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29/03/33

BONDING IN OPERATIVE
DENTISTRY
ENAMEL AND DENTIN ADHESION

5th year
UOD

2012

Reference:
-Fundamentals of Operative Dentistry
(Schwartz, 2nd. Ed.)Chapter 8
-Art and Science 5th Ed chapter5

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Topic outline:
Indications and advantages of adhesive dentistry
Adhesion mechanism
Factors affecting adhesion
Adhesion to enamel VS adhesion to dentin
Wet Vs dry adhesion technique
Challenges facing an ideal adhesive bond
microleakage
hypersensitivity
Requirements for an ideal bonding agent

Topic outline
Classification of bonding system
Clinical significance of bonding
Adhesion strategies and technique
Amalgam bonding and glass ionomer

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Definitions
1. Adhesion (or bonding) is defined in dentistry as The
forces or energies between atoms or molecules at
an interface that hold two surfaces together.
2. Adhesive strength = load bearing capacity
3. Durability = the time period of effect bond in
clinical use
4. Adaptation: maximum degree of proximity
between two adjacent surface

5. Adhesive(adherent): the material or film added to
produce adhesion
6. Adherend: the substrate to which the material
adhered e.g enamel ,dentin
7. Abhesive: a barrier against establishing adhesive
joint

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Adhesive failure: The bond that fails at the
interface between the two substrate
Cohesive failure: The bond fails within one of the
substrates, but not at the interface.

Adhesive joint; resin material ,tooth substrate and
hybrid layer in between
Hybridization : is the phenomenon of replacement of
the hydroxyapatite and the water in the surface
dentin by resin. This resin, in combination with the
collagen fibers, forms a hybrid layer.
In other words, hybridization is the process of resin
interlocking in the demineralized dentin surface .
This concept was given by Nakabayashi in 1982

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The thickness of a hybrid layer is not a critical
requirement for success. Dentin bond strength is
probably proportional to the interlocking between
resin and collagen, as well as to the “quality” of the
hybrid layer, not to its thickness

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HISTORY
1955 – Dr. M. G. Buonocore noted that
metal was treated with acid before painting to
provide a better bond between the
metal surface and the paint. He then
applied this procedure for the bonding of
composite resin to teeth.

ADVANTAGES OF ADHESIVE
DENTISTRY
1. Less tooth structure removed
2. Reduces microleakage at margins
3. Better distribution of stresses
4. Possible reinforcement of tooth structure
5. Easy to repair fillings with minimal tooth prep.
6. Tooth colored restorative material may be
added to teeth without preparations (veneers,
Maryland bridge)

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Debonded composite restoration

Tooth strength after restoration – amalgam vs C.R.
Strength of uncut tooth = 100%
MOD amalgam prep = 50%
MOD prep. + varnish + amalgam = 50%
MOD prep. + composite resin = 88%

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Indications
Expanding Indications for Adhesive Dentistry
1. Restoration of carious teeth
2. Abraded and eroded surfaces
3. Veneers (esthetics)
4. Re-contouring (diastema)
5. Preventive sealants
6. Bonding orthodontic brackets
7. To treat dentinal hypersensitivity

Mechanism of adhesion
Four theories of adhesion (MADE):
1. Mechanical
2. Chemical
-Adsorption
- Diffusion
3. Electrostatic

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Requirement of ideal adhesion:
Chemical affinity between the adhesive and the
substrate
Complete wettability of the substrate by the adhesive
-absolute substrate surface smoothness
-absolute substrate surface cleanliness
-complete substrate surface homogenecity
-strongly hydrophilic adhesive of minimal
surface tension

Requirements for good adhesion/bonding

materials must be in contact
wetting of the tooth surface must occur with low
surface tension and low viscosity of the adhesive
material
Enamel = high surface-free energy +
Dentin = low surface-free energy –
Tooth surface must be clean to provide high surfacefree energy

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Wetting
Wetting is an expression of the attractive forces between
molecules of adhesive and adherent. In other words, it is
the process of obtaining molecular attraction .
Wetting ability of an adhesive depends upon two factors:
• Cleanliness of the adherend:
Cleaner is the surface, greater is the adhesion.
• Surface energy of the adherend:
More the surface energy, greater is adhesion.

