ORIGINAL ARTICLE

Effect of fixed orthodontic appliances bonded

with different etching techniques on tooth
color: A prospective clinical study
Emad F. Al Maaitah,a Aban A. Abu Omar,b and Susan N. Al-Khateebc
Irbid, Jordan

Introduction: For most orthodontic patients, esthetic concerns are as important as functional demands. The
purpose of this study was to assess the effect of self-etching primer and conventional acid etching on tooth
color after orthodontic treatment. Methods: A total of 34 patients were enrolled in a clinical trial and divided
into 2 groups based on age: adolescents (#17 years) and adults (.17 years). Tooth color of all maxillary and
mandibular anterior teeth was measured before bonding and after debonding using a spectrophotometer
(Vita Easyshade Compact; Vita Zahnfabrik, Bad Sa €ckingen, Germany). Two types of etching techniques
were used for orthodontic bonding, self-etching primer and conventional acid etching, in a randomized
split-mouth design. Tooth color measurements were done according to the system of the Commission
Internationale de l’Eclairage (lightness, red/green, and yellow/blue). The corresponding tooth color
differences between pretreatment and posttreatment, etching groups, sexes, and age groups were
calculated. Results: Tooth color was significantly changed in all (L, a, b) color parameters (P \0.05). The light-
ness value decreased by 2.16 units, and the red/green and yellow/blue values increased by 0.32 and 1.78,
respectively. The average tooth color difference after orthodontic treatment was 2.85 units. No significant
difference was found between self-etching primer and conventional acid etching in their effects on tooth color
(P .0.05). Men and adolescents had more color change than did girls and adults (P\0.05). Conclusions: Fixed
orthodontic appliances caused tooth color changes; self-etching primer and conventional acid etching
had similar effects on tooth color; men and adolescents had greater color changes than did girls and adults.
(Am J Orthod Dentofacial Orthop 2013;144:43-9)

O
rthodontic treatment in the past had focused
mainly on improving occlusal functions,1 but
now esthetic concerns are as important as
functional demands. One factor that contributes to
optimal tooth esthetics is color. Tooth color results
from the interaction between light and the enamel
surface that is perceived by the human eye.2
In-vivo tooth color can be assessed by 2 means: visual
and instrumental assessments.3 The visual color
assessment was until recently considered the key for
From the Department of Preventive Dentistry, Faculty of Dentistry, Jordan
University of Science and Technology, Irbid, Jordan.
a
Assistant professor of orthodontics.
b
Postgraduate student.
c
Associate professor of orthodontics.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest and none were reported.
Reprint requests to: Emad F. Al Maaitah, Department of Preventive Dentistry,
Faculty of Dentistry, Jordan University of Science and Technology, PO Box
3030, Irbid 22110, Jordan; e-mail, efalmaaitah@just.edu.jo.
Submitted, October 2012; revised and accepted, February 2013.
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.02.020
dental color determination and matching.4 This
approach is considered quick and cost-effective.
However, a main drawback for this approach is that it
is highly subjective.5 Also, the range of shades available
for tooth matching does not cover all natural colors.6
The transformation of the system of the Commission
Internationale de l'Eclairage into numeric data and the
advances in computer and optical technologies made
the instrumental tooth color measurement an applicable
method.7
Several studies were conducted to evaluate and
compare the visual and instrumental color determina-
tion methods.8-12 Authors reported that instrumental
methods were more accurate and more reproducible
compared with human visual shade assessments and
can provide precise measurements of tooth color in vivo.
