Bonding techniques allow more conservative tooth preparations, less reliance on macromechanical retention, and less removal of unsupported

enamel. In dentistry, bonding of resins to tooth structure is a result of four possible mechanisms, as follows: 1. Mechanicalpenetration of resin and formation of resin tags within the tooth surface 2. Adsorptionchemical bonding to the inorganic component (hydroxyapatite) or organic components (mainly type I collagen) of tooth structure 3. Diffusionprecipitation of substances on the tooth surfaces to which resin monomers can bond mechanically or chemically 4. A combination of the previous three mechanisms The availability of new scientific information on the cause, diagnosis, and treatment of carious lesions and the introduction of reliable adhesive restorative materials have substantially reduced the need for extensive tooth preparations. Adhesive composite restorations are used to replace carious dental tissues, to restore fractured teeth, and to replace missing enamel or dentin in the cervical areas of teeth.With improvements in materials, these indications have progressively shifted from the anterior segment only to posterior teeth as well. Adhesive restorative techniques are currently used to accomplish the following: 1. Restore Class I, II, III, IV, V, and VI carious or traumatic defects 2. Change the shape and the color of anterior teeth 3. Improve retention for metallic crowns or for porcelain-fused-to-metal crowns 4. Bond all-ceramic restorations (Fig. 5-1) 5. Bond indirect resin-based restorations 6. Seal pits and fissures 7. Bond orthodontic brackets 8. Bond periodontal splints and conservative toothreplacement prostheses 9. Repair existing restorations (composite, amalgam, ceramic, or ceramometal) 10. Provide foundations for crowns

11. Desensitize exposed root surfaces 12. Seal beneath or bond amalgam restorations to tooth structure 13. Impregnate dentin that has been exposed to the oral fluids, making it less susceptible to caries 14. Bond fractured fragments of anterior teeth (Fig. 5-2) 15. Bond prefabricated and cast posts 16. Reinforce fragile roots internally 17. Seal apical restorations placed during endodontic surgery ADVANTAGES OF ENAMEL ADHESION As measured in the laboratory, shear bond strengths of composite to phosphoric acidetched enamel usually exceed 20 MPa (range 1-145 MPa). Such bond strengths provide adequate retention for a broad variety of procedures and prevent microleakage around enamel margins of restorations. Adhesive restorations provide other benefits, such as cusp reinforcement after tooth preparation. Adhesive restorations substantially reinforce remaining enamel and dentin, making them less susceptible to fracture.

Enamel Adhesion
Acid etching transforms the smooth enamel into an irregular surface (Fig. 5-3) and increases its surface free energy. When a fluid resin-based material is applied to the irregular etched surface, the resin penetrates into the surface, aided by capillary action. Monomers in the material polymerize, and the material becomes interlocked with the enamel surface (Fig. 54).16,62 The formation of resin microtags (micromechanical interlocking) within the enamel surface is the fundamental mechanism of resin-enamel adhesion. Consequently, most current phosphoric acid gels in use have concentrations of 30% to 40%, although some studies using lower concentrations have reported similar adhesion values.

An etching time of 60 seconds originally was recommended for permanent enamel using 30% to 40% phosphoric acid. Although one study concluded that shorter etch times resulted in lower bond strengths. Other studies using scanning electron microscopy showed that a 15-second etch resulted in a similar surface roughness as that provided by a 60-second etch. Other in vitro studies have shown similar bond strengths and microleakage for etching times of 15 and 60 seconds. Clinically, reduced etching times do not seem to diminish the retention of pit-and-fissure sealants. DENTIN ADHESION Adhesion to dentin remains difficult. Adhesive materials can interact with dentin in different waysmechanically, chemically, or both. The importance of micromechanical bonding, similar to what occurs in enamel bonding, has become accepted. Researchers now believe that dentin adhesion relies primarily on the penetration of adhesive monomers into the filigree of collagen fibers left exposed by acid etching. The bonding agent copolymerizes with the primer to form an intermingled layer of collagen fibers and resin commonly called the "hybrid layer." This hybrid layer, which was first described by Nakabayashi et al. in 1982,25 is considered the most important factor for ensuring a good bond between resin and dentin. ======================================== H Y B R I D L Y E R