Factors Affecting Adhesion to Tooth Structure
I. Tooth-related factors
II. Material-related factors
III. Prepared cavity-related factors
IV. Technique of restoration
V. Oral environmental factors

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I. Tooth-related factors
1. physiological effects:
- surface energy
- capillary attraction
- osmotic pressure
2. Compositional differences of tooth
tissues
3. Presence of smear layer
4. contaminants

II. Material- related factors
1.Biodegradation in oral cavity
2. Thermal coefficient of expansion
3. Dimensional stability
4. Modulus of elasticity and transfer of stress at the
interface

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III. Prepared cavity-related factors:
1.Adhesive cavity designs should be prepared
2.The resistance and retention required should be
estimated and built in the preparation
3.All carious lesion must be removed
4.Adequate finishing, debridement and toilet of the
cavity required

IV. Technique of restoration
1. avoid moisture contamination
2. use of liner and bases( must be restricted Rd less
than0.5mm)
3. constituents of temporary restorations
4.C-factor(bonded to free unbonded surface)
5.post operative and post restorative care

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V. Oral environmental factors
1. Occlusal loads
2. Chemical degradation potentials
3. Oral microorganisms
4. Humidity
5. Chewing habits

All these factors are all highly contributed
that affect the durability of the
restoration

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Bonding to tooth structure
Compositional and Structural Aspects of Enamel and
Dentin “Because the composition of enamel and
dentin are different, adhesion to the two tooth
tissues is also different”

Problems (obstacles)with bonding to dentin
1. High organic and water content
2. Smear unit
3. heterogeneous of dentin structure
4. Vitality of the pulp (pulpal and dentinal fluid)
5. Difference in D.permeability

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6. Intrapulpal pressure
7. Decreased percentage of hydroxyapatite
8. Divergence of dentinal tubules from the pulp

Dentin contains dentinal tubules which contain vital
processes of the pulp, odontoblasts. This makes the
dentin a sensitive structure.
• Dentin is a dynamic tissue which shows changes due
to aging, caries or operative procedures.
• Fluid present in dentinal tubules constantly flows
outwards which reduces the adhesion of the resin
composite to dentin .

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Smear unit:
Basically, when tooth surface is altered using hand or
rotary instruments, cutting debris are smeared on
enamel and dentin surface, this unit is called smear
unit (smear layer& smear plug)

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Components of Smear Layer
Smear layer consists of both organic and inorganic
Components. The inorganic material in the smear layer
is made up of tooth structure and some nonspecific
inorganic contaminants.
The organic components may consist of heated
coagulated proteins (deteriorated collagen by cutting
temperature), necrotic or odontoblastic processes,
saliva, blood cells and microorganisms. Densely or
loosely packed to various depths into dentinal
tubules.

Factors affecting dentin permeability
D.T diameter
D.T length
D.T No.
Amount of D.fluid
Intra pulpal pressure

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Principles of dentin hybridization
It involves:
1. Selective demineralization(conditioner)
2. Alteration of surface wettability(priming)
3. Resin impregnation(DBA)

Selective demineralization can be done
by
1. chemical conditioner )Acid)
2. physical conditioner (laser)
3. mechanical conditioner (micro abrasion)

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1. Chemical conditioners
Acids used to prepare tooth surfaces
Citric acid
Nitric
Oxalic
Acetic acid
Maleic acid (10%)
Polyacrylic acid (10%)
Phosphoric acid (10 - 37%)
Acidic monomer(phenyl P)

Conditioning
It is the process of cleaning the surface and activating the
calcium ions, to make them more reactive.
Etching
It is the process of increasing the surface reactivity by
demineralizing the superficial calcium layer and thus creating
the enamel tags (5-50 micron) . These tags are responsible for
micromechanical bonding between tooth and restorative
resin.

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Objectives of surface etching
-The acid-etching of a tooth surface allows for the
micro-mechanical adhesion of resin to the tooth
-Etching with acid removes a portion of the
superficial mineral component of enamel and
Dentin(10 micron)
-Micro porosities (5-50 micron depth)left behind produce
a roughened surface, or open dentinal tubules,
into which resin will penetrate and mechanically
grip the tooth providing retention for an overlying
restoration

Pattern of etching
Type I etching pattern: preferential removal of
enamel prism core
Type II etching pattern: preferential removal of prism
peripheries
Type III etching pattern: not related to prism
morphology

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Effective etching of dentin does not require long times
to produce acceptable dentin bond strengths.
Usually, 15 seconds is employed. If etching time is
too long and the etched zone is too deep, the
decalcified dentin may not be fully impregnated.
The etched but not impregnated space may reside
as a mechanically weak zone and promote
nanoleakage.

Factors affecting successful acid
etching
Acid concentration
Time of etching
Cleaning of the surface
Contamination

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II.Priming:

Primers are bonding-promoters e.g HEMA&TEGDMA
They are essentially composed of active bi-functional
hydrophilic/hydrophobic group of monomer molecules
[ in water, organic solvents such as ethanol or acetone
or a combination them].

Bifunctional gp
The hydrophilic part increases substrate surface
wettability and permeability enhance resin diffusion
into de-mineralized dentin.

The hydrophobic part penetrates inside the created
pores where it polymerizes forming retentive tags
inside, and co-polymerizes with the applied
bonding agent

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They are used to facilitate complete resin infiltration of de-mineralized
dentin with establishment of strong and gap-free resin-collagen
hybrid
The primer may be transported and agitated onto the substrate
surface using a smooth brush. It is evenly spread, thinned out, and
gently air-dried
Primers contain solvents to displace the water and carry the monomers
into the microporosities in the collagen network.
During application of the primer, most of the solvent evaporates
quickly. Thus several layers usually must be applied to ensure a
complete impregnation. The rule of thumb is that one should apply
as many layers as necessary to produce a persisting glistening
appearance on dentin.

