Assessment of enamel surface quality after orthodontic adhesive removal using ultrasonic scaler versus carbide bur

Assessment of enamel surface quality after orthodontic adhesive removal using ultrasonic scaler versus carbide bur | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of enamel surface quality after orthodontic adhesive removal using ultrasonic scaler versus carbide bur Husin Alnaser This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8970910/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 27 You are reading this latest preprint version Abstract Complete removal of orthodontic adhesive after bracket debonding remains challenging, as currently available techniques may compromise enamel integrity. This study aimed to compare enamel surface quality and procedural efficiency following adhesive removal using ultrasonic scaler tips versus tungsten carbide burs. Material and Methods . Fifty-four extracted human premolars were randomly allocated into two groups (n = 27 per group) according to the adhesive removal method: ultrasonic scaler or tungsten carbide bur. Orthodontic brackets were bonded and debonded after 24 hours. Residual adhesive was removed using the assigned technique and polished with Silicone OneGloss. Enamel surface evaluation included the Adhesive Remnant Index (ARI), adhesive remnant area percentage (ARA%), enamel surface defect area percentage (ESDA%), enamel damage index (EDI), and total adhesive removal time (seconds). Morphological assessment was performed using scanning electron microscopy (SEM). Quantitative image analysis was conducted using ImageJ software. Statistical analysis was performed using the Mann–Whitney U test and χ² test (p < 0.05). Results . The ultrasonic group demonstrated higher ARA% values and significantly lower ESDA% values compared to the carbide bur group (p < 0.001), indicating greater preservation of enamel integrity but increased residual adhesive. The carbide bur achieved more complete adhesive removal (lower ARI and ARA%) and significantly reduced procedure time (mean: 10 s vs 22 s; p < 0.001), but was associated with significantly greater enamel surface damage (higher ESDA% and EDI scores). SEM analysis confirmed smoother enamel morphology in the ultrasonic group and more pronounced grooves and microcracks following carbide bur use. Conclusion. Both techniques effectively removed residual orthodontic adhesive but produced distinctly different enamel surface outcomes. Ultrasonic instrumentation better preserved enamel integrity at the expense of longer working time and greater adhesive remnants, whereas tungsten carbide burs enabled faster and more complete adhesive removal but increased enamel surface damage. Optimization of combined or sequential protocols may help balance efficiency and enamel preservation. Orthodontic adhesive removal ultrasonic scaler tungsten carbide bur scanning electron microscopy (SEM) adhesive remnant index (ARI) adhesive remnant area (ARA%) enamel surface defect area (ESDA%) Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Malocclusions are widespread in the general population, and the need for orthodontic treatment varies depending on multiple factors, including patient age and the type and severity of the pathology. The most common malocclusions include crossbite, open bite, deep bite, and increased overjet. The prevalence and clinical impact of these conditions stimulate ongoing research aimed at improving early diagnosis, prevention, and effective correction during growth and development. In recent decades, fixed orthodontic appliances bonded to tooth surfaces using adhesive materials have become the leading method for the treatment of dental anomalies [ 1 ]. The development of adhesive fixation technologies has fundamentally transformed orthodontic practice by providing improved aesthetics, controlled tooth movement, enhanced patient comfort, and minimal periodontal involvement. Additionally, adhesive systems may facilitate oral hygiene due to a reduced contact surface and easier access for tooth brushing. However, the quality of adhesive bonding remains critical at all treatment stages, as bond failure may occur due to technical errors, inadequate adhesive properties, insufficient bond strength, or poor-quality brackets [ 3 , 11 ]. The final stage of orthodontic treatment is of particular importance and includes both bracket removal and complete elimination of residual adhesive from the enamel surface. Incomplete adhesive removal promotes plaque accumulation, which may result in caries, enamel demineralization, and irreversible surface damage, adversely affecting both aesthetics and tooth integrity. As enamel tissue cannot regenerate, its preservation is a primary concern in contemporary orthodontics [ 4 , 12 ]. Consequently, modern treatment strategies aim to minimize enamel damage while ensuring effective adhesive removal. The growing trend toward minimally invasive dentistry has also influenced orthodontics, encouraging the development of safer and more efficient debonding and adhesive removal techniques. Ghaleb et al. (2024) reported that tungsten carbide burs provide a relatively gentle method for adhesive removal based on ARI, SEM, and EDI assessments. Similarly, Sadri et al. (2021) identified tungsten carbide burs as an effective tool, although ARI values were not evaluated in their study. Thawaba et al. (2023) demonstrated that tungsten carbide and zirconium burs resulted in minimal enamel roughness, whereas Sugsompian et al. (2020) reported superior enamel surface quality with Sof-Lex discs and sandblasting systems compared to tungsten carbide burs based on SEM observations; however, atomic force microscopy revealed no significant differences in surface roughness. Despite extensive research, no single technique currently provides rapid, safe, and complete removal of orthodontic adhesive without causing even minor alterations to enamel morphology [ 1 ]. Conflicting findings and the absence of standardized evaluation criteria further complicate method selection. Therefore, the aim of this study was to comparatively evaluate enamel surface quality following orthodontic adhesive removal using an ultrasonic scaler and a carbide bur. Material and Methods Fifty-four