teeth in the buccolingual direction.
Thus, 19 first premolars (12 maxillary and 7 mandibu-
lar) with brackets bonded with Fuji Ortho LC, and 17
first premolars (12 maxillary and 5 mandibular) ce-
mented with Concise were evaluated. These numbers of
teeth were considered in the statistical analysis.
Analysis of variance (ANOVA) was used to eval-
uate the effect of materials (Fuji Ortho LC and Con-
cise), depths from the enamel surface (10, 20, 30, 50,
70, and 90 ␮m), positions (under the bracket, and on
the buccal surface in occlusal and cervical regions at 0,
100, and 200 ␮m from the brackets and in the lingual
surface), and their interactions. ANOVA was followed
by Tukey test. For the analysis, Statistics for Windows
4.3 (STAT SOFT, Tulsa, Okla) was used, and the
statistical significance was set at P ⫽ .05.
RESULTS
ANOVA (Table I) showed significance for the
factors material, position, and depth; the interactions
(material/depth, material/position, and depth/position) and
(material/position/depth) were also statistically signifi-
cant (P ⬍ .05). Table II shows that the interaction
depth*material presented significant differences be-
tween the materials tested at the distances of 10 and 20
␮m from the enamel surface; less demineralization was
found in enamel around the brackets cemented with the
glass ionomer in comparison with the control. The
interaction position*material (Table III) showed a sta-
tistically significant difference between the materials in
the cervical region of the bracket, with greatest mineral
loss (lowest hardness) for the Concise group. The
Tukey test applied to the triple interaction
38 Pascotto et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2004

Fig 1. Diagrammatic representation of positions and depth of indentations.

Table I. ANOVA results

Degrees of Sum of Avg square
Source freedom squares error error F P

Position 7 11863 238 622.816 190.47 .000000*

Material 1 55462 34 9653.552 5.7452 .022176*
Depth 5 10273 170 1376.481 746.35 .000000*
Position/material 7 2984 238 622.816 4.7907 .000046*
Position/depth 35 7550 1190 172.805 43.690 .000000*
Material/depth 5 30646 170 1376.481 22.264 .000000*
Position/material*depth 35 928 1190 172.805 5.3693 .000000*

*Statistically significant (P ⬍ .05).

material*position*depth showed statistically significant
differences at all positions evaluated on the buccal
surface, but only at 10 ␮m from the surface of the
enamel (Table IV); these were the highest hardness
values for Fuji Ortho LC. There was no significant
difference between the materials in the hardness ob-
served at the lingual surface of the teeth (not treated).
DISCUSSION
The present in vivo study evaluated the effect of
bonding materials on caries in enamel adjacent to
brackets. Mineral loss was assessed in vitro by cross-
sectional microhardness, a recognized analytical
method.
Although several studies have been conducted on
the cariostatic effect of fluoride-releasing materials by
using a split-mouth design,7,28,29 in this study the
subjects were randomly divided into 2 groups, and each
received only 1 tested material, because the prior
clinical, radiographic, and salivary examinations
showed that the patients were equivalent with regard to
caries risk or activity. This experimental design was
chosen rather than the split-mouth technique, to avoid
the carry-across effect due to fluoride release by the
glass ionomer cement on enamel around the brackets
bonded with composite resin. Apart from the random-
ization process, to minimize bias, the patients did not
know what bonding material was used (blind study);
American Journal of Orthodontics and Dentofacial Orthopedics Pascotto et al 39
Volume 125, Number 1

