过氧化氢漂白对正畸托槽粘接强度影响的实验研究
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摘要
目的：漂白可以改善自然牙齿的美观，这个方法可以用于内源性和外源性牙齿变色。过氧化氢牙齿漂白材料的使用在过去几年有快速的增长，虽然在使用方面还有许多问题没有答复。因此，还很少有人知道它们的生物学和物理学作用，特别是它们对牙齿修复材料和牙釉质正畸粘接剂粘结强度的影响。成年人对正畸治疗的关注的同时，他们对牙齿漂白也很感兴趣，所以测定漂白对正畸托槽粘接剂的釉质粘结强度的影响就十分重要。这项实验的目的是1观察30%过氧化氢漂白技术对釉质表面形态的影响，2 测定30%过氧化氢漂白对复合树脂釉质粘接强度的影响以及3托槽剪脱后釉质上粘接剂残余指数的评估。
方法：在10倍放大镜帮助下，挑选应正畸而拔除的48颗前磨牙。要求牙冠表面釉质完好，无龋坏、无裂纹、非四环素牙、非氟斑牙。牙齿挑选标准规定未做过像酒精、甲醛、过氧化氢和其他漂白剂等化学用品预处理。
将48颗前磨牙随机分为A、B、C、D四组，每组12颗，全部用洁治器和橡皮剖光杯低转速刷洗去除表面污渍和牙垢存放人工唾液中，温度为37℃，液体一天一换以防细菌滋生。A组牙未做特殊处理，作为对照组，实验时直接进行托槽粘接。其他三组先使用过氧化氢漂白方法，每天使用30%的过氧化氢漂白30min，清洗后浸泡于人工唾液中，连续1
周，B组漂白后即刻预备进行托槽粘接。C组漂白后再储存于人工唾液中1周预备进行托槽粘接。D组漂白后再储存于人工唾液中4周预备进行托槽粘接。
从A、B、C三组牙齿中各随机抽取2颗，用金刚石切割片截去牙根部，近远中纵向剖开，颊面取近远中向和牙合龈向的中1/3部分制成样本，清洗，脱水，干燥，喷金后置于扫描电镜下观察并照相。
将四组各取10颗牙齿按釉质粘合剂说明粘接正畸方丝弓托槽，均匀调配液体和糊剂，托槽按要求的位置就位并轻压，以探针沿托槽周围刮去多余的粘接剂。粘接剂固化5min后，标本放入37℃的人工唾液中保存， 24ｈ后备用于进行抗剪切强度的测定。所有操作均实验者本人完成。将每一个标本的根部镶入一个圆柱体状的石膏底座，釉质粘接面与底座垂直，牙冠完全暴露。安放剪切刀，固定样本的底座，使剪切方向和托槽槽沟垂直，定位使剪切刀刃施力方向和托槽底板平行并能够通过托槽底板，剪切刀具速度为0.5mm/min。仪器纪录托槽被剪下时的最大载荷力，根据托槽底面积，计算出抗剪切强度。
在10倍的放大镜观察下,分别统计托槽脱落后釉质表面残留的粘接剂量，并按粘接剂残余指数（ARI）对每一个样本进行分类。ARI可分为五级:5为釉质上无粘接剂，4为釉质上剩余少于10%粘接剂，3为釉质上剩余多于10%而少于90%粘接剂，2为釉质上剩余多于90%粘接剂，1为粘接剂全部剩余在釉质上。应用单因素方差分析对四组测试样本的抗剪切粘结强度进行统计学分析，应用卡方检验对四组测试样本的粘接剂残留指数进行比较。比较时将各组样本合并，各
分为两部分：少于10%的粘接剂残留在牙釉质面上（指数为5和4）；多于10%的粘接剂残留在牙釉质面上（指数为3、2和1）。所有的统计学分析都由SAS软件包处理。
结果：扫描电镜显示A组釉质表面结构致密均匀，平坦，无釉质结构，有广泛分布的细小颗粒，直线状的发育沟和划痕。B组牙釉质呈不规则状剥脱，釉质层呈卷心菜叶状卷起脱落，高低不平，表面无菌班和碎屑，无法辨认釉柱、釉间质排列结构。C组釉柱周围溶解，呈粗糙风化岩状，散在微孔增加，残存釉柱脊状隆起和明显矿物质沉积。低倍电镜下，釉质表面呈蜂窝状结构。
四组样本粘接托槽后的抗剪切强度测试结果的统计学分析显示A组样本的平均抗剪切强度为11.65 MPa，明显高于B组样本的4.43 MPa，差异有统计学意义，而与C组样本的13。41和D组样本的11。86无显著性差异。
托槽剪脱后牙面釉质上粘接剂残留指数分析结果显示A组样本粘接剂残留指数与B组样本差异有统计学意义，与C组和D组样本差异无统计学意义。
结论：用30%过氧化氢行牙齿漂白，的确能使牙釉质表面结构发生改变，使其脱矿，微空增多甚至釉柱溶解。而漂白后的牙齿，即刻进行正畸托槽的粘接，就会因过氧化氢暂时滞留在釉质内部，干扰粘结树脂的附着和抑制树脂的聚合或是过氧化氢引起的树脂终端的渗透性和结构的改变，使树脂突在釉质内部的锁结作用无法形成，从而影响到抗剪切粘结强度。漂白后的釉质储存于人工唾液中延期粘接,有助于消除过氧化氢对树脂粘接强度的影响。实验表明漂白后延迟一周粘接，会因牙齿内滞留的残余过氧化氢的清除和牙齿表面
结构的重新矿化，而使正畸托槽的抗剪切粘结强度恢复，达到临床正畸操作中所要求的托槽粘结强度。
Objective: The esthetics of the natural dentition can be improved by bleaching and this process can be applied to intrinsically and extrinsically stain teeth. The use of peroxide-based tooth-whitening materials has increased substantially in the past few years, despite many unanswered questions about their use. Thus, little is known of their biological and physical effects, particularly their effects on dental restorative materials and on the shear bond strength of