The effect of fixed orthodontic treatment on tooth
enamel had been widely investigated.13 One reported ad-
verse effect of fixed orthodontic treatment on tooth enamel
is retention and discoloration of resin tags after cleaning.14
The relationship between fixed orthodontic treat-
ment and tooth color has not been studied intensively;
43
44
only 1 in-vivo study has been conducted to assess the
effect of fixed orthodontic treatment on enamel color,
in which the authors concluded that fixed orthodontic
treatment resulted in tooth color changes after bracket
debonding.15 In-vitro studies also reported tooth color
changes after fixed orthodontic treatment.16-18
Acid etching of enamel aims to dissolve enamel rods
and to create surface porosity that allows for mechanical
retention of adhesive resin.19 Several studies have
been conducted to compare self-etching primer and
conventional etching techniques in terms of bond
strength, clinical chairside time, and enamel loss at
debonding.20-22 However, there are still no data in the
literature on the effect of different etching techniques
on tooth color.
Therefore, the aims of this prospective study were to
(1) assess the effect of fixed orthodontic treatment on
tooth enamel color, (2) evaluate the effect of different
acid etching techniques on tooth enamel color by
comparing self-etching primer with conventional
etching, and (3) determine other factors that might
affect tooth enamel color changes during fixed ortho-
dontic treatment such as tooth type, age, and sex.
MATERIAL AND METHODS
This prospective clinical study was conducted on
patients who required fixed orthodontic treatment.
These patients received their orthodontic treatment at
the dental teaching clinics of Jordan University of
Science and Technology in Irbid, Jordan. Ethical
approval for this study was obtained from the institu-
tional review board.
Thirty-eight consecutive patients (24 female, 14 male;
age range, 12-26 years; average age, 18 years 5 months)
were included in this study. Consequently, the
patients were divided into 2 groups: adolescent subjects
(#17 years) and adult subjects (.17) years.
The patients were selected according to the following
inclusion criteria: (1) no history of orthodontic treat-
ment; (2) need for maxillary and mandibular fixed
orthodontic treatment; (3) permanent dentition; (4) no
missing, impacted, or extracted teeth; (5) mild or no
dental crowding (\4 mm); (6) adequate oral hygiene
when first seen, with no plaque accumulation or gingival
inflammation; (7) no dental caries, decalcifications, or
restorations in the teeth under examination; (8) no
smoking habit; (9) medically and mentally fit with
no disabilities; and (10) signed the consent form to
participate in this study.
An organized protocol for patients' data recording
before and after orthodontic treatment was used. All
patients were examined at the same examination and
treatment clinic with good lighting conditions for the
July 2013  Vol 144  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Al Maaitah, Abu Omar, and Al-Khateeb
visual examinations. All patients were examined, and the
data were recorded in the morning under the same fluo-
rescent lamp of the dental unit. Cheek retractors were
used, and all teeth were polished with nonfluoridated
paste and then rinsed thoroughly with water. The teeth
were kept wet to prevent color changes from dryness.23
The spectrophotometer Vita Easyshade Compact
(Vita Zahnfabrik, Bad S€ackingen, Germany) (Fig 1) was
used to assess the color of the teeth before and after
treatment. This device provided precise color measure-
ment.12 Color assessment was based on the system of
the Commission Internationale de l'Eclairage involving
3 color parameters: lightness (L), red/green chromaticity
(a), and yellow/blue chromaticity (b).24 This system
allows for numeric information that relates well to actual
visual response and makes it the most popular one for
color measurement.25
Teeth included in the study were the maxillary and
mandibular central incisors, lateral incisors, and canines.
For all study teeth, 3 consecutive measures for each color
parameter (L, a, b) were recorded. The pretreatment and
posttreatment colors of teeth were determined as the
average value of the 3 consecutive measures for each
tooth. During color measurement, the sterile intraoral
device tip (mouthpiece) was held at a right angle to
the labial surface of each tooth, and the spectrophoto-
metric color assessment involved a standardized circular
area in the center of the middle third of the labial surface
of each tooth (Fig 2).
The device was calibrated before each session on the
white table supplied with it. During measurements, each
tooth was illuminated by the same internal light at the
probe tip of the device. Calibration was required to
prevent any deviation in the quantity of light from
internal light sources.
All measurements were taken by the same operator
(A.A.A.O.), who was calibrated for using the device for
3 weeks before the study.