extracted human premolars were included in this randomized in vitro study. The teeth were randomly allocated into two groups (n = 27 per group) according to the adhesive removal method: ultrasonic scaler or tungsten carbide bur. Orthodontic brackets were bonded to the buccal enamel surface and debonded after 24 hours. Residual adhesive was removed using the assigned system, followed by polishing with Silicone OneGloss. The following outcome measures were assessed: adhesive remnant index (ARI), enamel damage index (EDI), adhesive remnant area percentage (ARA%), enamel surface defect area percentage (ESDA%), and total adhesive removal time (seconds). Quantitative analysis of ARA% and ESDA% was performed using ImageJ software (National Institutes of Health, USA). SEM images were obtained at a standardized magnification (×500) and calibrated using the scale bar prior to analysis. For ARA% calculation, a standardized region corresponding to the bracket bonding area was selected, and its total surface area was measured. Residual adhesive was segmented using grayscale thresholding, and the adhesive-covered area was calculated. ARA% was defined as the ratio of adhesive remnant area to the total analyzed enamel area, expressed as a percentage. For ESDA% assessment, morphometric analysis of enamel surface defects (cracks, grooves, and areas of surface roughness) was performed within the same standardized region. Defective areas were manually delineated, and their cumulative surface area was calculated. ESDA% was defined as the percentage of enamel surface area exhibiting structural defects relative to the total analyzed area. Statistical analysis was performed using SPSS software 31.0.0.0 (IBM Corp., USA). Normality of data distribution was evaluated using the Shapiro–Wilk test. As quantitative variables did not follow a normal distribution (p < 0.05), intergroup comparisons for ARA%, ESDA%, and adhesive removal time were conducted using the nonparametric Mann–Whitney U test. Categorical variables (ARI and EDI scores) were analyzed using Pearson’s χ² test. Quantitative data are presented as median and interquartile range (Me [Q1; Q3]). Statistical significance was set at p < 0.05. All measurements were performed by a single investigator blinded to group allocation. To assess intra-examiner reproducibility, 10 randomly selected specimens were re-evaluated. Informed consent was obtained from all participants or their legal guardians prior to sample collection. All procedures were conducted in accordance with the Declaration of Helsinki and approved by the institutional ethics committee of I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia. Sample selection and preparation A total of 54 human premolars extracted for orthodontic or periodontal reasons were collected from the outpatient clinics of the Department of Maxillofacial Surgery at Sechenov University. All teeth were examined under fiber-optic illumination and selected according to the following inclusion criteria: intact buccal enamel surface; absence of carious lesions, visible cracks, fractures, white spot lesions, or enamel hypoplasia; absence of restorations; and no evidence of previously bonded orthodontic appliances. Residual organic debris was carefully removed from the tooth surfaces. The samples were then disinfected and stored in an aqueous hydrogen peroxide (H₂O₂) solution at room temperature to prevent dehydration. Immediately prior to experimental procedures, the teeth were thoroughly rinsed with distilled water [ 1 , 5 , 6 ]. Enamel and bonding protocol Enamel and bonding protocol The enamel surface was prepared for bracket bonding by etching with 37% phosphoric acid for 30 seconds. The etchant was thoroughly rinsed off with a water spray for 30 seconds, and the surface was dried using oil- and moisture-free air until a uniform chalky-white appearance was achieved. Orthodontic brackets were bonded to the buccal enamel surface following the standard adhesive protocol and stored for 24 hours. After this period, the brackets were removed. Residual adhesive was eliminated using either an ultrasonic scaler or a tungsten carbide bur, followed by enamel polishing [ 13 , 14 ]. Laboratory analyses The prepared tooth specimens were subjected to detailed laboratory analysis. Microstructural and elemental characterization was performed using scanning electron microscopy (SEM; Tescan Vega 3SB, Tescan, Brno, Czech Republic) combined with energy-dispersive X-ray spectroscopy (EDS; Oxford Instruments, Abingdon, UK). For SEM examination, the specimens were mounted on aluminum stubs. To minimize surface charging artifacts during enamel and residual resin analysis, the samples were coated with a thin carbon layer (approximately 10 nm) or examined under low-vacuum conditions, as appropriate. All specimens were coded and numbered prior to analysis. Random allocation into two groups (n = 27 per group) was performed using an online randomization tool (Random.org) to minimize allocation bias. Each group corresponded to one adhesive removal technique: ultrasonic scaler or tungsten carbide bur. The randomization process and group allocation scheme are illustrated in Fig. 1 . Representative SEM images of enamel surfaces after adhesive removal using the ultrasonic scaler and tungsten carbide bur are shown in Figs. 2 and 3 . Results SEM analysis was performed at ×500 magnification following image calibration using a scale bar. Quantitative morphometric assessment was conducted within a standardized region corresponding to the bracket bonding area. The ultrasonic group demonstrated significantly higher residual adhesive area percentages (ARA%) compared with the tungsten carbide bur group (p < 0.001), indicating greater retention of adhesive on the enamel surface. In contrast, the carbide bur group exhibited lower ARA% values, reflecting more complete adhesive removal. The thresholding and segmentation process performed in ImageJ is demonstrated in Fig. 4 . Assessment of enamel surface damage revealed significantly higher enamel surface defect area percentages (ESDA%) in the tungsten carbide bur group compared with the ultrasonic group (p < 0.001). This finding indicates a greater extent of structural enamel damage following bur application. Overall, the