International Orthodontics 2021; 19: 130–136

Websites:
www.em-consulte.com
www.sciencedirect.com
Original article

Shear bond strength of APC Plus adhesive

coated appliance system to enamel in wet
and dry conditions: An in vitro study

Zaid Nadhim Jawad Safar Ali 1, Allahyar Geramy 2, Soolmaz Heidari 3, Hannaneh Ghadirian 2

Available online: 3 February 2021
1. Nasser Al-musoay for Dental Specialization Center, Department of Orthodontics,
Department of Alnajaf Health and Medical Services, Al-shahied Najaf, Iraq
2. Tehran University of Medical Sciences, Faculty of Dentistry, Department of
Orthodontics, Tehran, Iran
3. Qazvin University of Medical Sciences, Dental Caries Prevention Research Center,
Department of Operative Dentistry, Qazvin, Iran

Correspondence:
Hannaneh Ghadirian, Tehran University of Medical Sciences, Faculty of Dentistry,
Department of Orthodontics, Tehran, Iran.
dr.h.ghadirian@gmail.com

Keywords Summary
Shear Strength
Orthodontic Brackets Objective > It is claimed that a hydrophilic primer, called the moisture insensitive primer (MIP), can
APC Plus be used with both dry and wet enamel surfaces. This study sought to assess the shear bond
Moisture-insensitive strength (SBS) of APC Plus adhesive coated appliance system to enamel using MIP in wet and dry
primer conditions.
Dental Enamel bonding Materials and Methods > This in vitro experimental study evaluated 24 extracted maxillary pre-
Dry molars with intact buccal enamel. The teeth were randomly divided into two groups (n = 12), and
Wet conditions APC Plus premolar brackets were bonded to their buccal surface using moisture insensitive primer
(MIP) under wet and dry enamel conditions. The SBS values were measured by a universal testing
machine. The adhesive remnant index (ARI) score was also determined under a stereomicroscope.
Data were analyzed using t-test and Mann–Whitney test at P < 0.05 level of significance.
Results > The SBS in wet condition was significantly lower than that in dry condition (mean value of
18.37 MPa versus 25.5 MPa, P < 0.001). The two groups had no significant difference regarding the
ARI scores (P > 0.05). However, in both groups, less adhesive was left on the tooth surface. This
suggests that bond failure occurred at the adhesive-enamel interface.
Conclusions > APC Plus adhesive coated appliance system in combination with hydrophilic MIP can
be effective in clinical conditions with high risk of moisture contamination.
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https://doi.org/10.1016/j.ortho.2021.01.001
© 2021 Published by Elsevier Masson SAS on behalf of CEO.
Shear bond strength of APC Plus adhesive coated appliance system to enamel in wet and dry conditions: An in
vitro study
Introduction
Fixed orthodontic appliances are bonded to tooth surfaces using
adhesive systems. The quality of bracket bonding is an impor-
tant factor in achieving favorable results and preventing early
debonding [1,2].
The minimal required SBS of 5.88 to 7.84 (6–8) MPa is ideal to
provide an effective bonding and is strong enough to allow
orthodontic tooth movement without debonding. On the
other hand, it is not too strong to damage the enamel
surface at the time of debonding upon completion of ortho-
dontic treatment [3,4]. Despite the high success rate
of bracket bonding, early debonding still occurs in 4.7% to
6% of the cases due to inexperience and poor skills of the
operator, moisture contamination, and excessive masticatory
forces [5].
Bracket debonding may incur significant costs. Thus, attempts
are ongoing by the manufacturers to design more efficient
adhesive systems. At present, composite resins are the
most efficient materials available for orthodontic bracket
bonding [6]. However, orthodontic bracket bonding to
etched enamel by the use of resin-based materials is a highly
technique-sensitive procedure. Moisture control is the most
important parameter in this process. Successful bracket bond-
ing highly depends on the provision of a dry field. Contami-
nation may occur after etching the tooth surface or after
primer application, compromising the bonding procedure
[7,8]. Ideal isolation of the tooth is often difficult to achieve,
particularly in the posterior teeth. Evidence shows that mois-
ture contamination by saliva can greatly decrease the bond