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After acid is rinsed, drying of dentin must be done
cautiously. Even a short air blast from an air-water
spray can inadvertently dehydrate the outer surface
and cause the remaining collagen scaffold to
collapse onto itself. Once this happens, the collagen
mesh readily excludes the penetration of primer
and bonding will fail.

However, excess moisture tends to dilute the primer
and interfere with resin interpenetration. The ideal
dentin moisture level varies according to the solvent
present in the adhesive.

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Self-etch systems have the great advantages of
eliminating the risk of incomplete primer/adhesive
penetration into the collagen scaffold and also
eliminating the subjectivity when determining the
amount of moisture on the dentin surface ideal for
primer diffusion. With these systems, the smear layer
is dissolved and incorporated into the hybrid layer.

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Ethanol or acetone based bonding
system
Acetone or ethanol diffuses into the moist D while
water diffuses into acetone or ethanol (water
chasing effect).
They occupy the spaces previously filled with water,
and then evaporate rapidly leaving sufficient room
to the coming infiltrated resin
Acetone and ethanol generate less surface tension
forces in collagen fibrils with ultimate increase in
bond strength

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Moist vs Dry Dentin
Collagen is one of the important factors in determining the dentin bonding. By
etching of dentin, removal of smear layer and minerals from dentin
structure occurs, exposing the collagen fibers . Areas from where minerals
are removed are filled with water. This water acts as a plasticizer for
collagen, keeping it in an expanded soft state. Thus, spaces for resin
infiltration are also preserved. But these collagen fibers collapse when
dry and if the organic matrix is denatured. This obstructs the resin from
reaching the dentin surface and forming a hybrid layer.

Reasons for better bonding in moist dentin
1. The acetone trails water and improves penetration of the monomers into the
dentin for better micromechanical bonding.
2. Water keeps collagen fibrils from collapsing, thus helping
in better penetration and bonding between resin and
dentin.

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Disadvantage of self etch
technique:

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Strong self-etch adhesives produce a similar pattern
on enamel as that obtained with phosphoric acid.
Mild self-etch systems present lower bond strength
to enamel compared to etch-and-rinse systems,
probably because of a shallower etching pattern.

Enamel bonding system
Enamel bonding depends on resin tags
becoming interlocked with the surface
irregularities created by etching.

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Macrotags: form between enamel rod
peripheries.
Microtags: smaller tags form across
the end of each rod.
Macrotags and microtags are the basis
for micro-mechanical bonding.

Microtags are much more numerous and contribute
to most of the micromechanical retention.

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Requirements for an ideal D.B.A
Should be hydrophilic in order to bond to wet D
Should contain hydrophobic part to co-polymerize
with the applied resin
Should have low viscosity for better diffusion
Should posses minimum film thickness for better
wettability

Should be biocompatible
Should posses high bond strength to both E.D
Should have good shelf life
Should minimize micro to nanoleakage

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The Development of DBA
Enamel etch (1955)
Dentine etch (1960)
Treatment of smear layer (1980)
Wet Bonding technique(1990)

First generation
Second generation

Third generation
Fourth generation: Total etch technique
Fifth generation:

Sixth generation: All in one,2000
Seventh generation

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1960s and 1970s First and Second Generation
Did not recommend dentin etching. Relied on
adhesion to smear layer.
Since dentin was not etched , the adhesion actually
was due to bonding to the smear layer weak bond
strength (2-3 Mpa(

1980s Third Generation
Acid etching of dentin.
Separate primer.
Increased bond strength.
Margin staining caused clinical failure over time

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Early 1990s Fourth Generation)Total etch technique)
Acid etching of dentin.
Separate primer.
Increased bond strength.

Fourth generation (total etch technique; etch &rinse tech
;three step technique)
Concept complete removal of the smear layer
Etching of both enamel &dentin
Primer
Bonding agent (three step)
Concept of “wet bonding” also introduced in late 1990.
Technique sensitive.
These system incorporated monomers with high diffusivity
and compatibility to wet dentin

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Moist dentin improve the performance
Not to wet not to dry (the key factor)
Strong and stable bond reach up to 27MPa

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Mid 1990s Fifth Generation (two steps )
Etch and rinse(total etch) (etch separately and then primer
&bonding in one bottle) Combined primer and
adhesive in one bottle.
Maintained high bond strengths .
Unit-dose packaging introduced
less technique sensitive
Post operative hypersensitivity

Late 1990s, Early 2000s Sixth Generation (self etch
approach) “Self-etching” primers.
Reduced incidience of post-treatment sensitivity.
Bond strengths lower than fourth- and fifthgenerations.
More simple
Post operative hypersensitivity

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Late 2002 Seventh Generation
“All-in-One”. Combines etching, priming and bonding.
Single solution.
Good bond strength(18 to 25 Mpa)and margin sealing.
They achieve the same objective as the 6th
generation except that they simplified the multiple
sixth generation materials into a single component,
single bottle system, thus avoiding any mistake in
mixing. Seventh generation bonding agents also have
disinfecting and desensitizing properties.