ultrasonic technique was associated with increased residual adhesive but reduced enamel surface defects, whereas the carbide bur achieved more complete adhesive removal at the expense of greater enamel surface damage. A comparative analysis of ARA% and ESDA% values between groups is presented in Fig. 5 . Adhesive Remnant Index (ARI) and Enamel Surface Assessment The distribution of Adhesive Remnant Index (ARI) scores is presented in Table 1 , and the percentage distribution of ARI scores between groups is illustrated in Fig. 6 . The assessment was performed using a four-point scale (0–3), reflecting the amount of adhesive remaining on the enamel surface after adhesive removal: 0 – no adhesive remnants; 1 – less than 50% of the enamel surface covered with adhesive; 2 – more than 50% of the enamel surface covered with adhesive; 3 – the entire adhesive layer remaining on the enamel surface. Table 1 Adhesive Remnant Index (ARI) scale ARI score Description of adhesive remnants % of enamel surface 0 Complete adhesive removal 0% 1 Less than 50% adhesive remaining 50% 3 Entire adhesive layer remaining 100% Based on qualitative SEM evaluation, specimens treated with the ultrasonic scaler predominantly demonstrated ARI scores of 1–2, indicating effective removal of the majority of adhesive, although small remnants persisted within micro-irregularities or along scratch lines created by scaler movement (Table 2 ). SEM observations revealed that the tungsten carbide bur produced a considerably rougher enamel surface compared with the ultrasonic scaler. The images demonstrated a progressive pattern of abrasive wear characterized by the formation of grooves and microcracks, accompanied by a reduction in residual adhesive but an increase in enamel surface damage. Although this method achieved effective adhesive removal (predominantly ARI ≈ 0–1), it compromised enamel surface integrity, resulting in deep mechanical scratches and microcracks. The distribution pattern of ARI values within each group is shown in Fig. 7 . Table 2 Assessment of the amount of adhesive residue when comparing methods Removal method ARI range Nature of adhesive residue Ultrasonic scaler 1–2 Small residues in micro-recesses, along scratches Tungsten carbide bur 0 Minimal residue, grainy morphology Enamel surface condition was evaluated using the Enamel Damage Index (EDI), which consists of four grades: 0 – smooth surface without scratches (perikymata may be visible); 1 – acceptable surface with isolated fine, scattered scratches; 2 – rough surface with numerous pronounced scratches or small grooves; 3 – surface with deep scratches, wide grooves, and defects visible to the naked eye. In the ultrasonic adhesive removal group, an EDI score of 2 predominated upon magnified examination, indicating the development of moderately pronounced surface roughness with multiple scratches. In contrast, the tungsten carbide bur group predominantly exhibited an EDI score of 3, both upon visual inspection and under magnification, indicating severe structural enamel damage characterized by deep grooves and macroscopically visible defects. Conclusion Within the limitations of this in vitro study, both the ultrasonic scaler and the tungsten carbide bur effectively removed residual orthodontic adhesive; however, they produced distinctly different enamel surface outcomes. Analysis of the Adhesive Remnant Index (ARI) demonstrated significant differences between the two methods. In the ultrasonic group, higher ARI scores predominated, with most specimens exhibiting ARI values of 2 or 3, indicating substantial adhesive retention on the enamel surface following debonding. In contrast, the tungsten carbide bur group showed predominantly low ARI scores. Complete adhesive removal (ARI = 0) was observed in 63.0% of cases, minimal remnants (ARI = 1) in 33.3%, and ARI = 2 only in isolated cases (3.7%); ARI = 3 was not recorded. Quantitative morphometric assessment confirmed these findings. The ultrasonic group demonstrated significantly higher adhesive remnant area (ARA%) values (mean 19%) compared to the tungsten carbide bur group (mean 11%) (p < 0.001). Conversely, evaluation of enamel structural defect area (ESDA%) revealed significantly greater surface damage in the tungsten carbide bur group (mean 28%) compared to the ultrasonic group (mean 10%) (p < 0.001). Qualitative assessment using the Enamel Damage Index (EDI) further supported these results. The ultrasonic method was associated predominantly with EDI = 2, corresponding to moderate surface roughness with multiple superficial scratches. In contrast, the tungsten carbide bur group mainly exhibited EDI = 3, characterized by deep grooves, pronounced surface irregularities, and structural enamel defects. Adhesive removal time also differed substantially between the methods. A comparison of procedural time between the two methods is presented in Fig. 8 .The ultrasonic technique required approximately 22 seconds on average, whereas the tungsten carbide bur achieved adhesive removal in approximately 10 seconds. Thus, while tungsten carbide burs enable faster and more complete adhesive removal, this efficiency is accompanied by increased enamel surface damage. Ultrasonic instrumentation, although less time-efficient and associated with greater adhesive retention, demonstrated superior enamel preservation. Taken together, these findings highlight a clinically relevant trade-off between efficiency and enamel safety. Future research should focus on optimizing combined or sequential protocols that achieve effective adhesive removal while minimizing irreversible enamel alterations. Abbreviations ARI Adhesive Remnant Index ARA% Adhesive Remnant Area Percentage ESDA% Enamel Surface Defect Area Percentage EDI Enamel Damage Index SEM Scanning Electron Microscopy EDS Energy-Dispersive X-ray Spectroscopy Declarations Ethics approval and consent to participate The study protocol was approved by the Institutional Ethics Committee of I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia (Protocol No. 05-25, dated 12 March 2025). All procedures were conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants or their legal representatives prior to tooth extraction and use of the extracted teeth for research purposes. Consent for publication Not applicable. Availability of data and materials The datasets analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The author declares that there are no competing interests. Funding This research received no external funding. Authors' contributions HA conceived and designed the study, performed the experiments, conducted data analysis, and wrote the manuscript. The author read and approved the final manuscript. Acknowledgements Not applicable. References Alkahlout AE, El-Gazzar RI, Shamaa MS. Effect of air abrasion techniques vs tungsten carbide burs on enamel surface after orthodontic adhesive remnant removal. J Contemp Dent Pract. 