orthodontic adhesives to human tooth enamel. Because some adults who are interested in orthodontic treatment might have also had their teeth bleached or might be interested in bleaching, it seems important to determine whether bleaching would significantly influence the bonding strength of orthodontic bracket adhesives to the enamel surface. The purpose of our study was to 1 observe the influence of 30% hydrogen peroxide bleaching technique on the enamel surface morphology, 2 determine the effect of 30% hydrogen peroxide bleaching on the shear bond strength of metallic orthodontic brackets and 3 evaluate the adhesive remnant index after debonding.
Method: Under 10×magnification, 48 noncarious
premolars fleshly extracted for orthodontic reasons were used in this study. Teeth with hypoplastic areas, crack, tetracycline or fluorotic of the enamel structure were excluded. The criteria for tooth selection dictated no pretreatment with a chemical agent such as alcohol, formalin, or hydrogen peroxide, or any other form of bleaching. The teeth were stored in artificial saliva at 37℃after all stains and debris were removed using a dentifrice and rubber cup rotating in a slow speed handpiece. The liquid was changed weekly to avoid bacterial growth.
The 48 premolars were randomly divided into 4 groups of 12 teeth. Group A that was not subjected to any pretreatment and evaluated as a control group, was prepared for bonding brackets directly. The teeth in the other groups were immersed in 30% hydrogen peroxide solutions for 30 min every day and then stored in artificial saliva. This procedure was repeated over 7 days. Following bleaching, Group B was prepared for bonding brackets immediately; Group C was stored in artificial saliva for 7 days; Group D was stored in artificial saliva for 28 days.
Paired teeth were selected random from Group A, B and C. Premolars were transversely sectioned with diamond discs in a buccal-lingual direction and removed the roots. The enamel buccal surface was remained 1/3 in the mesio-distal and cervico-occlusal directions, and then made into the sample. Samples were washed with water spray, dehydrated with 70% alcohol, and dried with air. After samples evaporated and coated with 15um of gold in a Polaron EIKO.IB-3 scanning electron
microscope coating unit, the specimens’ configuration were examined microscopically and photographed with a Hitachi S-3500N scanning electron microscope.