Another classification
(clinical application)
Three steps (etching,priming,and resin impregnation)
Two steps( etching –priming)and resin
impregnation/or etching then priming and resin
impregnation together
One step, all together (etchant, primer and resin)
all in one step

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Recent classification of bonding systems
(Van Meerbeek2003)
1.Etch and Rinse approach
Three - step ;conditioner, primer, adhesive
Two step; conditioner, (primer adhesive)
2.Self –Etch approach
Two-step (conditioner primer),adhesive
One step(conditioner&primer&adhesive)
3.Glass-Ionomer Approach

Adhesive system based on etch and rinse (three
step) technique are more clinically reliable and
durable than the self etching adhesives

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Recent adhesive systems
Bio-active adhesive system include anti-microbial
monomer MDPB e.g clearfil
HEMA free adhesive system e.g G-bond
POSS nano-filled adhesive system e.g nano-bond

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Bonded Amalgam
Adhesive systems, filled adhesives, and resin
cements can be used in association with amalgam
in the so-called bonded amalgam restoration. The
purpose of this technique is to reduce the need for
macromechanical retention, which would save tooth
structure, and reinforce the remaining structure by
creating a bonded interface between the restorative
material and the cavity walls.

The bonding between the adhesive and the amalgam is
achieved by the establishment of an interpenetration
zone. Although laboratorial studies show better results
for bonded amalgams compared to conventional,
nonbonded amalgam in terms of bond strength,
microleakage, and retention, these findings are not
supported by clinical data, which show no difference
between bonded restorations and those retained by
mechanical undercuts.

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Bonded Amalgam Restoration
91

Technique:
Etch the enamel & dentin walls of the preparation with ~35%
phosphoric acid gel for 15-20seconds. Wash & dry the
preparation.
Apply primer to the conditioned dentin.
Then evenly apply dentin bonding agent.
Before the bonding agent is dried, condense freshly triturated high
copper amalgam into the uncured bonding agent, forcing the two
materials to intermingle.
They harden together in an interlocking matrix which provides
tremendous adhesion of amalgam to dentin
Carve, finish & polish the final restoration as usual

Bonded Amalgam Restoration
92

Bonding to tooth structure:
Bonded amalgam restoration has advantages of:
Conservative tooth preparation.
Better marginal seal along with improved retention & resistance.
Decrease the micro-leakage so the postoperative sensitivity & recurrent
caries.
Strengthening of restored tooth.
Bonded amalgam restoration has disadvantages of:
It is time consuming.
It is technique sensitive.
It is expensive.

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Glass Ionomer:
Glass ionomers are water-based, self-adhesive
restorative materials in which the filler is a reactive
glass called fluoroaluminosilicate glass and the matrix
is polymer or copolymer of carboxylic acids. The
setting reaction of these materials involves an acidbase reaction.

There are two main types of glass ionomers:
• Conventional glass ionomer
• Resin-modified glass ionomer

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Adhesion
Glass ionomer materials have good clinical adhesion
to tooth structure. Unlike the resin-based composite
materials, etching of the enamel or dentin
surface by phosphoric acid is not needed. Hence
these materials are sometimes referred to as being
self-adhesive. Preconditioning of the tooth surface
is recommended.

Adhesion
One of the following procedures is used for
the pretreatment:
• The cavity surface is conditioned using 10% to
20% polyacrylic acid(identified by manufacturers as (primer or
self -conditioner) for 10 seconds, washed well and dried.
• For some resin-modified glass ionomer restoratives
a dilute polycarboxylic acid based solution is applied on the
cavity surface and set through light. This ensures good contact
of the viscous mix of the glass ionomer with the tooth while not
impeding ion exchange reactions.

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The mechanism of adhesion to the tooth structure
is mostly chemical in nature and proceeds through
an exchange of ions arising from both the tooth
Laboratory measurements of bond strengths of
conventional and resin-modified glass ionomers to
tooth structure have generally yielded lower values
than with the combination of resin adhesives and
composites. The failure is usually cohesive in the
glass ionomer;and restoration.