2025;26(4):366–72. https://doi.org/10.5005/jp-journals-10024-3865 . Arhun N, Arman A. Effects of orthodontic mechanics on tooth enamel: a review. Semin Orthod. 2007;13:281–91. Beniash E, Stifler CA, Sun CY, Jung GS, Qin Z, Buehler MJ, et al. The hidden structure of human enamel. 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Paolone G, Mandurino M, Baldani S, Paolone MG, Goracci C, Scolavino S, Gherlone E, Cantatore G, Gastaldi G. Quantitative volumetric enamel loss after orthodontic debracketing/debonding and clean-up procedures: a systematic review. Appl Sci. 2023;13:5369. https://doi.org/10.3390/app13095369 . Pallarés-Serrano S, Pallarés-Serrano A, Pallarés-Sabater A. In vitro study on the influence of the buccal surface convexity of the tooth upon enamel loss after bracket removal. Mater (Basel). 2024;17:1519. https://doi.org/10.3390/ma17071519 . Pinho M, Pinto G, Mesquita P, Souza J, Pinhão Ferreira A, Henriques B. Damage on tooth enamel after removal of orthodontic adhesive by Arkansas’ stone and tungsten carbide burs. Rev Port Estomatol Med Dent Cir Maxilofac. 2017;58:32–8. https://doi.org/10.24873/j.rpemd.2017.05.011 . Poole DFG, Newman HN. Dental plaque and oral health. Nature. 1971;234:329–31. Sadri K, Mohammadi SA, Behroozian A, Fathi P. Comparison of the direction of enamel microcracks in five different debonding methods: an in vitro study. Iran J Orthod. 2021;16(1):1–6. https://doi.org/10.22034/IJO.2021.540946.1005 . Salehi P, Pakshir H, Naseri N, Baherimoghaddam T. The effects of composite resin types and debonding pliers on the amount of adhesive remnants and enamel damage: a stereomicroscopic evaluation. J Dent Res Dent Clin Dent Prospects. 2013;7(4):199–205. https://doi.org/10.5681/joddd.2013.032 . Sugsompian K, Tansalarak R, Piyapattamin T. Comparison of enamel surface roughness from different polishing methods: scanning electron microscopy and atomic force microscopy investigation. Eur J Dent. 2020;14:299–305. Thawaba AA, Albelasy NF, Elsherbini AM, Hafez AM. Evaluation of enamel roughness after orthodontic debonding and clean-up procedures using zirconia, tungsten carbide, and white stone burs: an in vitro study. BMC Oral Health. 2023;23:478. https://doi.org/10.1186/s12903-023-03194-6 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8970910","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627898080,"identity":"7f81691c-547a-4a04-a72b-8c3d174b1fa0","order_by":0,"name":"Husin Alnaser","email":"data:image/png;base64,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","orcid":"","institution":"I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation","correspondingAuthor":true,"prefix":"","firstName":"Husin","middleName":"","lastName":"Alnaser","suffix":""}],"badges":[],"createdAt":"2026-02-25 19:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8970910/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8970910/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107838578,"identity":"dcea035a-805e-463a-9759-86e08b7e67ea","added_by":"auto","created_at":"2026-04-26 17:11:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":151009,"visible":true,"origin":"","legend":"\u003cp\u003eOnline random number generator (random.org) for randomizing 54 samples into groups (n=27). The number 9 was generated\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8970910/v1/ab2f44f434f051fc9e917b23.png"},{"id":107838580,"identity":"17baed4d-3ffe-44c1-a33a-3b768673670b","added_by":"auto","created_at":"2026-04-26 17:11:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":519291,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eEnamel surface after adhesive removal using an ultrasonic scaler\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8970910/v1/3ccf68d25f05c3826ef77afc.png"},{"id":107838581,"identity":"c6abde9e-f28d-499f-acf8-7ca7a3dc32dd","added_by":"auto","created_at":"2026-04-26 17:11:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":713121,"visible":true,"origin":"","legend":"\u003cp\u003eEnamel surface after adhesive removal using a tungsten carbide bur\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8970910/v1/b8a17b5e2fe7d2885da260bc.png"},{"id":107870376,"identity":"78fae004-9f62-416c-9249-5bde28dff194","added_by":"auto","created_at":"2026-04-27 07:39:31","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1101029,"visible":true,"origin":"","legend":"\u003cp\u003eThresholding method for residual adhesive image processing in ImageJ\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8970910/v1/5904ecc086ed5c847fdb2e7f.png"},{"id":107870561,"identity":"85f971aa-3942-4920-9e73-14b70f0d4480","added_by":"auto","created_at":"2026-04-27 07:39:55","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":45583,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of ARA% and ESDA% values between groups\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8970910/v1/febf7a7b5b82c55d2884c6c5.png"},{"id":107838582,"identity":"e94b63fe-84f4-4590-997b-d7c12502b57d","added_by":"auto","created_at":"2026-04-26 17:11:19","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":42025,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePercentage distribution of the adhesive residue index (ARI) when removing adhesive with both methods\u003c/em\u003e.