strength [9].
The conventional Bisphenol-A Glycidyl Methacrylate (Bis-GMA)
resins are hydrophobic and effective only on dry field. To over-
come this problem, hydrophilic bonding agents were introduced
to the market to enable successful bonding to moisture-con-
taminated enamel surfaces [10]. It is claimed that the moisture
insensitive primer (MIP), a hydrophilic primer introduced by 3 M
Unitek Dental Products (Monrovia, CA, USA), can be used with
both dry and wet enamel surfaces. Some previous studies
showed that the shear bond strength of MIP primer is sufficient
to achieve appropriate clinical results. However, there is still a
lack of information regarding this type of orthodontic product.
Furthermore, previous studies on this material applied the con-
ventional bracket systems (operator-on coated brackets)
[11,12]. In this study, adhesive-precoated bracket (APC) system
was used.
APCs were introduced in 1991 by 3 M Unitek with the aim of
reducing bonding steps. The composite used on the bracket has
a composition similar to the adhesive called TransbondTM intro-
duced by the company. This material might be used with various
primers. Some studies show that metal APC brackets have lower
bond strength than the uncoated brackets used with Trans-
bondTM adhesives [13,14].
tome 19 > n81 > March 2021
Original article
Accordingly, this study sought to assess the SBS provided by APC
Plus adhesive coated appliance system in wet and dry conditions
when used in combination with hydrophilic MIP.
Materials and methods
This in vitro experimental study evaluated 24 human maxillary
premolars extracted as part of an orthodontic treatment plan
(not related to this study). A total of 24 teeth were collected. The
teeth were stored in 0.5% chloramine T solution for one week at
4 8C as soon as they were extracted. Then, the samples were
stored in distilled water at the same temperature until the
beginning of the experiment. The inclusion criteria were
extracted maxillary premolars with intact enamel of their buccal
surface. The exclusion criteria were carious lesions or restoration
of the buccal surface, gross enamel hypoplasia, enamel defects,
cracks, buccal fluorosis, abfractions, demineralization, anoma-
lies, and amelogenesis imperfecta. All teeth were examined
visually and also under a stereomicroscope to ensure a sound
buccal surface.
The buccal surface of the teeth was polished with fluoride-free
pumice slurry using a prophy rubber cup and a slow-speed hand-
piece for 10 s for the purpose of standardization. Next, the
surface was rinsed with air/water spray for 15 s and dried with
oil-free air spray for 10 s. The teeth were then randomly divided
into two groups (n = 12) for bonding in dry and wet conditions.
In group 1 (dry condition), the exposed enamel surface was
etched with 37% phosphoric acid (FineEtch; Spident Co., Ltd.,
Korea) for 15 s. The etched surface was then rinsed with water
and dried with oil-free air spray to obtain a chalky white
appearance. TransbondTM MIP (3 M Unitek, Monrovia, California)
was then applied on the etched enamel surface followed by
gentle air spray for 2 to 5 s for uniform distribution of primer and
evaporation of solvent. The metal brackets (APCTM PLUS adhe-
sive coated appliance system, 3 M Unitek, Monrovia, California)
were directly placed on the etched and primed enamel surfaces
and pressed consistently. The brackets were subjected to 30 g
compressive force using a force gauge (Dontrix gauge,
Invecta®, GAC, Bohemia, NY, USA) [15].
The excess adhesive was removed. The mesial and distal mar-
gins were light-cured with a curing unit (Woodpecker, China)
with 1000 mW/cm2 light intensity at 470–480 nm wavelength
for 20 s (10 s from each side) at the closest distance to the
adhesive.
In group 2 (wet condition), the exposed enamel surface was
etched with 37% phosphoric acid for 15 s. After etching, the
teeth were rinsed with air and water spray. Excess water was
removed from the labial enamel surface, but the bonding sur-
face remained moist, according to the manufacturer's instruc-
tions. TransbondTM MIP was applied on the wet enamel surface.
The rest of the procedure was the same as group 1. The compo-
sition of primer and adhesive is provided in table I.
131
 ZNJ. Safar Ali, A. Geramy, S. Heidari, H. Ghadirian
Original article