Table II. Knoop microhardness (avg ⫾ SD) for The findings in Table II show that a narrow caries
materials at different depths from enamel surface lesion (up to 30 ␮m depth) developed adjacent to the
Interaction of
materials, but statistically significant differences be-
depth/material Fuji Ortho LC Concise P (␣) tween the treatments were found at distances of 10 and
20 ␮m from the enamel surface. Mineral loss in enamel
10 ␮m 248.5 ⫾ 31.3 198.9 ⫾ 34.8 .000017* was 33% adjacent to the composite resin and 21%
20 ␮m 291.0 ⫾ 28.3 270.2 ⫾ 32.5 .000017*
30 ␮m 324.1 ⫾ 23.9 322.4 ⫾ 26.1 .999972
around the glass ionomer. Thus, Fuji Ortho LC reduced
50 ␮m 352.4 ⫾ 17.3 356.0 ⫾ 17.1 .983543 enamel demineralization adjacent the brackets by 12%.
70 ␮m 370.5 ⫾ 13.7 371.2 ⫾ 12.5 1.000000 The mineral loss adjacent to Concise agrees with the
90 ␮m 377.7 ⫾ 8.8 377.4 ⫾ 9.2 1.000000 results of O’Reilly and Featherstone,30 who found 15%
*Differences between materials statistically significant by Tukey test. of mineral loss at the 25-␮m depth. The effect of Fuji
Ortho LC agrees with in vitro data10,11,31 observed with
this material and other glass ionomer cements for
Table III. Knoop microhardness (avg ⫾ SD) for orthodontic bonding.4,24,29,32
materials at different positions, under and occlusal The data in Table III show 2 relevant aspects about
and cervical to the brackets on labial and lingual dental caries and the effect of the material in reducing
(control) surfaces
enamel demineralization. First, reduced enamel hard-
Interaction of ness around the composite resin was observed in the
place/material Fuji Ortho LC Concise P (␣) cervical region of the bracket compared with that in the
Occlusal/0 ␮m 313.5 ⫾ 27.8 302.8 ⫾ 26.5 .066694 occlusal area. This higher mineral loss in the cervical
Occlusal/100 ␮m 327.9 ⫾ 22.3 319.0 ⫾ 24.9 .312063 region than in the occlusal area has been observed by
Occlusal/200 ␮m 340.5 ⫾ 19.7 332.7 ⫾ 18.6 .531468 others in vitro.27,28,33 The explanation for the observa-
Under 358.3 ⫾ 15.6 348.9 ⫾ 13.1 .205428 tion in vivo is the greater dental plaque accumulation
Cervical/0 ␮m 291.8 ⫾ 28.2 274.6 ⫾ 26.1 .000039* and the patient’s difficulty in cleaning this area. In
Cervical/100 ␮m 314.3 ⫾ 20.1 292.4 ⫾ 24.9 .000029*
Cervical/200 ␮m 327.7 ⫾ 19.5 310.5 ⫾ 19.9 .000039*
vitro, the explanation would be the lower mineraliza-
Lingual 345.0 ⫾ 12.8 347.3 ⫾ 17.2 .999998 tion and the higher carbonate on the cervical face than
in the occlusal region. The second consideration about
*Differences between materials statistically significant by Tukey test.
the findings in Table III is that statistically significant
differences between the materials at P ⫽ .05 were
they used standardized toothpaste, kept their habitual observed in the cervical area, but not in the occlusal
oral hygiene, and received instructions not to use any region. Thus, the effect of Fuji Ortho LC in reducing
mouth rinse. The indentations were made at 10, 20, 30, enamel demineralization adjacent to the bond is more
50, 70, and 90 ␮m from the external surface of the evident in the cervical area. The findings are relevant
enamel to observe mineral changes at the outermost because they show that the effect of this material occurs
part of the enamel. The experimental period of 4 weeks on the tooth surface where the patient has difficulty in
was used, because measurable demineralization can be cleaning dental plaque by toothbrushing. This effect
observed around orthodontic appliances 1 month after can be attributed to the fluoride-releasing ability of
bonding.2,30 In addition, 2 internal controls (under the glass ionomer cements when submitted to cariogenic
bracket and at the lingual face) were used to evaluate challenges.34
the effect of the acid etching and the individual enamel Finally, the data in Table IV show that at 10 ␮m
hardness. from the surface, the only position with no significant
Regarding these additional controls, the findings difference between the materials was the one on the
showed that the reduction in enamel demineralization lingual surface (not treated). However, the difference in
might be attributed to the experimental material evalu- enamel hardness under the brackets bonded with Con-
ated. Thus, the microhardness of the enamel under cise or Fuji Ortho might be attributed to the acid
brackets bonded with Fuji Ortho LC or Concise was etching during the bonding with the resin. This effect
statistically similar (Table III), showing that the results was also described by O’Reilly and Featherstone,30
regarding demineralization are due to caries and not to who found a mineral loss of 3% to 8% directly under
the acid-etching effect of the material. Also, the result the brackets retained with composite resin. Neverthe-
found at the lingual surface (control, not treated) less, the reduced hardness in enamel adjacent to the
showed that the teeth of the 2 groups were similar, brackets cemented with Concise in comparison with
because the enamel hardness was statistically similar those with Fuji Ortho LC can be attributed to dental
(Table III). caries and not to acid etching. This is clear because Fuji
40 Pascotto et al
Table IV. Knoop microhardness (avg ⫾ SD) for materials and positions at depth of 10 ␮m
Interaction of material*place*depth Fuji Ortho LC
Fuji/Concise/occlusal 0␮m/10␮m 225.0 ⫾ 34.8
Fuji/Concise/occlusal 100␮m/10␮m 244.8 ⫾ 29.3
Fuji/Concise/occlusal 200␮m/10␮m 264.7 ⫾ 25.8
Fuji/Concise/underneath/10␮m 313.1 ⫾ 27.2
Fuji/Concise/cervical 0␮m/10␮m 192.0 ⫾ 42.2
Fuji/Concise/cervical 100␮m/10␮m 222.4 ⫾ 36.5
Fuji/Concise/cervical 200␮m/10␮m 243.9 ⫾ 29.2
Fuji/Concise/lingual/10␮m 281.9 ⫾ 25.4
*Differences between materials statistically significant by Tukey test.
Ortho LC reduced enamel demineralization not only at
the edge of the bracket (position 0) but also at 100 and
200 ␮m away from it, where the acid-etching effect
would not be expected.
Considering that the findings of this study were
observed after 30 days and that orthodontic treatment
takes a longer period of time, during which fluoride
release by glass ionomer decreases, because it is higher in
the first days,15,35 a longer evaluation should be made.
CONCLUSIONS
This in vivo study showed that a resin-modified
glass ionomer cement could reduce enamel demineral-
ization around a bonded bracket mainly in a tooth area
at high caries risk. It is suggested that its use as a
bonding material should be encouraged during orth-
odontic treatment.
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