When primer and bonding resins are applied to etched dentin, they penetrate the intertubular dentin, forming a resin-dentin interdiffusion zone, or hybrid layer. They also penetrate and polymerize in the open dentinal tubules, forming resin tags. Most dentin-bonding systems have acids that remove the smear layer and partially demineralize the intertubular dentin. In most systems, these acidic components are weaker than the 37% phosphoric acid commonly used to etch enamel surfaces. When viewed under high magnification, dentin without a smear has many irregularities for micromechanical retention (Fig. 2-30). Ideally, such etchants remove the smear layer, but leave the smear plugs because they greatly reduce dentin permeability and sensitivity. Etchants should not excessively damage exposed

collagen fibers because much of the bond strength develops from resin encapsulating these fibers. After the acids, hydrophilic adhesive resins are applied that penetrate into the inherently moist dentin surfaces and copolymerize with the composite restoration. Although some of the bond forms from resin tagsextending into the dentinal tubules, most of the bond strength develops from resin that penetrates and adapts to the demineralized intertubular dentin and exposed collagen fibers. The resultant resin interdiffusion zone often is termed the hybrid layer. For bonding systems to produce a hybrid layer efficiently, it is crucial to keep the dentin hydrated. Often, the rinsing and drying of dentin that follows tooth preparation or specific etching steps results in dehydrated superficial layers of dentin. Etched dentin no longer contains intercollagen hydroxyapatite crystals (50 volume %). It consists only of the remaining collagen (29 volume %) and water (21 volume %). Dehydration, whether intentional or not, causes the remaining collagen sponge to collapse with collagen molecules forming a mat and excluding monomers necessary for hybrid layer formation. Etched dentin must be kept moist or be intentionally rehydrated. Rehydration can be accomplished with a moist cotton pledget or applicator tip in contact with the surfaces for approximately 10 seconds or by the use of rewetting agents. If dentin moisture is inadequate, the hybrid layer does not form, and the bonding system fails to seal and bond. It is suspected that inadequate precautions in this regard in many bonding instructions during the early 1990s may have contributed to the premature failure of many dentin bonding systems.

The various strategies that currently are used for bonding to dentin are summarized in Table

Current Strategies for Adhesion of Resins to Dentin*

rrent Strategies for Adhesion of Resins to Dentin* Current Strategiesor Adhesion of Resins to CC Dentin* Current Strategies for Adhesion of Resins to Dentin*
Etchant (E) Primer (P) Bonding Agent (B)

Three-step Total Etch (E + P + B)

Removes the smear layer Exposes intertubular and peritubular collagen Opens the tubules in a funnel configuration Decreases surface free energy

Includes bifunctional molecules (simultaneously hydrophilic and hydrophobic) Envelops the external surface of collagen fibrils Re-establishes

Includes monomers that are mostly hydrophobic, such as Bis-GMA; however can contain a small percentage of hydrophilic monomers, such as HEMA Copolymerizes with the primer molecules Penetrates and polymerizes into the interfibrillar spaces to serve as a structural backbone to the hybrid layer

One-bottle Total-Etch (E + [PB])

Removes the smear layer Exposes intertubular and peritubular collagen Opens tubules in a funnel configuration

surface-free energy to levels compatible with a more hydrophobic restorative material Penetrates into the dentin tubules to form resin tags The first coat applied on etched dentin works as a primerit increases the surface-free energy of dentin The second coat (and third, fourth, and so on) acts as the bonding agent used in three-step

Two-Bottle Self-etch ([EP] + B)

