ADHESION TO ENAMEL AND DENTIN

Board Review/Study Guide

PRINCIPLES OF ADHESION ADHESIVE MECHANISMS

1. Retention of Restoration 1. Substrate demineralization
2. Offset Polymerization Shrinkage
2. Micromechanical Interlocking
3. Prevent/Reduce Microleakage
4. Improve Marginal Adaptation a. Etched enamel
5. Prevent Marginal Discoloration b. Dentin Hybridization
6. Conserve Tooth Structure 2. Chemical
a. Ionic bond of resin to HA in dentin

ADHESIVE SUBSTRATES:
ENAMEL BONDING
1. Enamel
a. Composition 1. Predictable & Durable
i. 86% Inorganic (Hydroxyapatite) 2. Technique insensitive
ii. 2% Organic (Collagen) 3. Micromechanical
iii. 12% H2O 4. Enamel Etching
b. Homogeneous Structure a. 30-40% H3PO4
2. Dentin b. 15 sec/”frosty” appearance
a. Composition c. 15 sec rinse adequate to remove precipitates
i. 50% HA d. Effective etch 10 microns deep
ii. 30% Collagen 5. Penetration w/ hydrophobic monomers
iii. 20% H2O
b. Variable
i. Primary vs Secondary vs Tertiary
ii. Sclerotic/Hypermineralized
DENTIN BONDING
iii. Tubule size/density 1. Unpredictable & durability questionable
iv. Tubular fluid flow 2. Technique Sensitive
v. Smear layer 3. Micromechanical & chemical (Self-etch)
vi. Hypomineralized (caries/erosion) 4. Dentin Conditioning
a. “Total Etch” – H3PO4
b. Self-Etch – acidic monomers
c. Depth of demineralization varies with strength
of conditioner
5. Hybridization with hydrophilic primers and
hydrophobic adhesives (2 & 1 steps)

Col JP Jessup 2014

 DENTIN ADHESIVE CLASSIFICATION

ADHESIVES

ETCH & RINSE SELF-ETCH

ADHESIVES ADHESIVES

3 STEP (3E&Ra) 2 STEP (2E&Ra) 2 STEP SE 1 STEP SE

[4th Gen] [5th Gen] [6th Gen] [7th Gen]
ETCH, PRIME, BOND ETCH, (PRIME & BOND) (ETCH & PRIME), BOND (ETCH & PRIME & BOND)

2 STEP MILD 1 STEP MILD

(2SEa_m) (1SEa_m)
COMBINING PRIMER + ADHESIVE = “SIMPLIFIED”
pH > 1.5 pH > 1.5

2 STEP STRONG 1 STEP STRONG

(2SEa_s) (1SEa_s)
pH < 1.5 pH < 1.5

Col JP Jessup 2014

 ETCH & RINSE ADHESIVES

ETCH & RINSE ADHESIVES

1. 37% H3PO4 etchant applied to enamel & dentin, then rinsed

off (“Total Etch”)
2. Results in 5-8 micron dentin “hybrid” or “interdiffusion”
zone
3. Smear layer/plugs completely removed
4. Simultaneous enamel etch
5. Acid-etched enamel peripheral seal contributes to longevity
of the bond
6. Technique sensitive…over-drying conditioned dentin results
in collapse of collagen fibrils preventing resin penetration
(“Wet Bonding”)
7. Incomplete penetration of resin to full depth of
demineralization results in “nano-leakage” & hydrolysis of 3 STEP ETCH & RINSE ADHESIVES (3E&Ra)
bond
PROS:
1. Best bond to enamel of all classes
2. Highest bond strengths of all adhesives
3 STEP ETCH & RINSE ADHESIVES (3E&Ra)
3. Dual cure options
1. Previously known as 4th generation 4. Consider use with CHX for bond preservation & rewetting
2. Separate condition, prime, adhesive steps (Non Simplified) agent
3. Previously considered the “gold standard” for dental
CONS:
adhesives
1. Multiple steps
4. Variable performance by brand
2. Technique sensitive
5. Primer – hydrophilic bifunctional monomer (HEMA)
a. Overetching of dentin
a. Chases/displaces water in interdiffusion zone
b. Overwet/overdry dentin
b. Link between hydrophilic collagen & hydrophobic resin
c. Insufficient primer penetration
c. Dissolved in solvents
d. Insufficient solvent evaporation (*****)
i. Acetone, H20, Ethanol
ii. Residual solvent decreases strength/durability of e. Overthinning adhesive – air inhibited layer
bond (Most adverse effect)
iii. Ethanol>H20>Acetone 3 STEP ETCH & RINSE ADHESIVES (3E&Ra)
d. Actively apply/agitate for 30 sec to ensure penetration EXAMPLES
6. Adhesive Resin
a. Unfilled or lightly filled (Optibond FL) solvent free OPTIBOND FL (KERR)
1. Highest performing 3E&Ra (AFR=1.8)
monomers
2. Highest filler loading of all adhesives – contributes to
b. This separate hydrophobic layer critical to bond
bond durability
durability
3. Ethanol based primer
c. Links primer to resin composite
SCOTCHBOND MP (3M ESPE)
d. Light cured
1. Intermediate performance (AFR=3.9)
e. Avoid over thinning (rippled or brush thinned)
2. H2O based solvent – more difficult to remove
3. Contains polyalkenoic acid polymer inhibiting
monomer penetration to full depth of hybrid zone –
leads to degradation of bond
Col JP Jessup 2014
3E&Ra CLASS (AFR=3.1)
 ETCH & RINSE ADHESIVES