According to the recommendations provided by the manufacturers of enamel adhesion system, the buccal surface of the tooth was etched with 37% phosphoric acid and applied the liquid primer. Following that the pastes were mixed symmetrically, edgewise brackets were bonded to location with enamel adhesive in 10 teeth from each group respectively and press lightly, excess composite removed with a probe. Five minutes curing later, the specimens were kept in artificial saliva at 37℃ for 24h to prepare the shear bond strength test. The operator himself completed all procedures.
After this process, the root of each tooth was mounted vertically in a cylinder gypsum pedestal so that the crown was exposed. The embedded specimen was secured in a jig attached to the base plate of a universal testing machine. A steel knife-edge was placed parallel to the specimen surface so that the shear force applied the load directly to the bracket soleplate. A crosshead speed of 0.5 mm/min was used, and the maximum load necessary to debond the bracket was recorded. The force required to remove the brackets was measured, and the shear bond strength w
方法：在10倍放大镜帮助下，挑选应正畸而拔除的48颗前磨牙。要求牙冠表面釉质完好，无龋坏、无裂纹、非四环素牙、非氟斑牙。牙齿挑选标准规定未做过像酒精、甲醛、过氧化氢和其他漂白剂等化学用品预处理。
将48颗前磨牙随机分为A、B、C、D四组，每组12颗，全部用洁治器和橡皮剖光杯低转速刷洗去除表面污渍和牙垢存放人工唾液中，温度为37℃，液体一天一换以防细菌滋生。A组牙未做特殊处理，作为对照组，实验时直接进行托槽粘接。其他三组先使用过氧化氢漂白方法，每天使用30%的过氧化氢漂白30min，清洗后浸泡于人工唾液中，连续1
周，B组漂白后即刻预备进行托槽粘接。C组漂白后再储存于人工唾液中1周预备进行托槽粘接。D组漂白后再储存于人工唾液中4周预备进行托槽粘接。
从A、B、C三组牙齿中各随机抽取2颗，用金刚石切割片截去牙根部，近远中纵向剖开，颊面取近远中向和牙合龈向的中1/3部分制成样本，清洗，脱水，干燥，喷金后置于扫描电镜下观察并照相。
将四组各取10颗牙齿按釉质粘合剂说明粘接正畸方丝弓托槽，均匀调配液体和糊剂，托槽按要求的位置就位并轻压，以探针沿托槽周围刮去多余的粘接剂。粘接剂固化5min后，标本放入37℃的人工唾液中保存， 24ｈ后备用于进行抗剪切强度的测定。所有操作均实验者本人完成。将每一个标本的根部镶入一个圆柱体状的石膏底座，釉质粘接面与底座垂直，牙冠完全暴露。安放剪切刀，固定样本的底座，使剪切方向和托槽槽沟垂直，定位使剪切刀刃施力方向和托槽底板平行并能够通过托槽底板，剪切刀具速度为0.5mm/min。仪器纪录托槽被剪下时的最大载荷力，根据托槽底面积，计算出抗剪切强度。
在10倍的放大镜观察下,分别统计托槽脱落后釉质表面残留的粘接剂量，并按粘接剂残余指数（ARI）对每一个样本进行分类。ARI可分为五级:5为釉质上无粘接剂，4为釉质上剩余少于10%粘接剂，3为釉质上剩余多于10%而少于90%粘接剂，2为釉质上剩余多于90%粘接剂，1为粘接剂全部剩余在釉质上。应用单因素方差分析对四组测试样本的抗剪切粘结强度进行统计学分析，应用卡方检验对四组测试样本的粘接剂残留指数进行比较。比较时将各组样本合并，各
分为两部分：少于10%的粘接剂残留在牙釉质面上（指数为5和4）；多于10%的粘接剂残留在牙釉质面上（指数为3、2和1）。所有的统计学分析都由SAS软件包处理。
结果：扫描电镜显示A组釉质表面结构致密均匀，平坦，无釉质结构，有广泛分布的细小颗粒，直线状的发育沟和划痕。B组牙釉质呈不规则状剥脱，釉质层呈卷心菜叶状卷起脱落，高低不平，表面无菌班和碎屑，无法辨认釉柱、釉间质排列结构。C组釉柱周围溶解，呈粗糙风化岩状，散在微孔增加，残存釉柱脊状隆起和明显矿物质沉积。低倍电镜下，釉质表面呈蜂窝状结构。
四组样本粘接托槽后的抗剪切强度测试结果的统计学分析显示A组样本的平均抗剪切强度为11.65 MPa，明显高于B组样本的4.43 MPa，差异有统计学意义，而与C组样本的13。41和D组样本的11。86无显著性差异。
托槽剪脱后牙面釉质上粘接剂残留指数分析结果显示A组样本粘接剂残留指数与B组样本差异有统计学意义，与C组和D组样本差异无统计学意义。
结论：用30%过氧化氢行牙齿漂白，的确能使牙釉质表面结构发生改变，使其脱矿，微空增多甚至釉柱溶解。而漂白后的牙齿，即刻进行正畸托槽的粘接，就会因过氧化氢暂时滞留在釉质内部，干扰粘结树脂的附着和抑制树脂的聚合或是过氧化氢引起的树脂终端的渗透性和结构的改变，使树脂突在釉质内部的锁结作用无法形成，从而影响到抗剪切粘结强度。漂白后的釉质储存于人工唾液中延期粘接,有助于消除过氧化氢对树脂粘接强度的影响。实验表明漂白后延迟一周粘接，会因牙齿内滞留的残余过氧化氢的清除和牙齿表面
结构的重新矿化，而使正畸托槽的抗剪切粘结强度恢复，达到临床正畸操作中所要求的托槽粘结强度。