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8970910/v1/1b480ee88a3399469def7c7c.png"},{"id":107869819,"identity":"eba4a4cc-1c63-4038-92d1-a4bf16283377","added_by":"auto","created_at":"2026-04-27 07:38:14","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":23086,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart of ARI values with distribution within each group\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-8970910/v1/c8773182e4e09e5a2aaea5ef.png"},{"id":107838585,"identity":"d4ac226b-49f2-4163-97ea-4c09aaf75d7e","added_by":"auto","created_at":"2026-04-26 17:11:19","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":19999,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of adhesive removal time in both methods\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-8970910/v1/cca5f96be53a2bde8ff3c644.png"},{"id":107872077,"identity":"63aeaf66-582c-4103-a960-c34327f56734","added_by":"auto","created_at":"2026-04-27 07:55:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2454912,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8970910/v1/8566fbac-e8ff-4e96-a734-8ece2d19f1dd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of enamel surface quality after orthodontic adhesive removal using ultrasonic scaler versus carbide bur","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMalocclusions are widespread in the general population, and the need for orthodontic treatment varies depending on multiple factors, including patient age and the type and severity of the pathology. The most common malocclusions include crossbite, open bite, deep bite, and increased overjet. The prevalence and clinical impact of these conditions stimulate ongoing research aimed at improving early diagnosis, prevention, and effective correction during growth and development.\u003c/p\u003e \u003cp\u003eIn recent decades, fixed orthodontic appliances bonded to tooth surfaces using adhesive materials have become the leading method for the treatment of dental anomalies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The development of adhesive fixation technologies has fundamentally transformed orthodontic practice by providing improved aesthetics, controlled tooth movement, enhanced patient comfort, and minimal periodontal involvement. Additionally, adhesive systems may facilitate oral hygiene due to a reduced contact surface and easier access for tooth brushing. However, the quality of adhesive bonding remains critical at all treatment stages, as bond failure may occur due to technical errors, inadequate adhesive properties, insufficient bond strength, or poor-quality brackets [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe final stage of orthodontic treatment is of particular importance and includes both bracket removal and complete elimination of residual adhesive from the enamel surface. Incomplete adhesive removal promotes plaque accumulation, which may result in caries, enamel demineralization, and irreversible surface damage, adversely affecting both aesthetics and tooth integrity. As enamel tissue cannot regenerate, its preservation is a primary concern in contemporary orthodontics [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Consequently, modern treatment strategies aim to minimize enamel damage while ensuring effective adhesive removal.\u003c/p\u003e \u003cp\u003eThe growing trend toward minimally invasive dentistry has also influenced orthodontics, encouraging the development of safer and more efficient debonding and adhesive removal techniques. Ghaleb et al. (2024) reported that tungsten carbide burs provide a relatively gentle method for adhesive removal based on ARI, SEM, and EDI assessments. Similarly, Sadri et al. (2021) identified tungsten carbide burs as an effective tool, although ARI values were not evaluated in their study. Thawaba et al. (2023) demonstrated that tungsten carbide and zirconium burs resulted in minimal enamel roughness, whereas Sugsompian et al. (2020) reported superior enamel surface quality with Sof-Lex discs and sandblasting systems compared to tungsten carbide burs based on SEM observations; however, atomic force microscopy revealed no significant differences in surface roughness.\u003c/p\u003e \u003cp\u003eDespite extensive research, no single technique currently provides rapid, safe, and complete removal of orthodontic adhesive without causing even minor alterations to enamel morphology [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Conflicting findings and the absence of standardized evaluation criteria further complicate method selection. Therefore, the aim of this study was to comparatively evaluate enamel surface quality following orthodontic adhesive removal using an ultrasonic scaler and a carbide bur.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eFifty-four extracted human premolars were included in this randomized in vitro study. The teeth were randomly allocated into two groups (n\u0026thinsp;=\u0026thinsp;27 per group) according to the adhesive removal method: ultrasonic scaler or tungsten carbide bur. Orthodontic brackets were bonded to the buccal enamel surface and debonded after 24 hours. Residual adhesive was removed using the assigned system, followed by polishing with Silicone OneGloss.\u003c/p\u003e \u003cp\u003eThe following outcome measures were assessed: adhesive remnant index (ARI), enamel damage index (EDI), adhesive remnant area percentage (ARA%), enamel surface defect area percentage (ESDA%), and total adhesive removal time (seconds).\u003c/p\u003e \u003cp\u003eQuantitative analysis of ARA% and ESDA% was performed using ImageJ software (National Institutes of Health, USA). SEM images were obtained at a standardized magnification (\u0026times;500) and calibrated using the scale bar prior to analysis.\u003c/p\u003e \u003cp\u003eFor ARA% calculation, a standardized region corresponding to the bracket bonding area was selected, and its total surface area was measured. Residual adhesive was segmented using grayscale thresholding, and the adhesive-covered area was calculated. ARA% was defined as the ratio of adhesive remnant area to the total analyzed enamel area, expressed as a percentage.\u003c/p\u003e \u003cp\u003eFor ESDA% assessment, morphometric analysis of enamel surface defects (cracks, grooves, and areas of surface roughness) was performed within the same standardized region. Defective areas were manually delineated, and their cumulative surface area was calculated. ESDA% was defined as the percentage of enamel surface area exhibiting structural defects relative to the total analyzed area.