TABLE I applied into the cubes, and the teeth were tied to the stainless-
Composition of MIP and adhesive coated on APC Plus bracket. steel wire with elastic O-rings, centred by a mark that bisected
each cube (figure 1). This ensured that all brackets on all teeth
Materials Composition (Wt%) were mounted in the same 3-dimensional space and orientation
Transbond TM
MIP Ethyl alcohol (30–40) relative to the aluminium cubes. The level of acrylic almost
Bisphenol A diglycidyl ether dimethacrylate corresponded to the level of cementoenamel junction.
(Bis-GMA) (10–30) The bond strength was measured using a universal testing
2-Hydroxyethyl methacrylate (10–30) machine (Zwick/Roell Z050, Ulm, Germany). Load was applied
2-Hydroxy-1,3-dimethacryloxypropane (7–13)
to the occlusal edge of the bonded bracket base by a knife-edge
Copolymer itaconic and acrylic acid (7–13)
Diurethane dimethacrylate (3–7) steel blade. The load was applied occluso-gingivally parallel to the
Water (3–7) buccal tooth surface at a crosshead speed of 0.5 mm/min. The
load at failure (recorded in Newtons) was divided by the bracket
APC PLUS adhesive Silane treated glass (35–45)
Silane treated quartz (35–45) base area in square millimetres (mm2) to determine the SBS in
Polyethylene glycol dimethacrylate megapascals (MPa). The bracket base size was determined by
(PEGDMA) (5–15) measuring the width and length of the bracket by a digital caliper.
1,2,3-propanetricarboxylic acid, 2-hydroxy-, Immediately after debonding, the bracket and the enamel
reaction products with 2-isocyanatoethyl
surfaces were inspected under a stereomicroscope at
methacrylate (5–15)
Bisphenol A diglycidyl ether dimethacrylate  10 magnification to determine the adhesive remnant index
(1–10) (ARI) score. The ARI score was determined according to Artun
Silane treated silica (1–5) and Bergland [17] as follows:
Diphenyliodonium hexafluorophosphatelane  0: no adhesive left on the tooth;
(< 1)  1: less than half of the adhesive left on the tooth;

 2: more than half of the adhesive left on the tooth;

 3: all adhesive left on the tooth, with a distinct impression of

Next, the bonded samples were stored in distilled water at 37 8C
for 24 hours to allow complete polymerization of orthodontic
composite. The samples then underwent 3500 thermal cycles
between 5–55 8C, with a dwell time of 30 seconds and a transfer
time of 10 seconds [16].
The teeth were then mounted in auto-polymerizing acrylic resin
in an aluminium cubic mold. A mounting jig measuring
0.019  0.025-inch was also fabricated of stainless steel archwire
to hold the samples. The mounting jig was suspended above the
cubes, fitted snugly in place by red wax. The cold cure acrylic was
the bracket mesh.
Based on the results of Lee and Kanavakis [18], the minimum
sample size in each group was estimated as 12 using two-
sample test analysis formula of PASS II considering a = 0.05,
b = 0.2, mean 1 = 10.8, mean 2 = 13, std1 = 1.99, and
std2 = 1.39.
The SBS data were analysed using independent sample t-test,
while the ARI scores were compared using the Mann–Whitney
test. Level of significance was set at 0.05. All statistical analyses
were carried out using SPSS version 22 (SPSS Inc., IL, USA).