2 STEP ETCH & RINSE ADHESIVES (2E&Ra) 2 STEP ETCH & RINSE ADHESIVES (2E&Ra)
th
1. Previously known as 5 generation 1. Etching: Similar to 3E&Ra
2. Combine primer and adhesive steps (Simplified) a. Dentinal moisture level more sensitive than 3E&Ra
3. Comparable SBS to 3E&Ra upon initial application b. No rewetting effect of primers
4. Resultant hybrid layer contains hydrophilic monomers 2. Priming & Bonding
without benefit of overlying hydrophobic layer; “semi- a. reduced penetration to depth of demineralization
permeable”- increases hydrolytic degradation of bond b. Should be applied with extended application times and
5. Suboptimal polymerization & increased water sorption - multiple coats
decreases stability /durability of bond c. Should use vigorous rubbing application mode
6. Higher conc. of solvents; more residual solvent – further 3. Due to high use of highly volatile acetone solvent, subject to
decreases polymerization & strength evaporation of solvent and loss of efficacy over time
7. Higher frequency of acetone use in this class 4. May by incompatible with dual cure and self-cure composite
8. As a class, among the worst performing adhesives core materials and luting cements – pH dependent

2 STEP ETCH & RINSE ADHESIVES (2E&Ra)

EXAMPLES

OPTIBOND SOLO PLUS (KERR) (AFR=4.6)

OPTIBOND SOLO (KERR) (AFR=6.8)
PRIME AND BOND NT (Dentsply) (AFR=6.3)
SCOTCHBOND 1 XT (3M-ESPE) (AFR=1.4)
ONE-STEP (BISCO) (AFR=17.1)
2E&Ra CLASS (AFR=5.8)

Col JP Jessup 2014

 SELF- ETCHING ADHESIVES

Self-etching adhesives can also be classified according to the relative pH of their self-etching conditioners. This
is useful as the self-etching adhesives with ultra-mild to intermediately strong conditioners significantly
outperformed those using strong conditioners. Conditioner strength influenced the management of the smear
layer & depth of demineralization as shown in the graphic below.

2SEa_m & 1SEa_m 2SEa_s &

1SEa_s

SELF-ETCHING ADHESIVES

1. Conditioners are acidified monomers which solubilize or 6. Many contain functional monomers which form chemical
remove the smear layer and demineralize dentin to ionic bonds to hydroxyapatite
varying depths based on their pH a. 10-MDP (Clearfil) +++
2. Conditioners are not rinsed off b. 4-META ++
3. Do not etch enamel well, so “selective etch” of enamel
with H3PO4 is advocated to improve marginal
adaptation/decrease staining.
4. Simultaneous demineralization & hybridization
5. Less technique sensitive than etch and rinse adhesives

Col JP Jessup 2014

 SELF- ETCHING ADHESIVES

MILD TWO-STEP SELF-ETCHING ADHESIVES (2SEa_m) STRONG TWO-STEP SELF-ETCHING ADHESIVES

th (2SEa_s)
1. 6 Generation Adhesives
2. Combine conditioner & primer, separate adhesive (Non 1.
th
6 Generation
Simplified) 2. Among the WORST performing class
3. The new “Gold Standard” 3. Strong acidified primer completely removes smear layer,
4. Demineralize dentin to depth of 1 micron or less tubule plugs, deep demineralization of dentin without
5. Partially demineralize dentin, leaving residual hydroxyapatite adequate buffering – leads to continuous etching and
which in-turn protect the collagen fibril from degradation incomplete polymerization, inadequate penetration,
6. High immediate bond strength with improved longevity and nanoleakage, etc…..
durability compared to 3E&Ra
7. Avoid most problems associated with E&Ra etching of dentin.
8. Carefully perform selective etch to avoid H3PO4 etching of
dentin when using 2SEa-m primers
9. Adhesive Bonding Agents are hydrophobic, solvent free
monomers (bis-GMA & TEDGMA)