Objective: The esthetics of the natural dentition can be improved by bleaching and this process can be applied to intrinsically and extrinsically stain teeth. The use of peroxide-based tooth-whitening materials has increased substantially in the past few years, despite many unanswered questions about their use. Thus, little is known of their biological and physical effects, particularly their effects on dental restorative materials and on the shear bond strength of orthodontic adhesives to human tooth enamel. Because some adults who are interested in orthodontic treatment might have also had their teeth bleached or might be interested in bleaching, it seems important to determine whether bleaching would significantly influence the bonding strength of orthodontic bracket adhesives to the enamel surface. The purpose of our study was to 1 observe the influence of 30% hydrogen peroxide bleaching technique on the enamel surface morphology, 2 determine the effect of 30% hydrogen peroxide bleaching on the shear bond strength of metallic orthodontic brackets and 3 evaluate the adhesive remnant index after debonding.
Method: Under 10×magnification, 48 noncarious
premolars fleshly extracted for orthodontic reasons were used in this study. Teeth with hypoplastic areas, crack, tetracycline or fluorotic of the enamel structure were excluded. The criteria for tooth selection dictated no pretreatment with a chemical agent such as alcohol, formalin, or hydrogen peroxide, or any other form of bleaching. The teeth were stored in artificial saliva at 37℃after all stains and debris were removed using a dentifrice and rubber cup rotating in a slow speed handpiece. The liquid was changed weekly to avoid bacterial growth.
The 48 premolars were randomly divided into 4 groups of 12 teeth. Group A that was not subjected to any pretreatment and evaluated as a control group, was prepared for bonding brackets directly. The teeth in the other groups were immersed in 30% hydrogen peroxide solutions for 30 min every day and then stored in artificial saliva. This procedure was repeated over 7 days. Following bleaching, Group B was prepared for bonding brackets immediately; Group C was stored in artificial saliva for 7 days; Group D was stored in artificial saliva for 28 days.
Paired teeth were selected random from Group A, B and C. Premolars were transversely sectioned with diamond discs in a buccal-lingual direction and removed the roots. The enamel buccal surface was remained 1/3 in the mesio-distal and cervico-occlusal directions, and then made into the sample. Samples were washed with water spray, dehydrated with 70% alcohol, and dried with air. After samples evaporated and coated with 15um of gold in a Polaron EIKO.IB-3 scanning electron
microscope coating unit, the specimens’ configuration were examined microscopically and photographed with a Hitachi S-3500N scanning electron microscope.