Figure 1
Mounting jig procedure
a: fabricated from 0.019  0.025-inch stainless steel archwire attached to the bracket by elastic O-ring
132

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Shear bond strength of APC Plus adhesive coated appliance system to enamel in wet and dry conditions: An in
vitro study

Results
The table II shows the measures of central dispersion of the SBS
in the two groups. The results revealed that the SBS in wet
condition was significantly lower than that in dry condition
Original article
(P < 0.001). table III shows the frequency of ARI scores in the
two groups. The two groups had no significant differences
regarding the ARI scores (P > 0.05). The figure 2 shows bracket
images after debonding.

TABLE II
Measures of central dispersion of SBS (MPa) in the two groups (n = 12).

Group Mean Std. deviation Minimum Maximum

Dry 28.50 3.55 24.13 35.01

Wet 18.37 4.03 10.86 25.75

TABLE III
Frequency of ARI scores in the two groups.

Group ARI score 0 ARI score 1 ARI score 2 ARI score 3

Dry 9 (75%) 3 (25%) 0 (0%) 0 (0%)

Wet 7 (58.3%) 3 (25%) 1 (8.3%) 1 (8.3%)

Figure 2
Images after debonding
a: brackets with corresponding Adhesive Remnant index
b: sample from dry group showing fractured labial enamel
133