Decreases surface-free systemsit fills the spaces between the dense network of collagen energy fibers The SEP does not remove the smear layer, but fixes it Uses the same type of bonding agent and exposes about 0.5-1 m of included in the three-step, total-etch systems. intertubular collagen because of its acidity (pH = 1.22.0) The resin tags form on resin penetration into the microchannels of the primerimpregnated smear plug The smear plug is impregnated with acidic monomers, but it is not removed When it impregnates the smear plug, the SEP prepares the pathway for the penetration of the subsequently placed fluid resin into the microchannels that permeate the smear plug

All-in-one Self-etch (EPB)

Etches enamel Incorporates the smear layer into interface Being an aqueous solution of a phosphonated monomer, it demineralizes and penetrates dentin simultaneously, leaving a precipitate on the hybrid layer Forms a thin layer of adhesive, leading to low bond strengths; a multi-coat approach is recommended Incompatible with self-cure composite resinsIncorporates the smear layer into interface

Being an aqueous solution of a phosphonated monomer, it demineralizes and penetrates dentin simultaneously, leaving a precipitate on the hybrid layer. Forms a thin layer of adhesive, leading to low bond strengths; a multi-coat approach is recommended Incompatible with self-cure composite resins

* The term etch and rinse is an alternative term for the total-etch systems.

** For good adhesion, close contact must exist between the adhesive and the

substrate (enamel or dentin). The surface tension of the adhesive must be lower than the surface energy of enamel and dentin. Bonding to Tooth Structure Mechanical adhesion: Penetration of resin into tooth to form tags Adsorption adhesion : Chemical bonding to HA or collagen Diffusion adhesion : Precipitation of substances onto tooth surface that resins can attach to (mechanical or chemical) Electrostatic adhesion : Involved in metal bonding Bond to Enamel Macrotags : Interprism resin penetration Microtags : Intraprism resin penetration Microtags provide the major retention Challenges in Dentin Bonding (1)Composition of dentin: *50 % V= HA (less mineral) *25 % V= collagen *25 % V= water includes tubules-(more water) (2) Dentin Structure and Organization: **dentin is not uniformly mineralized: peritubular dentin is more mineralized than intertubular dentin **tubule density changes with location: More holes and more hole area as pulp is approached **Dentin changes with time: Sclerotic dentin -more mineralless collagen (3) Dentin covered by Smear Layer **adherent layer of tooth debris, saliva and bacteria **covers surface and plugs tubules to reduces dentin permeability **weak cohesion and adhesion (cannot be removed with air/water syringe) (4) Smear layer and Bonding **interferes with resin bonding

**newer dentin bonding systems (DBS) either remove smear layer (total-etch) OR alter smear layer (self-etch)

When primer and bonding resins are applied to etched dentin, they penetrate the i ntertubular dentin, forming a resin-dentin interdiffusion zone, or hybrid layer. They also p enetrate and polymerize in the open dentinal tubules, forming resin tags.
Current Dentin Bonding Systems Available 3 step total-etch technique 2 step total-etch technique 2 step self-etch technique 1 step self-etch technique

(1)Total-Etch 3 step Technique

Step 1: Total etch (35% H3PO4) Smear layer removed Surface dentin demineralized Dentin vulnerable to desiccation Step 2: Hydrophilic Primer applied Re-wets dentin Establishes Hybrid layer Step 3: Adhesive Composite placement Limitations: Too many steps dentin moisture variable some sensitivity reported

(2)Total-Etch 2 step Technique

Step 1: Total etch (35% H3PO4) Smear layer removed Surface dentin demineralized Dentin vulnerable to desiccation Step 2: Primer/Adhesive mixture applied Re-wets dentin (not as effective) Establishes Hybrid layer Composite placement Limitations: 1-Too many steps 2-dentin moisture variable3-most sensitivity reported

Ways to minimize post-op sensitivity when using total etch techniques

1- Do Not desiccate dentin Keep dentin moist 2-Rewet with wetting agent Water, Gluma, dentin primers, multiple adhesive layers, 3-RMGI liner or base prior to etching