A randomized split-mouth design was used for
bonding the maxillary and mandibular anterior teeth
with 2 etching techniques: self-etching primer and
conventional etching. This design was selected so that
the patients would act as their own controls to prevent
any effect from differences in their daily diets.
The split-mouth design was selected for each patient
by randomly using closed envelopes and asking the
patient to choose an envelope that contained the design
to be used.
After polishing the teeth with nonfluoridated paste,
moisture was controlled using a continuous saliva ejec-
tor and cotton rolls.
The assigned quadrants of teeth for conventional
acid etching were etched with 37% phosphoric acid
Al Maaitah, Abu Omar, and Al-Khateeb
Fig 1. Vita Easyshade Compact device used for color
measurement.
Fig 2. Spectrophotometric color assessment of the labial
surface.
(3M ESPE, Seefeld, Germany) for 15 seconds, followed
by rinsing with water for 15 seconds, and then dried
with an oil-free and moisture-free compressed air
flow until the etched surfaces exhibited a frosty white
appearance with no traces of moisture.
A thin coat of Transbond XT primer (3M Unitek,
Monrovia, Calif) was then applied on the whole labial
surface of each tooth followed by a gentle air burst
for primer thinning according to the manufacturer's
instruction. Transbond Plus Self Etching Primer
(3M Unitek) was applied on the whole labial surface of
the teeth in the quadrants assigned for the self-
etching primer with a rubbing motion for 5 seconds
followed by a gentle air burst for primer thinning
according to the manufacturer's instruction. Since
bracket positioning is variable from tooth to tooth and
from patient to patient, it was thought that application
of the primer to the whole labial surface would make the
American Journal of Orthodontics and Dentofacial Orthopedics
45
process more standardized. Metal orthodontic brackets
(0.022 3 0.028-in, Roth system; GAC International,
Bohemia, NY) were then bonded with Transbond XT
adhesive (3M Unitek).
All excess resin flash was removed, and the brackets
were light-cured with a curing light (Biolux, CFON
1163; BIO-ART Dental Equipment, S~ao Carlos, Brazil)
for 10 seconds per tooth according to the manufac-
turer's instructions.
Posterior teeth were bonded using the conventional
etching technique. All patients were treated by the
same orthodontist (A.A.A.O.) from bonding to
debonding the appliances.
During orthodontic treatment, the patients were
instructed to brush and floss their teeth regularly and
maintain good oral hygiene. To prevent potential tooth
discoloration and staining, chlorhexidine mouth rinse
was not used during treatment.
After completion of orthodontic treatment, the
fixed orthodontic appliances were debonded and the
adhesive remnants were cleaned using a spiral
12-fluted tungsten carbide bur (1172RA; Ortho-Care,
Bradford, United Kingdom) on a slow-speed hand piece.
The extent of resin removal was assessed visually by the
same operator (A.A.A.O.). The teeth were then polished
with nonfluoridated paste and rinsed thoroughly with
water.
The color difference (DE) for each etching group was
calculated using the difference in the L, a, and b values
before and after orthodontic treatment according to the
following equation: DE 5 [(L1 L2)2 1 (a1 a2)2 1
(b1 b2)2]1/2. Subscript letters 1 and 2 indicate before
and after treatment, respectively.
Because of poor oral hygiene and associated gingival
enlargement and formation of white spot lesions,
4 patients were excluded from the study after debond-
ing. This left only 34 patients (21 female, 13 male) as
the study sample. The pretreatment average age of these
patients was 18 years 7 months (range, 12-26 years).
They were divided into 2 groups: adolescents
(#17 years) and adults (.17 years).
Only maxillary and mandibular anterior teeth (canine
to canine) were studied. Accordingly, 408 stainless steel
brackets were bonded with 1 of 2 etching techniques in
a randomized split-mouth design; 204 brackets were
bonded with self-etching primer, and 204 brackets
were bonded with conventional etching.