Resin-modified glass ionomers have been recognized as one of
the best treatments for minimizing postoperative sensitivity in
restored teeth. There are two reasons for this. First, because
prior etching is not needed during placement, the collagen
fibrils are not demineralized and collapse of the denuded layers
cannot occur.
Second, the dual setting mechanism and gradual build-up of
modulus allow the material to absorb a considerable amount
of shrinkage stresses, thus minimizing the effect of contraction
forces at the tooth-restoration interfaces

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Adhesion in restorative dentistry

  • 1. 29/03/33 BONDING IN OPERATIVE DENTISTRY ENAMEL AND DENTIN ADHESION 5th year UOD 2012 Reference: -Fundamentals of Operative Dentistry (Schwartz, 2nd. Ed.)Chapter 8 -Art and Science 5th Ed chapter5 1
  • 2. 29/03/33 Topic outline: Indications and advantages of adhesive dentistry Adhesion mechanism Factors affecting adhesion Adhesion to enamel VS adhesion to dentin Wet Vs dry adhesion technique Challenges facing an ideal adhesive bond microleakage hypersensitivity Requirements for an ideal bonding agent Topic outline Classification of bonding system Clinical significance of bonding Adhesion strategies and technique Amalgam bonding and glass ionomer 2
  • 3. 29/03/33 Definitions 1. Adhesion (or bonding) is defined in dentistry as The forces or energies between atoms or molecules at an interface that hold two surfaces together. 2. Adhesive strength = load bearing capacity 3. Durability = the time period of effect bond in clinical use 4. Adaptation: maximum degree of proximity between two adjacent surface 5. Adhesive(adherent): the material or film added to produce adhesion 6. Adherend: the substrate to which the material adhered e.g enamel ,dentin 7. Abhesive: a barrier against establishing adhesive joint 3
  • 4. 29/03/33 Adhesive failure: The bond that fails at the interface between the two substrate Cohesive failure: The bond fails within one of the substrates, but not at the interface. Adhesive joint; resin material ,tooth substrate and hybrid layer in between Hybridization : is the phenomenon of replacement of the hydroxyapatite and the water in the surface dentin by resin. This resin, in combination with the collagen fibers, forms a hybrid layer. In other words, hybridization is the process of resin interlocking in the demineralized dentin surface . This concept was given by Nakabayashi in 1982 4
  • 5. 29/03/33 The thickness of a hybrid layer is not a critical requirement for success. Dentin bond strength is probably proportional to the interlocking between resin and collagen, as well as to the “quality” of the hybrid layer, not to its thickness 5
  • 6. 29/03/33 HISTORY 1955 – Dr. M. G. Buonocore noted that metal was treated with acid before painting to provide a better bond between the metal surface and the paint. He then applied this procedure for the bonding of composite resin to teeth. ADVANTAGES OF ADHESIVE DENTISTRY 1. Less tooth structure removed 2. Reduces microleakage at margins 3. Better distribution of stresses 4. Possible reinforcement of tooth structure 5. Easy to repair fillings with minimal tooth prep. 6. Tooth colored restorative material may be added to teeth without preparations (veneers, Maryland bridge) 6
  • 7. 29/03/33 Debonded composite restoration Tooth strength after restoration – amalgam vs C.R. Strength of uncut tooth = 100% MOD amalgam prep = 50% MOD prep. + varnish + amalgam = 50% MOD prep. + composite resin = 88% 7
  • 8. 29/03/33 Indications Expanding Indications for Adhesive Dentistry 1. Restoration of carious teeth 2. Abraded and eroded surfaces 3. Veneers (esthetics) 4. Re-contouring (diastema) 5. Preventive sealants 6. Bonding orthodontic brackets 7. To treat dentinal hypersensitivity Mechanism of adhesion Four theories of adhesion (MADE): 1. Mechanical 2. Chemical -Adsorption - Diffusion 3. Electrostatic 8
  • 9. 29/03/33 Requirement of ideal adhesion: Chemical affinity between the adhesive and the substrate Complete wettability of the substrate by the adhesive -absolute substrate surface smoothness -absolute substrate surface cleanliness -complete substrate surface homogenecity -strongly hydrophilic adhesive of minimal surface tension Requirements for good adhesion/bonding materials must be in contact wetting of the tooth surface must occur with low surface tension and low viscosity of the adhesive material Enamel = high surface-free energy + Dentin = low surface-free energy – Tooth surface must be clean to provide high surfacefree energy 9
  • 10. 29/03/33 Wetting Wetting is an expression of the attractive forces between molecules of adhesive and adherent. In other words, it is the process of obtaining molecular attraction . Wetting ability of an adhesive depends upon two factors: • Cleanliness of the adherend: Cleaner is the surface, greater is the adhesion. • Surface energy of the adherend: More the surface energy, greater is adhesion. Factors Affecting Adhesion to Tooth Structure I. Tooth-related factors II. Material-related factors III. Prepared cavity-related factors IV. Technique of restoration V. Oral environmental factors 10
  • 11. 29/03/33 I. Tooth-related factors 1. physiological effects: - surface energy - capillary attraction - osmotic pressure 2. Compositional differences of tooth tissues 3. Presence of smear layer 4. contaminants II. Material- related factors 1.Biodegradation in oral cavity 2. Thermal coefficient of expansion 3. Dimensional stability 4. Modulus of elasticity and transfer of stress at the interface 11