(3)Self-Etching 2 Step Technique

Step 1: Apply Self-Etching Primers Smear layer modified Surface dentin demineralized Hybrid layer developed Step 2: Apply Adhesive More Complete seal and better penetration Composite placement 1-Lower sensitivity reported 2-Concerns about stability 3-Seal does not appear to be as good

(4)Self-Etching 1 Step Technique

Step 1: Apply Self-Etching Primer/Adhesive mixture Smear layer modified Surface dentin demineralized Hybrid layer developed

Composite placement 1-Lower sensitivity reported 2-Concerns about stability 3-Seal does not appear to be as good

Advantages Self-etch adhesives:

Extremely easy to apply, no etch, no rinsing! In vitro, they result in high dentin bond strengths

Major Disadvantages of Self-etch adhesives:

Acidity - 2.5 > pH > 1.1, therefore they do not etch enamel to the same depth as H3PO4 May result in clinical signs of enamel leakage at 1 year (Opdam et al., 1998) Thermal cycling (30,000X) decreases enamel bond strengths (Miyasaki et al., 2000). Their acidity may inhibit the polymerization of self-cured composite resins (Tay et al., 2002). ==========

Clinical Application of Bonding:

Direct anterior composites Direct posterior composites Indirect composites Porcelain veneers, inlays, crowns Fiber-reinforced posts Periodontal splints Adhesive amalgam restorations Endodontic sealer Reattachment of fractured tooth fragments Pit and fissure sealants

Orthodontic brackets Root desensitization

Cuent Strategies for Adhesion of Resins to Dentin* Current Strategies for Adhesion of Resins to ntin*p

Challenges in Dentin Bonding Substrate. Bonding to enamel is a relatively simple process, without major technical requirements or difficulties. Bonding to dentin presents a much greater challenge.

Several factors account for this difference between enamel and dentin bonding.
(1)Dentin contains a substantial proportion of water and organic material, primarily type I collagen. (2)Dentin also contains a dense network of tubules that connect the pulp with the dentinoenamel junction (DEJ) . (3) Movement of fluid from the pulp to the DEJ is a result of a slight but constant pulpal pressure. Dentinal tubules enclose cellular extensions from the odontoblasts and are in direct communication with the pulp. (4)Bond strengths are generally less in deep dentin than in superficial dentin. (5)Whenever tooth structure is prepared with a bur or other instrument, residual organic and inorganic components form a smear layer.The smear layer fills the orifices of dentinal tubules, forming smear plugs. The removal of the smear layer and smear plugs with acidic solutions results in an increase flow of fluids from the pulp through the tubules.

When primer and bonding resins are applied to etched dentin, they penetrate the intertubular dentin, forming a resin-dentin interdiffusion zone, or hybrid layer. They also penetrate and polymerize in the open dentinal tubules, forming resin tags.