The examiner (A.A.A.O.) was calibrated for 3 weeks
before starting the study to ensure intraexaminer
reliability for color measurement. At the end of the
calibration period, 7 patients were randomly selected
and reexamined (before starting orthodontic treatment)
by the same operator 1 week later. The differences
July 2013  Vol 144  Issue 1
46
Table I. Mean Commission Internationale de l'Eclairage values for all studied teeth before and after orthodontic
treatment
Color parameter n Pretreatment mean 6 SD Posttreatment mean 6 SD
L 408 80.86 6 5.99
a 408 0.10 6 1.51
b 408 22.36 6 5.87
*P \0.001.
between the first and second measurements of tooth
color were assessed by the Pearson correlation
coefficient and paired t test.
Statistical analysis
Statistical analysis was performed using the
Statistical Package for the Social Sciences for Windows
program (version 17.0; SPSS, Chicago, Ill). Descriptive
statistics including means and standard deviations
were calculated for all variables in the study. A paired
t test was used to detect changes in all tooth color
parameters before and after treatment. A 2-way analysis
of variance (ANOVA) test was used to assess the effects
of etching technique, tooth type, and their interactions
on tooth color changes. Independent t tests were used
to detect changes in tooth color between the sexes and
between the age groups. Results were considered signif-
icant at P \0.05.
RESULTS
In the error testing, a significant correlation was
found between the first and second readings (0.942),
and there was no significant difference between the first
and second readings using the paired t test, with
a significance level of P 5 0.893.
Treatment duration for all patients was 12 to 15
months. Since there was no significant variation in
treatment duration between patients, it was not
considered as a variable for statistical analysis.
The mean pretreatment values for the L, a, and
b color parameters were 80.86 6 5.99, 0.10 6 1.51,
and 22.36 6 5.87, respectively.
The mean posttreatment values for the L, a, and
b color parameters were 78.7 6 6.06, 0.42 6 1.50,
and 24.14 6 5.86, respectively.
By comparing the pretreatment and posttreatment
means, the color parameters showed statistically
significant changes after orthodontic treatment. The
mean L value decreased by 2.16 units (P \0.001), and
the means of both a and b increased by 0.32 and
1.78 units, respectively (P \0.001), as shown in Table I.
All measured teeth showed significant color changes
after fixed orthodontic treatment; the color differences
July 2013  Vol 144  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Al Maaitah, Abu Omar, and Al-Khateeb
Mean difference Significance (P value)
78.70 6 6.06 2.16 \0.001*
0.42 6 1.50 10.32 \0.001*
24.14 6 5.86 11.78 \0.001*
of all measured teeth ranged from 1.75 to 3.50 units.
The mean total tooth color difference for all teeth was
2.85 units (SD, 6 0.3).
Color difference was assessed with respect to etching
techniques, tooth types, and their interactions using the
2-way mixed ANOVA test.
The results showed that etching technique, tooth
type, and their interactions had no statistical significant
effect on tooth color differences (Table II).
The mean tooth color differences in male and female
subjects were 2.91 and 2.83 units, respectively. The
results showed that male patients had more statistically
significant tooth color changes than did female patients
(P \0.05) (Table III).
The mean tooth color differences in adolescents and
adults were 2.93 and 2.76 units, respectively. The results
showed that adolescents had more statistically signifi-
cant tooth color changes than did adults (Table IV).
DISCUSSION
In this prospective clinical study, we aimed to assess
the effects of fixed orthodontic treatment, etching
technique, and other factors such as age, sex, and tooth
type on tooth color. The advantage of in-vivo studies
over in-vitro ones is that in-vivo studies are better suited
for observing the whole effect of an experiment; also,
the results of in-vitro studies are always interpreted
with caution because they lack the exact ability to
simulate oral environment.