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 ZNJ. Safar Ali, A. Geramy, S. Heidari, H. Ghadirian
Original article
Discussion
The results revealed that the SBS in wet condition was signifi-
cantly lower than that in dry condition (mean value of
18.37 MPa versus 25.5 MPa, P < 0.001). Jain et al. [19] showed
the importance of adhesive thickness in the values of shear
bond strength. In order to standardize the amount of composite
on the bracket base, flash-free adhesive pre-coated brackets
(APC) were used in the present study.
The reason for lower SBS in wet condition may be that the
enamel porosities created by enamel acid-etching are blocked
by water, saliva, or blood contamination, which in turn, signi-
ficantly decreases the penetration of adhesive. As a result, both
the number and length of resin tags decrease, compromising
the bond strength [20]. A previous study showed that regardless
of the adhesive type, there were statistically significant differ-
ences in bond strength before and after saliva contamination
[21]. Several investigations reported that the MIP provided
significantly higher mean bond strength under dry conditions
compared to water, blood, and saliva contaminated conditions
[6,10,21].
It is difficult to compare the bond strength values reported by
different studies conducted in dry conditions because of the
variability in methodologies. The situation is even more complex
in wet conditions due to the lack of standardization in moisture
contamination.
In this study, the SBS provided by MIP (hydrophilic primer) was
significantly different in dry and wet enamel conditions with the
use of APC Plus brackets. This may be due to the presence of
ethanol and HEMA in the composition of Transbond MIP, which
are moisture-tolerant and can improve the bond strength in
minimal moisture conditions. Also, the carboxylate salt comple-
xes that form between the residual enamel calcium and the
ionized carboxyl groups of methacrylate functioned polyal-
keonic acid copolymer can break or reform to establish a revers-
ible hydrolytic bond mechanism along with micromechanical
retention. This mechanism may improve the bond strength in
the presence of moisture contamination [22]. Superior perfor-
mance of APC Plus brackets in wet conditions is partly because of
the lower level of hydrophobic monomers in its composition
compared to the conventional orthodontic composite and also
the presence of conventional glass ionomer. The weight per-
centage of bis-GMA present in resin coating of APC Plus brackets
is less than 10%, while this value is 10% to 20% in the conven-
tional orthodontic composite. Furthermore, another potential
reason for higher tolerance of APC Plus brackets in wet condition
is the presence of polyethylene glycol dimethacrylate (PEGDMA)
in its resin structure [12,23–25].
Addition of PEGDMA increases the tolerance of bonding agent to
water in bonding to dentin, where the unpredictable volume of
water in the tissue makes the bonding process more compli-
cated. Therefore, adding PEGDMA is likely to enhance the pen-
etration of bis-GMA-based adhesives into the wet enamel and
134
facilitate the homogeneous distribution of hydrophobic compo-
nents in the interface [12,26]. The current findings were in line
with some studies that showed the lower bond strength for MIP
in wet condition. Furthermore, they found that under wet con-
ditions, MIP should be used in conjunction with a hydrophilic
adhesive system rather than a hydrophobic system [6,23].
Clinically, the location of bond failure in debonded orthodontic
brackets is also important. Scales, such as the ARI score, which
quantify the amount of residual resin on the tooth surface after
debonding, can be used to assess the location of bond failure.
The ARI scores did not indicate any significant difference
between the two groups in this study (P > 0.05). Both groups
showed that less adhesive was left on the tooth surface. This
suggests that in both groups, bond failure occurred at the adhe-
sive-enamel interface. The main advantage here is the decreased
time required to remove the residual bonding agent and the
lower risk for enamel damage during adhesive removal [24].
However, the most favourable failure is score 2 or 3 due to the
probability of less enamel fracture [27].
The acceptable maximum tensile bond strength to etched enamel
is suggested to be 6–8 MPa [4]. Retief [28] suggested the bond
strength of 13.8 MPa to avoid enamel fracture. The samples with
the highest bond strength in this study (35 and 34.14 MPa)
showed fracture of labial enamel surface, shearing away from
the underlying dentin. A situation similar to this in the clinical
setting would be catastrophic. Enamel damage has been reported
in a great number of samples when using MIP with no contami-
nation [29]. The present study is in line with the study of Rosa et al.
[30], which showed the high bond strength value (18.31 MPa)
provided by TransbondTM MIP in a moisture-free environment and
as a result, the possibility of the damage to the enamel surface
during debonding. The SBS provided by adhesive materials should
be compatible with the clinical requirement [31].
However, great emphasis on the need for low bracket bond
strength shall be given cautiously because it is not possible to
accurately determine the magnitude of the forces to the tooth
during the biomechanical processes of an orthodontic treat-
ment; nor the forces resulting from mastication. In addition,
the magnitude of these forces might be increased in parafunc-
tional conditions. Moreover, the issue of aging and fatigue of the
adhesive in a humid environment i.e., the mouth, should be
considered, which can reduce the bond strength in the long run.
Despite numerous studies, there is still no agreement on the
amount of acceptable clinical bond strength for orthodontic
brackets.
Regarding the decision on the type of material, bonding char-
acteristics should also be taken into account along with the bond
strength. Some of these characteristics are mechanisms and
depth of penetration of different adhesives into the porosities
formed by enamel etching [29].
There is no standard protocol for bond strength testing in ortho-
dontics [32]. This makes it difficult to draw a reliable conclusion
tome 19 > n81 > March 2021
Shear bond strength of APC Plus adhesive coated appliance system to enamel in wet and dry conditions: An in
vitro study

by comparing one study to another. This was a potential limita-
tion of this study. Standardization of in vitro testing in bioma-
terials remains a problem. Difficult simulation of clinical oral
environment is another potential limitation of in vitro studies.
Future in vivo studies are required to confirm the results of this in
vitro study.
Conclusions
Considering the limitations of this in vitro study, it can be
concluded that APC Plus brackets in combination with hydro-
philic MIP can be effective in clinical situations, where there is a
risk of moisture contamination. It can decrease the chair time by
decreasing the procedural steps of bonding.
Original article
The bond strength obtained in wet conditions is higher than the
ideal range mentioned in the articles for the bond strength of
brackets. Though, considering various unpredictable conditions
in in-vivo studies that are not comparable to laboratory con-
ditions, such as the possibility of high biomechanical forces or
mastication, and also the possibility of long-term destruction of
the adhesive layer in a wet mouth, the use of APC PLUS brackets
with MIP seems to be useful on the wet enamel.
Funding: This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Disclosure of interest: The authors declare that they have no competing
interest.

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tome 19 > n81 > March 2021