\u003c/p\u003e \u003cp\u003eStatistical analysis was performed using SPSS software 31.0.0.0 (IBM Corp., USA). Normality of data distribution was evaluated using the Shapiro\u0026ndash;Wilk test. As quantitative variables did not follow a normal distribution (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), intergroup comparisons for ARA%, ESDA%, and adhesive removal time were conducted using the nonparametric Mann\u0026ndash;Whitney U test.\u003c/p\u003e \u003cp\u003eCategorical variables (ARI and EDI scores) were analyzed using Pearson\u0026rsquo;s χ\u0026sup2; test.\u003c/p\u003e \u003cp\u003eQuantitative data are presented as median and interquartile range (Me [Q1; Q3]). Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eAll measurements were performed by a single investigator blinded to group allocation. To assess intra-examiner reproducibility, 10 randomly selected specimens were re-evaluated.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ewas obtained from all participants or their legal guardians prior to sample collection. All procedures were conducted in accordance with the Declaration of Helsinki and approved by the institutional ethics committee of I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSample selection and preparation\u003c/h2\u003e \u003cp\u003eA total of 54 human premolars extracted for orthodontic or periodontal reasons were collected from the outpatient clinics of the Department of Maxillofacial Surgery at Sechenov University. All teeth were examined under fiber-optic illumination and selected according to the following inclusion criteria: intact buccal enamel surface; absence of carious lesions, visible cracks, fractures, white spot lesions, or enamel hypoplasia; absence of restorations; and no evidence of previously bonded orthodontic appliances.\u003c/p\u003e \u003cp\u003eResidual organic debris was carefully removed from the tooth surfaces. The samples were then disinfected and stored in an aqueous hydrogen peroxide (H₂O₂) solution at room temperature to prevent dehydration. Immediately prior to experimental procedures, the teeth were thoroughly rinsed with distilled water [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEnamel and bonding protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eEnamel and bonding protocol\u003c/div\u003e \u003cp\u003eThe enamel surface was prepared for bracket bonding by etching with 37% phosphoric acid for 30 seconds. The etchant was thoroughly rinsed off with a water spray for 30 seconds, and the surface was dried using oil- and moisture-free air until a uniform chalky-white appearance was achieved. Orthodontic brackets were bonded to the buccal enamel surface following the standard adhesive protocol and stored for 24 hours. After this period, the brackets were removed.\u003c/p\u003e \u003cp\u003eResidual adhesive was eliminated using either an ultrasonic scaler or a tungsten carbide bur, followed by enamel polishing [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eLaboratory analyses\u003c/h3\u003e\n\u003cp\u003eThe prepared tooth specimens were subjected to detailed laboratory analysis. Microstructural and elemental characterization was performed using scanning electron microscopy (SEM; Tescan Vega 3SB, Tescan, Brno, Czech Republic) combined with energy-dispersive X-ray spectroscopy (EDS; Oxford Instruments, Abingdon, UK).\u003c/p\u003e \u003cp\u003eFor SEM examination, the specimens were mounted on aluminum stubs. To minimize surface charging artifacts during enamel and residual resin analysis, the samples were coated with a thin carbon layer (approximately 10 nm) or examined under low-vacuum conditions, as appropriate.\u003c/p\u003e \u003cp\u003eAll specimens were coded and numbered prior to analysis. Random allocation into two groups (n\u0026thinsp;=\u0026thinsp;27 per group) was performed using an online randomization tool (Random.org) to minimize allocation bias. Each group corresponded to one adhesive removal technique: ultrasonic scaler or tungsten carbide bur. The randomization process and group allocation scheme are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eRepresentative SEM images of enamel surfaces after adhesive removal using the ultrasonic scaler and tungsten carbide bur are shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSEM analysis was performed at \u0026times;500 magnification following image calibration using a scale bar. Quantitative morphometric assessment was conducted within a standardized region corresponding to the bracket bonding area.\u003c/p\u003e \u003cp\u003eThe ultrasonic group demonstrated significantly higher residual adhesive area percentages (ARA%) compared with the tungsten carbide bur group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating greater retention of adhesive on the enamel surface. In contrast, the carbide bur group exhibited lower ARA% values, reflecting more complete adhesive removal.\u003c/p\u003e \u003cp\u003eThe thresholding and segmentation process performed in ImageJ is demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAssessment of enamel surface damage revealed significantly higher enamel surface defect area percentages (ESDA%) in the tungsten carbide bur group compared with the ultrasonic group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This finding indicates a greater extent of structural enamel damage following bur application.\u003c/p\u003e \u003cp\u003eOverall, the ultrasonic technique was associated with increased residual adhesive but reduced enamel surface defects, whereas the carbide bur achieved more complete adhesive removal at the expense of greater enamel surface damage. A comparative analysis of ARA% and ESDA% values between groups is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eAdhesive Remnant Index (ARI) and Enamel Surface Assessment\u003c/h3\u003e\n\u003cp\u003eThe distribution of Adhesive Remnant Index (ARI) scores is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and the percentage distribution of ARI scores between groups is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. The assessment was performed using a four-point scale (0\u0026ndash;3), reflecting the amount of adhesive remaining on the enamel surface after adhesive removal: 0 \u0026ndash; no adhesive remnants; 1 \u0026ndash; less than 50% of the enamel surface covered with adhesive; 2 \u0026ndash; more than 50% of the enamel surface covered with adhesive; 3 \u0026ndash; the entire adhesive layer remaining on the enamel surface.