This study was based on instrumental tooth shade
determinations before and after fixed orthodontic
treatment. Several studies have concluded that instru-
mental tooth shade measurements are superior to visual
methods.8-12
The quantitative measurements of tooth color in the
oral environment are exposed to several systemic and
random errors; this is the major limitation of this clinical
study. Random errors are linked to instrument variability,
so all measured color parameters of each tooth were
averaged to reduce the variability of instrumental tooth
color measurement and to minimize the random errors.23
Systemic errors are present in all instruments used
for tooth shade recording and result from calibration
Al Maaitah, Abu Omar, and Al-Khateeb 47

patient factors such as age, diet, and care of appliance

Table II. Results of 2-way ANOVA for tooth color dif-
will be accounted for evenly, since each patient acts as
ferences regarding tooth type and etching technique
his or her own control.
(self-etching and conventional etching)
During treatment, the patients were instructed to
Type III sum Mean brush and floss their teeth regularly and to avoid
Source of variation of squares square Significance chlorhexidine mouthwashes to prevent potential tooth
Intercept 3321.62 3321.62 0.00 discoloration. Oral hygiene was monitored for all
Etching 0.01 0.01 0.89
Tooth type 0.13 0.07 0.48
patients during the treatment. When the oral hygiene
Etching 3 tooth type 0.01 0.01 0.93 started to deteriorate, the patients were sent to the
Error 36.19 0.09 hygienist for proper instructions and treatment.
Several in-vitro studies have been conducted to
assess the effect of orthodontic bonding on tooth
Table III. Means and standard deviations of tooth color.16-18 On this issue, only 1 clinical trial was
color difference (DE) in male and female patients conducted by Karamouzos et al15 using the conven-
tional acid etching technique. They reported that tooth
Color Male Female Mean Significance color changed significantly after orthodontic treatment.
change mean (SD) mean (SD) difference P value
In our study, we found that all color parameters
DE 2.91 (0.33) 2.83 (0.20) 0.078 0.004*
showed statistically significant changes after fixed
*P \0.01. orthodontic treatment. The mean L value decreased by
2.16 units, and the means of the a and b values increased
by 0.32 and 1.78, respectively. This agreed with the
Table IV. Means and standard deviations of tooth findings of others who reported reductions of L values
color difference (DE) in adolescents and adults and increases of both a and b values, and showed that
teeth tend to become darker and shift into more
Color Adolescent Adult Mean Significance
change mean (SD) mean (SD) difference P value reddish-yellowish colors in a clinically visible color
DE 2.93 (0.23) 2.76 (0.33) 0.178 \0.001* change.15,17
Paul et al8 reported that L values that changed less
*P \0.001. than 2.0 units were considered clinically acceptable
and not visible clinically. In our study, L values were
above this threshold and were clinically relevant as the
techniques, variations of measurement geometry, and teeth became darker in color.
instrumental metamerism.5 These errors are difficult to In our study, tooth color changes ranged from 1.75 to
be managed and can affect instrument accuracy.26 3.50 units after fixed orthodontic treatment. This find-
The probe tip of the device was placed perpendicular ing agrees with the changes reported by Kim et al17
and flush to the tooth surface according to the manufac- (2.44 units) and Karamouzos et al15 (2.12-3.61 units).
turer's instructions. The middle third of the tooth was In this study, tooth type had no significant effect on
selected for the measurement; this is because the middle color change. This agreed with a previous report.15
third was described as the site that best represents the Several studies were concerned about the clinical
color of the tooth.6 Also, it is the site where the perceptibility of color differences and showed that
orthodontic bracket will be positioned. The incisal and a color change of more than 1 color change unit is
gingival thirds were excluded because the first is almost perceived by the human eye as a difference.25,26
translucent and the latter is affected by back-scattered The standard value of the clinical detection limit of
light from the gingiva. color matching was set to 3.7 color change units, beyond
All color measurements were expressed using the which the difference is clinically visible.28 In this study,
Commission Internationale de l'Eclairage color system; the results showed that the highest color change value
the advantages of this system are its communicability was 3.5 units, suggesting that the tooth color changes
and ability to express color difference in numeric units were not clinically visible to human eyes.
that can be related to visual perception and clinical Several etiologic factors might contribute to enamel
significance.27 color change as a result of fixed orthodontic treatment.