  • 12. 29/03/33 III. Prepared cavity-related factors: 1.Adhesive cavity designs should be prepared 2.The resistance and retention required should be estimated and built in the preparation 3.All carious lesion must be removed 4.Adequate finishing, debridement and toilet of the cavity required IV. Technique of restoration 1. avoid moisture contamination 2. use of liner and bases( must be restricted Rd less than0.5mm) 3. constituents of temporary restorations 4.C-factor(bonded to free unbonded surface) 5.post operative and post restorative care 12
  • 13. 29/03/33 V. Oral environmental factors 1. Occlusal loads 2. Chemical degradation potentials 3. Oral microorganisms 4. Humidity 5. Chewing habits All these factors are all highly contributed that affect the durability of the restoration 13
  • 14. 29/03/33 Bonding to tooth structure Compositional and Structural Aspects of Enamel and Dentin “Because the composition of enamel and dentin are different, adhesion to the two tooth tissues is also different” Problems (obstacles)with bonding to dentin 1. High organic and water content 2. Smear unit 3. heterogeneous of dentin structure 4. Vitality of the pulp (pulpal and dentinal fluid) 5. Difference in D.permeability 14
  • 15. 29/03/33 6. Intrapulpal pressure 7. Decreased percentage of hydroxyapatite 8. Divergence of dentinal tubules from the pulp Dentin contains dentinal tubules which contain vital processes of the pulp, odontoblasts. This makes the dentin a sensitive structure. • Dentin is a dynamic tissue which shows changes due to aging, caries or operative procedures. • Fluid present in dentinal tubules constantly flows outwards which reduces the adhesion of the resin composite to dentin . 15
  • 16. 29/03/33 Smear unit: Basically, when tooth surface is altered using hand or rotary instruments, cutting debris are smeared on enamel and dentin surface, this unit is called smear unit (smear layer& smear plug) 16
  • 17. 29/03/33 Components of Smear Layer Smear layer consists of both organic and inorganic Components. The inorganic material in the smear layer is made up of tooth structure and some nonspecific inorganic contaminants. The organic components may consist of heated coagulated proteins (deteriorated collagen by cutting temperature), necrotic or odontoblastic processes, saliva, blood cells and microorganisms. Densely or loosely packed to various depths into dentinal tubules. Factors affecting dentin permeability D.T diameter D.T length D.T No. Amount of D.fluid Intra pulpal pressure 17
  • 20. 29/03/33 Principles of dentin hybridization It involves: 1. Selective demineralization(conditioner) 2. Alteration of surface wettability(priming) 3. Resin impregnation(DBA) Selective demineralization can be done by 1. chemical conditioner )Acid) 2. physical conditioner (laser) 3. mechanical conditioner (micro abrasion) 20
  • 21. 29/03/33 1. Chemical conditioners Acids used to prepare tooth surfaces Citric acid Nitric Oxalic Acetic acid Maleic acid (10%) Polyacrylic acid (10%) Phosphoric acid (10 - 37%) Acidic monomer(phenyl P) Conditioning It is the process of cleaning the surface and activating the calcium ions, to make them more reactive. Etching It is the process of increasing the surface reactivity by demineralizing the superficial calcium layer and thus creating the enamel tags (5-50 micron) . These tags are responsible for micromechanical bonding between tooth and restorative resin. 21
  • 22. 29/03/33 Objectives of surface etching -The acid-etching of a tooth surface allows for the micro-mechanical adhesion of resin to the tooth -Etching with acid removes a portion of the superficial mineral component of enamel and Dentin(10 micron) -Micro porosities (5-50 micron depth)left behind produce a roughened surface, or open dentinal tubules, into which resin will penetrate and mechanically grip the tooth providing retention for an overlying restoration Pattern of etching Type I etching pattern: preferential removal of enamel prism core Type II etching pattern: preferential removal of prism peripheries Type III etching pattern: not related to prism morphology 22
  • 23. 29/03/33 Effective etching of dentin does not require long times to produce acceptable dentin bond strengths. Usually, 15 seconds is employed. If etching time is too long and the etched zone is too deep, the decalcified dentin may not be fully impregnated. The etched but not impregnated space may reside as a mechanically weak zone and promote nanoleakage. Factors affecting successful acid etching Acid concentration Time of etching Cleaning of the surface Contamination 23
  • 26. 29/03/33 II.Priming: Primers are bonding-promoters e.g HEMA&TEGDMA They are essentially composed of active bi-functional hydrophilic/hydrophobic group of monomer molecules [ in water, organic solvents such as ethanol or acetone or a combination them]. Bifunctional gp The hydrophilic part increases substrate surface wettability and permeability enhance resin diffusion into de-mineralized dentin. The hydrophobic part penetrates inside the created pores where it polymerizes forming retentive tags inside, and co-polymerizes with the applied bonding agent 26