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdhesive Remnant Index (ARI) scale\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eARI score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription of adhesive remnants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% of enamel surface\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete adhesive removal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than 50% adhesive remaining\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 50% adhesive remaining\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEntire adhesive layer remaining\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBased on qualitative SEM evaluation, specimens treated with the ultrasonic scaler predominantly demonstrated ARI scores of 1\u0026ndash;2, indicating effective removal of the majority of adhesive, although small remnants persisted within micro-irregularities or along scratch lines created by scaler movement (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSEM observations revealed that the tungsten carbide bur produced a considerably rougher enamel surface compared with the ultrasonic scaler. The images demonstrated a progressive pattern of abrasive wear characterized by the formation of grooves and microcracks, accompanied by a reduction in residual adhesive but an increase in enamel surface damage.\u003c/p\u003e \u003cp\u003eAlthough this method achieved effective adhesive removal (predominantly ARI\u0026thinsp;\u0026asymp;\u0026thinsp;0\u0026ndash;1), it compromised enamel surface integrity, resulting in deep mechanical scratches and microcracks. The distribution pattern of ARI values within each group is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssessment of the amount of adhesive residue when comparing methods\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRemoval method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eARI range\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNature of adhesive residue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUltrasonic scaler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSmall residues in micro-recesses, along scratches\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTungsten carbide bur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimal residue, grainy morphology\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEnamel surface condition was evaluated using the Enamel Damage Index (EDI), which consists of four grades: 0 \u0026ndash; smooth surface without scratches (perikymata may be visible);\u003c/p\u003e \u003cp\u003e1 \u0026ndash; acceptable surface with isolated fine, scattered scratches; 2 \u0026ndash; rough surface with numerous pronounced scratches or small grooves; 3 \u0026ndash; surface with deep scratches, wide grooves, and defects visible to the naked eye.\u003c/p\u003e \u003cp\u003eIn the ultrasonic adhesive removal group, an EDI score of 2 predominated upon magnified examination, indicating the development of moderately pronounced surface roughness with multiple scratches.\u003c/p\u003e \u003cp\u003eIn contrast, the tungsten carbide bur group predominantly exhibited an EDI score of 3, both upon visual inspection and under magnification, indicating severe structural enamel damage characterized by deep grooves and macroscopically visible defects.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWithin the limitations of this in vitro study, both the ultrasonic scaler and the tungsten carbide bur effectively removed residual orthodontic adhesive; however, they produced distinctly different enamel surface outcomes.\u003c/p\u003e \u003cp\u003eAnalysis of the Adhesive Remnant Index (ARI) demonstrated significant differences between the two methods. In the ultrasonic group, higher ARI scores predominated, with most specimens exhibiting ARI values of 2 or 3, indicating substantial adhesive retention on the enamel surface following debonding. In contrast, the tungsten carbide bur group showed predominantly low ARI scores. Complete adhesive removal (ARI\u0026thinsp;=\u0026thinsp;0) was observed in 63.0% of cases, minimal remnants (ARI\u0026thinsp;=\u0026thinsp;1) in 33.3%, and ARI\u0026thinsp;=\u0026thinsp;2 only in isolated cases (3.7%); ARI\u0026thinsp;=\u0026thinsp;3 was not recorded.\u003c/p\u003e \u003cp\u003eQuantitative morphometric assessment confirmed these findings. The ultrasonic group demonstrated significantly higher adhesive remnant area (ARA%) values (mean 19%) compared to the tungsten carbide bur group (mean 11%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Conversely, evaluation of enamel structural defect area (ESDA%) revealed significantly greater surface damage in the tungsten carbide bur group (mean 28%) compared to the ultrasonic group (mean 10%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eQualitative assessment using the Enamel Damage Index (EDI) further supported these results. The ultrasonic method was associated predominantly with EDI\u0026thinsp;=\u0026thinsp;2, corresponding to moderate surface roughness with multiple superficial scratches. In contrast, the tungsten carbide bur group mainly exhibited EDI\u0026thinsp;=\u0026thinsp;3, characterized by deep grooves, pronounced surface irregularities, and structural enamel defects.\u003c/p\u003e \u003cp\u003eAdhesive removal time also differed substantially between the methods. A comparison of procedural time between the two methods is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e.The ultrasonic technique required approximately 22 seconds on average, whereas the tungsten carbide bur achieved adhesive removal in approximately 10 seconds. Thus, while tungsten carbide burs enable faster and more complete adhesive removal, this efficiency is accompanied by increased enamel surface damage. Ultrasonic instrumentation, although less time-efficient and associated with greater adhesive retention, demonstrated superior enamel preservation.