Bonding was carried out using 2 techniques, These factors can affect surface texture and structural
self-etching and conventional etching, which were composition of the enamel. One factor that was
randomly alternated between subjects in the split- attributed to tooth color change is the change in
mouth design. The advantage of this design is that surface roughness of the enamel. This roughness can

American Journal of Orthodontics and Dentofacial Orthopedics July 2013  Vol 144  Issue 1
48
affect light scattering of the tooth.29 Enamel surface
roughness could have resulted from enamel etching
since acids cause dissolution of enamel prisms30,31 or
from debonding techniques or adhesive removal
procedures.16,32
Another factor that might contribute to tooth color
changes is irreversible adhesive resin infiltration into
enamel; it can reach up to 30 to 50 mm.19 This
infiltration might change the refraction index of the
enamel and thus affect diffusing light components;
the L parameter is mainly affected by this factor, as
reported before.33 Also, these resin tags can become
discolored and affect enamel color.16 Discoloration of
these tags could result from adsorption of food stains
or corrosion of orthodontic appliances.34,35 It has been
reported that these stains contributed to the change in
the b parameter toward the yellowish dimension.36
Cinader37 showed that the microscopic morphology of
the etching pattern of a self-etching primer (Transbond
Plus) was similar to that of conventional phosphoric
acid etching. However, several studies found that self-
etching primers produced less aggressive etching patterns
compared with conventional acid etching.38,39
Accordingly, it has been suggested that shorter resin
tags of adhesive material will be formed as a result.
To the best of our knowledge, no previous studies,
either in vitro or in vivo, have compared a self-etching
primer and conventional acid etching with regard to
their effect on tooth color.
In our study, we found no statistically significant
difference between self-etching primer and conven-
tional acid etching on tooth color changes after
treatment with fixed orthodontic appliances. This might
be attributed to the similarity of etching patterns
reported before or because the outermost layer of the
resin tag will discolor first, whether it is long or short.37
Subsequently, it might be logical to think about another
important factor: treatment duration. In our study,
treatment durations ranged between 12 and 15 months
and were not considered as a variable in the analysis.
This suggests the need for further investigation to look
at the effect of treatment duration and also to assess
tooth color after debonding during the retention phase,
since resin tags remain and will be susceptible to further
discoloration.
This study showed that male patients tend to have
more tooth color changes as a result of fixed orthodontic
treatment than do female patients. To the best of our
knowledge, no previous studies have looked at the
relationship between sex and tooth color change caused
by orthodontic treatment. However, this sex difference
might be related to differences in dietary habits or the
quality of oral hygiene between male and female
July 2013  Vol 144  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Al Maaitah, Abu Omar, and Al-Khateeb
patients, since males tend to have lower oral hygiene
quality than do females and subsequently more
susceptibility to tooth color changes. Also, it has been
found that male patients tend to develop enamel
demineralization more than do females; this could be
linked in some way to the quality of oral hygiene and
the process of enamel infiltration and susceptibility to
discoloration and demineralization in male patients
compared with females.40,41
This study showed that adolescents tend to have
more color changes after fixed orthodontic treatment
than do adults. Again, no previous studies looked at
this factor in relation to tooth color after orthodontic
treatment. This can be explained by the fact that the
teeth of younger patients are more prone to acid attacks
and also have increased enamel porosity than those of
adults.42 This can increase their susceptibility for more
staining adsorption.
CONCLUSIONS
Within the limitations of this trial, the following
conclusions were obtained.
1. Fixed orthodontic treatment is associated with
significant tooth color changes.
2. Etching technique (self-etching primer and
conventional phosphoric acid etching) showed no
statistically significant difference in tooth color
change after fixed orthodontic treatment.
3. Tooth type had no statistically significant effect
on tooth color change after fixed orthodontic
treatment.
4. Male patients had greater tooth color changes
than did female patients after fixed orthodontic
treatment.
5. Adolescents showed greater color changes than did
adults after fixed orthodontic treatment.
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July 2013  Vol 144  Issue 1