  • 27. 29/03/33 They are used to facilitate complete resin infiltration of de-mineralized dentin with establishment of strong and gap-free resin-collagen hybrid The primer may be transported and agitated onto the substrate surface using a smooth brush. It is evenly spread, thinned out, and gently air-dried Primers contain solvents to displace the water and carry the monomers into the microporosities in the collagen network. During application of the primer, most of the solvent evaporates quickly. Thus several layers usually must be applied to ensure a complete impregnation. The rule of thumb is that one should apply as many layers as necessary to produce a persisting glistening appearance on dentin. 27
  • 29. 29/03/33 After acid is rinsed, drying of dentin must be done cautiously. Even a short air blast from an air-water spray can inadvertently dehydrate the outer surface and cause the remaining collagen scaffold to collapse onto itself. Once this happens, the collagen mesh readily excludes the penetration of primer and bonding will fail. However, excess moisture tends to dilute the primer and interfere with resin interpenetration. The ideal dentin moisture level varies according to the solvent present in the adhesive. 29
  • 30. 29/03/33 Self-etch systems have the great advantages of eliminating the risk of incomplete primer/adhesive penetration into the collagen scaffold and also eliminating the subjectivity when determining the amount of moisture on the dentin surface ideal for primer diffusion. With these systems, the smear layer is dissolved and incorporated into the hybrid layer. 30
  • 31. 29/03/33 Ethanol or acetone based bonding system Acetone or ethanol diffuses into the moist D while water diffuses into acetone or ethanol (water chasing effect). They occupy the spaces previously filled with water, and then evaporate rapidly leaving sufficient room to the coming infiltrated resin Acetone and ethanol generate less surface tension forces in collagen fibrils with ultimate increase in bond strength 31
  • 32. 29/03/33 Moist vs Dry Dentin Collagen is one of the important factors in determining the dentin bonding. By etching of dentin, removal of smear layer and minerals from dentin structure occurs, exposing the collagen fibers . Areas from where minerals are removed are filled with water. This water acts as a plasticizer for collagen, keeping it in an expanded soft state. Thus, spaces for resin infiltration are also preserved. But these collagen fibers collapse when dry and if the organic matrix is denatured. This obstructs the resin from reaching the dentin surface and forming a hybrid layer. Reasons for better bonding in moist dentin 1. The acetone trails water and improves penetration of the monomers into the dentin for better micromechanical bonding. 2. Water keeps collagen fibrils from collapsing, thus helping in better penetration and bonding between resin and dentin. 32
  • 33. 29/03/33 Disadvantage of self etch technique: 33
  • 34. 29/03/33 Strong self-etch adhesives produce a similar pattern on enamel as that obtained with phosphoric acid. Mild self-etch systems present lower bond strength to enamel compared to etch-and-rinse systems, probably because of a shallower etching pattern. Enamel bonding system Enamel bonding depends on resin tags becoming interlocked with the surface irregularities created by etching. 34
  • 35. 29/03/33 Macrotags: form between enamel rod peripheries. Microtags: smaller tags form across the end of each rod. Macrotags and microtags are the basis for micro-mechanical bonding. Microtags are much more numerous and contribute to most of the micromechanical retention. 35
  • 36. 29/03/33 Requirements for an ideal D.B.A Should be hydrophilic in order to bond to wet D Should contain hydrophobic part to co-polymerize with the applied resin Should have low viscosity for better diffusion Should posses minimum film thickness for better wettability Should be biocompatible Should posses high bond strength to both E.D Should have good shelf life Should minimize micro to nanoleakage 36
  • 37. 29/03/33 The Development of DBA Enamel etch (1955) Dentine etch (1960) Treatment of smear layer (1980) Wet Bonding technique(1990) First generation Second generation Third generation Fourth generation: Total etch technique Fifth generation: Sixth generation: All in one,2000 Seventh generation 37
  • 38. 29/03/33 1960s and 1970s First and Second Generation Did not recommend dentin etching. Relied on adhesion to smear layer. Since dentin was not etched , the adhesion actually was due to bonding to the smear layer weak bond strength (2-3 Mpa( 1980s Third Generation Acid etching of dentin. Separate primer. Increased bond strength. Margin staining caused clinical failure over time 38
  • 39. 29/03/33 Early 1990s Fourth Generation)Total etch technique) Acid etching of dentin. Separate primer. Increased bond strength. Fourth generation (total etch technique; etch &rinse tech ;three step technique) Concept complete removal of the smear layer Etching of both enamel &dentin Primer Bonding agent (three step) Concept of “wet bonding” also introduced in late 1990. Technique sensitive. These system incorporated monomers with high diffusivity and compatibility to wet dentin 39
  • 40. 29/03/33 Moist dentin improve the performance Not to wet not to dry (the key factor) Strong and stable bond reach up to 27MPa 40
  • 41. 29/03/33 Mid 1990s Fifth Generation (two steps ) Etch and rinse(total etch) (etch separately and then primer &bonding in one bottle) Combined primer and adhesive in one bottle. Maintained high bond strengths . Unit-dose packaging introduced less technique sensitive Post operative hypersensitivity Late 1990s, Early 2000s Sixth Generation (self etch approach) “Self-etching” primers. Reduced incidience of post-treatment sensitivity. Bond strengths lower than fourth- and fifthgenerations. More simple Post operative hypersensitivity 41