MILD TWO-STEP SELF-ETCHING ADHESIVES (2SEa_m) STRONG TWO-STEP SELF-ETCHING ADHESIVES

(2SEa_m)
EXAMPLES
EXAMPLES
CLEARFIL SE BOND (KURARAY)
1. Highest performing 2SEa-m (AFR=2.2) ADPER SCOTCHBOND SE(3M-ESPE) (AFR=5.3)
2. Contains 10-MDP PRISMA UNIVERSAL BOND 3 (DENTSPLY) (AFR=3.7)
CLEARFIL SE PROTECT, LINER BOND (KURARAY) 2SEa_S CLASS (AFR=8.4)
ADHESE (IVOCLAR) (AFR=3.6)
2SEa_m CLASS (AFR=2.5)

Col JP Jessup 2014

 SELF- ETCHING ADHESIVES

MILD ONE-STEP SELF-ETCHING ADHESIVES (1SEa_m) STRONG ONE-STEP SELF-ETCHING ADHESIVES

1. 7th Generation Adhesives (2SEa_s)
2. Combine conditioner+primer+bond in 1 step [may be in one th
th th 1. 7 Generation
bottle (7 ) or mixed (6 ) prior to application]
2. Simplified Adhesive
3. Simplified Adhesive
3. Among the WORST performing class
4. Shallow demineralization of dentin to <1 micron
4. All of the problems of 1SEa_m PLUS…..
5. Highest concentration of hydrophilic monomers, many use
5. Strong acidified primer completely removes smear layer,
acetone as solvent
tubule plugs, deep demineralization of dentin without
6. Complex intermixing of chemicals cause shelf life problems
adequate buffering – leads to continuous etching and
7. Lower immediate bond strengths
incomplete polymerization, inadequate penetration,
8. High hydrophilic monomer content creates semipermeable
nanoleakage, etc…..
membrane, increased water sorption, polymer swelling,
incomplete polymerization
9. Incompatible with dual cure and self-cure composites,
depending on pH of adhesive
10. Recent studies show better long term performance than
2E&Ra most likely due to mild conditioner and shallow
demineralization as well as incorporation of 10-MDP chemical
bonding
11. Strategies to improve performance:
a. Selective etching of enamel with H3PO4
STRONG ONE-STEP SELF-ETCHING ADHESIVES
b. Application of hydrophobic bonding layer
c. Active application
(1SEa_S)
d. Application of multiple layers and prolonged application EXAMPLES
times
ADPER PROMPT-L POP (3M-ESPE)
PROMPT-L POP (3M-ESPE) (AFR=8.8)
XENO 3 (DENTSPLY) (AFR=4.8)
1SEa_s Class (AFR=5.4)

MILD ONE-STEP SELF-ETCHING ADHESIVES (1SEa_m) UNIVERSAL ADHESIVES

EXAMPLES 1.
th
8 Generation?
2. Modified Self-Etch Adhesive formulations marketed for
CLEARFIL S3 BOND (KURARAY) choice between SE, E&R, or selective etch conditioning
G-BOND (GC) 3. Also marketed for bonding to additional substrates of
OPTIBOND ALL IN ONE (3M) metals and ceramics due to incorporation of functional
2SEa_m CLASS (AFR=3.6) molecules such as MDP and silane
4. Include self-curing activator for use with self & dual cure
luting resin cements

Col JP Jessup 2014

COMPARING PERFORMANCE OF DENTAL ADHESIVE CLASSES

2SEa-m

3E&Ra

ANNUAL FAILURE RATE

1SEa-m

1SEa-s

2E&Ra

2SEa-s

CLINICAL METHODS TO MINIMIZE BOND DEGRADATION

1. E&R adhesive’s use of strong acid etching of dentin results in complete removal of HA in hybrid layer and
relatively deep zone of demineralization
a. May result in incomplete infiltration of resin monomer to full depths of demineralization and resultant
exposed collagen fibrils at base of hybrid zone with no remaining HA to stabilize them
i. Improve resin impregnation by vigorous rubbing application of bonding agents, application of multiple
coats of bonding resin, and prolonged application times.
b. Exposed collagen fibrils are susceptible to enzymatic degradation by MMPs released during
demineralization
i. Use a MMP-inhibitor such as CHX or EDTA as a re-wetting agent prior to primer/bonding agent
application or use a conditioner containing BAC (BISCO)
2. Simplified adhesives contain higher concentrations of hydrophilic monomers without the benefit of an overlying
hydrophobic resin layer
a. Leads to entrapment of solvent & water within the polymer network which prevents adequate cross-linking
and degree of conversion; and plasticization of the polymer by water sorption
i. Improve polymer strength by the addition of hydrophobic resin layer & increased photo polymerization
time

Col JP Jessup 2014