According to the recommendations provided by the manufacturers of enamel adhesion system, the buccal surface of the tooth was etched with 37% phosphoric acid and applied the liquid primer. Following that the pastes were mixed symmetrically, edgewise brackets were bonded to location with enamel adhesive in 10 teeth from each group respectively and press lightly, excess composite removed with a probe. Five minutes curing later, the specimens were kept in artificial saliva at 37℃ for 24h to prepare the shear bond strength test. The operator himself completed all procedures.
After this process, the root of each tooth was mounted vertically in a cylinder gypsum pedestal so that the crown was exposed. The embedded specimen was secured in a jig attached to the base plate of a universal testing machine. A steel knife-edge was placed parallel to the specimen surface so that the shear force applied the load directly to the bracket soleplate. A crosshead speed of 0.5 mm/min was used, and the maximum load necessary to debond the bracket was recorded. The force required to remove the brackets was measured, and the shear bond strength w
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Bishara SE, Denehy GE, Goepferd SJ. A conservative postorthodontic treatment of enamel stains. Am J Orthod Dentofacial Orthop. 1987,92(1): 2~7
Adibfar A, Steele A, Torneck CD, et al. Leaching of hydrogen peroxide from bleached bovine enamel. J Endod.
1992, 18(10): 488~491
孙翔，陈吉华，沈丽娟，等。漂白剂对牙釉质和树脂粘结强度的影响。中国临床康复，2003, 7(3): 3206~3207。
Josey AL, Meyers IA, Romaniuk K, et al. The effect of a vital bleaching technique on enamel surface morphology and the bonding of composite resin to enamel. J Oral Rehabil. 1996, 23(4): 244~250
Josey AL, Meyers IA, Romaniuk K, et al. The effect of a vital bleaching technique on enamel surface morphology and the bonding of composite resin to enamel. J Oral Rehabil. 1996, 23(4): 244~250
Swift EJ Jr. Restorative considerations with vital tooth bleaching. J Am Dent Assoc. 1997, 128 Suppl:60~64
顾冬云，周晓蕾。漂白剂、遮色剂对树脂-釉质粘结强度影响的实验研究。医用生物力学，1996, 11(3): 155~159
Sung EC, Chan SM, Mito R, et al. Effect of carbamide peroxide bleaching on the shear bond strength of composite to dental bonding agent enhanced enamel. J Prosthet Dent. 1999, 82(5): 595~599
Rotstein I, Dankner E, Goldman A, et al. Histochemical analysis of dental hard tissues following bleaching. J Endod. 1996, 22(1): 23~25
Perdigao J, Francci C, Swift EJ Jr, et al. Ultra-morphological study of the interaction of dental adhesives with carbamide peroxide-bleached enamel. Am J Dent. 1998, 11(6): 291~301
Lewinstein I, Hirschfeld Z, Stabholz A, et al. Effect of hydrogen peroxide and sodium perborate on the microhardness of human enamel and dentin. J Endod. 1994, 20(2): 61~63
Araujo EM, Baratieri LN, Vieira LC, et al. In situ effect of 10% carbamide peroxide on microhardness of human enamel: function of time. Esthet Restor Dent. 2003, 15(3): 166~173
Lopes GC, Bonissoni L, Baratieri LN, et al. Effect of bleaching agents on the hardness and morphology of enamel. J Esthet Restor Dent. 2002, 14(1): 24~30
Cooley RL, Burger KM. Effect of carbamide peroxide on composite resin. Quintessenceint, 1991, 22: 817~820
Monaghan P, Lim E, Lautenschlager E.Effects of home bleaching preparations on composite resin color. J Prosthet Dent. 1992, 68(4): 575~578
Titley KC, Torneck CD, Smith DC, et al. Adhesion of composite resin to bleached and unbleached bovine enamel. J Dent Res. 1988,67(12): 1523~1528
Zalkind M, Arwaz JR. Surface morphology changes in human enamel, dentin and cementum following bleaching: a scanning electron microscopy study. Endod Dent Traumatol. 1996, 12(2): 82~88
James W, Curtis JR, Gene L, et al. Assessing the effects of 10 percent carbamide peroxide on oral soft tissues. JADA.
1996, 127: 1218~1223