  • 42. 29/03/33 Late 2002 Seventh Generation “All-in-One”. Combines etching, priming and bonding. Single solution. Good bond strength(18 to 25 Mpa)and margin sealing. They achieve the same objective as the 6th generation except that they simplified the multiple sixth generation materials into a single component, single bottle system, thus avoiding any mistake in mixing. Seventh generation bonding agents also have disinfecting and desensitizing properties. Another classification (clinical application) Three steps (etching,priming,and resin impregnation) Two steps( etching –priming)and resin impregnation/or etching then priming and resin impregnation together One step, all together (etchant, primer and resin) all in one step 42
  • 43. 29/03/33 Recent classification of bonding systems (Van Meerbeek2003) 1.Etch and Rinse approach Three - step ;conditioner, primer, adhesive Two step; conditioner, (primer adhesive) 2.Self –Etch approach Two-step (conditioner primer),adhesive One step(conditioner&primer&adhesive) 3.Glass-Ionomer Approach Adhesive system based on etch and rinse (three step) technique are more clinically reliable and durable than the self etching adhesives 43
  • 44. 29/03/33 Recent adhesive systems Bio-active adhesive system include anti-microbial monomer MDPB e.g clearfil HEMA free adhesive system e.g G-bond POSS nano-filled adhesive system e.g nano-bond 44
  • 45. 29/03/33 Bonded Amalgam Adhesive systems, filled adhesives, and resin cements can be used in association with amalgam in the so-called bonded amalgam restoration. The purpose of this technique is to reduce the need for macromechanical retention, which would save tooth structure, and reinforce the remaining structure by creating a bonded interface between the restorative material and the cavity walls. The bonding between the adhesive and the amalgam is achieved by the establishment of an interpenetration zone. Although laboratorial studies show better results for bonded amalgams compared to conventional, nonbonded amalgam in terms of bond strength, microleakage, and retention, these findings are not supported by clinical data, which show no difference between bonded restorations and those retained by mechanical undercuts. 45
  • 46. 29/03/33 Bonded Amalgam Restoration 91 Technique: Etch the enamel & dentin walls of the preparation with ~35% phosphoric acid gel for 15-20seconds. Wash & dry the preparation. Apply primer to the conditioned dentin. Then evenly apply dentin bonding agent. Before the bonding agent is dried, condense freshly triturated high copper amalgam into the uncured bonding agent, forcing the two materials to intermingle. They harden together in an interlocking matrix which provides tremendous adhesion of amalgam to dentin Carve, finish & polish the final restoration as usual Bonded Amalgam Restoration 92 Bonding to tooth structure: Bonded amalgam restoration has advantages of: Conservative tooth preparation. Better marginal seal along with improved retention & resistance. Decrease the micro-leakage so the postoperative sensitivity & recurrent caries. Strengthening of restored tooth. Bonded amalgam restoration has disadvantages of: It is time consuming. It is technique sensitive. It is expensive. 46
  • 47. 29/03/33 Glass Ionomer: Glass ionomers are water-based, self-adhesive restorative materials in which the filler is a reactive glass called fluoroaluminosilicate glass and the matrix is polymer or copolymer of carboxylic acids. The setting reaction of these materials involves an acidbase reaction. There are two main types of glass ionomers: • Conventional glass ionomer • Resin-modified glass ionomer 47
  • 48. 29/03/33 Adhesion Glass ionomer materials have good clinical adhesion to tooth structure. Unlike the resin-based composite materials, etching of the enamel or dentin surface by phosphoric acid is not needed. Hence these materials are sometimes referred to as being self-adhesive. Preconditioning of the tooth surface is recommended. Adhesion One of the following procedures is used for the pretreatment: • The cavity surface is conditioned using 10% to 20% polyacrylic acid(identified by manufacturers as (primer or self -conditioner) for 10 seconds, washed well and dried. • For some resin-modified glass ionomer restoratives a dilute polycarboxylic acid based solution is applied on the cavity surface and set through light. This ensures good contact of the viscous mix of the glass ionomer with the tooth while not impeding ion exchange reactions. 48
  • 49. 29/03/33 The mechanism of adhesion to the tooth structure is mostly chemical in nature and proceeds through an exchange of ions arising from both the tooth Laboratory measurements of bond strengths of conventional and resin-modified glass ionomers to tooth structure have generally yielded lower values than with the combination of resin adhesives and composites. The failure is usually cohesive in the glass ionomer;and restoration. Resin-modified glass ionomers have been recognized as one of the best treatments for minimizing postoperative sensitivity in restored teeth. There are two reasons for this. First, because prior etching is not needed during placement, the collagen fibrils are not demineralized and collapse of the denuded layers cannot occur. Second, the dual setting mechanism and gradual build-up of modulus allow the material to absorb a considerable amount of shrinkage stresses, thus minimizing the effect of contraction forces at the tooth-restoration interfaces 49