\u003c/p\u003e \u003cp\u003eTaken together, these findings highlight a clinically relevant trade-off between efficiency and enamel safety. Future research should focus on optimizing combined or sequential protocols that achieve effective adhesive removal while minimizing irreversible enamel alterations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eARI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdhesive Remnant Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eARA%\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdhesive Remnant Area Percentage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESDA%\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnamel Surface Defect Area Percentage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEDI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnamel Damage Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSEM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eScanning Electron Microscopy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnergy-Dispersive X-ray Spectroscopy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institutional Ethics Committee of I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia (Protocol No. 05-25, dated 12 March 2025). All procedures were conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants or their legal representatives prior to tooth extraction and use of the extracted teeth for research purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that there are no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHA conceived and designed the study, performed the experiments, conducted data analysis, and wrote the manuscript. The author read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlkahlout AE, El-Gazzar RI, Shamaa MS. Effect of air abrasion techniques vs tungsten carbide burs on enamel surface after orthodontic adhesive remnant removal. J Contemp Dent Pract. 2025;26(4):366\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5005/jp-journals-10024-3865\u003c/span\u003e\u003cspan address=\"10.5005/jp-journals-10024-3865\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArhun N, Arman A. Effects of orthodontic mechanics on tooth enamel: a review. 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Nature. 1971;234:329\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadri K, Mohammadi SA, Behroozian A, Fathi P. Comparison of the direction of enamel microcracks in five different debonding methods: an in vitro study. Iran J Orthod. 2021;16(1):1\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.22034/IJO.2021.540946.1005\u003c/span\u003e\u003cspan address=\"10.22034/IJO.2021.540946.1005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalehi P, Pakshir H, Naseri N, Baherimoghaddam T. The effects of composite resin types and debonding pliers on the amount of adhesive remnants and enamel damage: a stereomicroscopic evaluation. 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BMC Oral Health. 2023;23:478. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12903-023-03194-6\u003c/span\u003e\u003cspan address=\"10.1186/s12903-023-03194-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Orthodontic adhesive removal, ultrasonic scaler, tungsten carbide bur, scanning electron microscopy (SEM), adhesive remnant index (ARI), adhesive remnant area (ARA%), enamel surface defect area (ESDA%)","lastPublishedDoi":"10.21203/rs.3.rs-8970910/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8970910/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eComplete removal of orthodontic adhesive after bracket debonding remains challenging, as currently available techniques may compromise enamel integrity. This study aimed to compare enamel surface quality and procedural efficiency following adhesive removal using ultrasonic scaler tips versus tungsten carbide burs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial and Methods\u003c/strong\u003e. Fifty-four extracted human premolars were randomly allocated into two groups (n = 27 per group) according to the adhesive removal method: ultrasonic scaler or tungsten carbide bur. Orthodontic brackets were bonded and debonded after 24 hours. Residual adhesive was removed using the assigned technique and polished with Silicone OneGloss. Enamel surface evaluation included the Adhesive Remnant Index (ARI), adhesive remnant area percentage (ARA%), enamel surface defect area percentage (ESDA%), enamel damage index (EDI), and total adhesive removal time (seconds). Morphological assessment was performed using scanning electron microscopy (SEM). Quantitative image analysis was conducted using ImageJ software. Statistical analysis was performed using the Mann–Whitney U test and χ² test (p \u0026lt; 0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e. The ultrasonic group demonstrated higher ARA% values and significantly lower ESDA% values compared to the carbide bur group (p \u0026lt; 0.001), indicating greater preservation of enamel integrity but increased residual adhesive. The carbide bur achieved more complete adhesive removal (lower ARI and ARA%) and significantly reduced procedure time (mean: 10 s vs 22 s; p \u0026lt; 0.001), but was associated with significantly greater enamel surface damage (higher ESDA% and EDI scores). SEM analysis confirmed smoother enamel morphology in the ultrasonic group and more pronounced grooves and microcracks following carbide bur use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion.\u003c/strong\u003e Both techniques effectively removed residual orthodontic adhesive but produced distinctly different enamel surface outcomes. Ultrasonic instrumentation better preserved enamel integrity at the expense of longer working time and greater adhesive remnants, whereas tungsten carbide burs enabled faster and more complete adhesive removal but increased enamel surface damage. Optimization of combined or sequential protocols may help balance efficiency and enamel preservation.\u003c/p\u003e","manuscriptTitle":"Assessment of enamel surface quality after orthodontic adhesive removal using ultrasonic scaler versus carbide bur","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-26 17:11:14","doi":"10.21203/rs.3.rs-8970910/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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