From Pickards Composites

The majority of resin composites are inherently hydrophobic (water-hating) materials and so some form of intermediary bonding resin needs to be applied to the tooth. Bonding to enamel The bonding of composites to enamel is dependent upon the mechanical retention of resin tags within the highly mineralized enamel.These tags created by the etching action of acids (phosphoric acid has been most widely used). Currently, the etching times with phosphoric acid vary between 1530 seconds depending on the state of the tooth. Enamel is a substrate that can be dried relatively easily and the use of intermediate hydrophobic resins dictates such an approach, even though vigorous post-etch drying for 1020 seconds will cause collapse of the exposed hydroxyapatite crystals. In this way, the ideal enamel etch pattern would show clinically as a frosty appearance awaiting these resin intermediaries. Bonding to dentine Bonding to dentine presents a more difficult problem because it is a living, wet tissue and contains less mineralized tissue than enamel. Resin-based adhesives have been developed for bonding to dentine and these generally work by removing the surface smear layer and infiltrating the exposed dentine. Whilst it is possible to dry out dentine after etching, in the same way as enamel, the net result may prevent satisfactory resin penetration for some of the bonding agents in use. This is because the drying causes the fragile, exposed collagen network to collapse and the resin cannot penetrate this collapsed structure. The main problem of dentine bonding is that a hydrophobic resin composite is required to stick to a watery substrate. Resin technology has now developed such that it is possible to produce a bonding agent in a solvent that will infiltrate and stick to wet dentine (Fig. 6.10) and maintain the bond over a significant time period (Fig. 6.10h). Bonding to wet dentine (and enamel) Most dentine bonding agents require smear layer removal with weak acids. There are two ways of doing this. The more established systems use a separate etch stage with phosphoric acid followed by the bonding agent, whilst others combine acid and the bonding agent and are therefore called self-etching. Separate etching stage The smear layer is removed with acid (Fig. 6.10ac) and then the bonding agent is applied (Fig. 6.10d and e). This dentine bonding system uses alcohol and water as the solvent base for the hydrophilic resin: these materials will be capable of re-wetting a dried collagen surface, although their penetration time into the substrate may be slightly longer than the more volatile solvent bases such as acetone. Solvents such as acetone mix freely with water and therefore require a moist tooth surface for thorough dentine penetration in the technique described as wet bonding. This does not mean bonding through a pool of blood and saliva, but it does mean that the tooth surface should not be dried out too much as this will cause collapse of the exposed collagen network and enamel crystallites with grossly inadequate penetration of the bonding agent. Judging the correct degree of wetness in these situations is a problem. Some suggest that surplus water should be removed by the use of a cotton-wool pledget. For these materials, the desiccating effect of an air blast and the frosted appearance of etched enamel should be avoided (cf., Fig. 6.10c).

A low-molecular-weight hydrophilic resin (e.g. Hydroxy Ethyl MethAcrylate: HEMA), in a suitable solvent (e.g. water, alcohol, acetone), is flooded over the altered surface of the dentine (Fig. 6.10df). It then flows into the dentinal tubules and the porous intertubular dentine between them. The type of solvent in use is critical for the method of handling the bonding agent. Data sheets may give some indication of content or, alternatively, it is a reasonable test to smell the bonding system before use (although dont make a habit of it) to determine the type of solvent in use. Having acted as a good wetting agent on the dentine and enamel, layers of increasingly resinous hydrophilic material are applied and the relative stiffness of the resin component is increased by gentle evaporation of solvent. Many systems therefore involve either a lightcuring stage or a self-curing reaction. The dentine and patient are consequently embedded in an increasingly hydrophobic and stiff resin matrix which acts as a firm foundation on which to build a composite restoration. The region between the unaffected dentine and the restoration is a mixture of both and so is called the hybrid zone (Fig. 6.10f). Another name for it is the interdiffusion zone which also indicates the 5 the resins into the intertubular dentine. After curing, all resin-based materials will have a thin layer of slippery, greasy, unpolymerized material on the surface where they are exposed to the air the air-inhibited layer and this allows increments of material to be bonded to each other. The most important consideration for achieving a sound, reliable bond is the avoidance of any contamination between these layers. Self-etching adhesives A problem with bonding agents that have a separate etching stage is that successful bonds will only be achieved if the adhesive resin penetrates to the depth of demineralization caused by the acid-etching. Materials that use a self-etching combination will not suffer from this problem because the two components are already combined (Fig. 6.12). They will also not require a separate washing and drying stage before the application of the bonding agent, so helping to reduce the risk of contamination. Self-etching adhesives would therefore appear to offer the ideal solution of simple handling and technique insensitivity, giving excellent dentine bonds, but the evidence for successful enamel bonding with these materials has been less convincing (Fig. 6.12). These materials may be applied as two separate stages (Fig. 6.12) or alternatively as one component (Fig. 6.13b). New techniques for cavity preparation and finishing will offer huge scope for the development of simpler bonding agents.