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Dentin Bonding

LearningObjectives 1. List 4 factorsthat hinderin creatingsuperiordentingbonding. 2. List 8 propertiesof an ideal dentinbondingagent. 3. Describevariousgenerationsof dentingbondingagentsand describethe progress madein developingideal dentinadhesives.

The achievementof an adhesivebondbetweenenameland dentinand restorative materialshas beenan objectof generationsof dentalresearchand development. Adhesiverestorativeandpreventivedentistrybeganin 1955whenacid etchingof the enamelsurfacewasproposedto increaseadhesion.Enamel,whenacid etched,shows predictableandhighbondstrengthsto resin-basedrestorativematerials. The bond strengthsof compositeresin to phosphoricacid-etchedenamelare in the rangeof 20 MPa. DifficultiesIn DentinalBonding Althoughadhesionto enamelhas becomeroutine,dentinaladhesionis moredifficult becauseof the complexstructureand variablecompositionof dentin. It is generally agreedthat the majordifferencebetweenthe successof enamelbondingandthat of dentinalbondinglies in the substratesurface.Enamelis composedlargelyof hydroxyapatiteand has a very low watercontent.By contrast,dentinvaries considerablyandmaybe very dense,with only1% of the surfaceat the dentinoenamel junctionconsistingof tubules,or veryporousat the pulpal floor, whereas muchas 22% of the total surfaceareamayconsistof dentinaltubules.Dentinis permeatedby fluids transportedfromthe pulp, and thereis bothlooselyand tightlyboundwaterevenin enamel. Dentinalbondingis also complicatedby the formationof a smearlayer whenthe dentin is cut or ground.Bacteriacan becomeentrappedin this smearlayer and multiply beneathrestorations. The factorscontributingto the lack of successin creatingsuperiordentinbonding couldbe listedas follows: Dentincontains20%waterby weightwhichmakescloseappositionof hydrophobic materialsto the hydrophilicdentindifficult. Pulpalbiocompatibility.

Photopolymerizedresinbasedmaterialscreatepolymerizationshrinkageforceswhich needto be overcomeby sufficientlyhighbondstrength. Until recently,cliniciansdid not properlyunderstandthe presenceand natureof the smearlayer. Last few yearshaveseena steadyprogressbeingmadetowardthe developmentof variousdentinbondingagentsor dentinadhesivesof increasingbondstrengths.These bondingagentshavebeenclassifiedchronologicallyinto "generations,"with earliest generationshowingunreliablebondstrengths. The Ideal DentinBondingAgent Accordingto a consensusarrivedat a workshopheld in 1961at the Universityof Indiana DentalSchool,the ideal dentinbondingagentshouldhavethe followingproperties: 1. Providea highbondstrengthto dentin,whichshouldbe presentimmediatelyafter placementand whichshouldbe permanent 2. Providea bondstrengthto dentinsimilarto that to enamel 3. Showgoodbiocompatibilityto dental tissues,includingthe pulp 4. Minimizemicroleakageat the marginsof restorations 5. Preventrecurrentcariesand marginalstaining 6. Be easyto use and minimallytechniquesensitive 7. Possessa goodshelf life 8. Be compatiblewith a widerangeof resins In addition,the resin shouldhavea low film thickness(circa> 10mm),if the systemis to be suitablefor use with indirectrestorations. Historyof DentinBondingAgents The first attemptto developan adhesivesystemfor bondingto dentinwasmadeby Hagger,a Swisschemistworkingfor the AmalgamatedDentalCompanyin Londonand Zurichin 1951. Thefirst commercialproduct(SevritonCavitySeal), basedon glycerophosphoricacid dimethacrylate,wasusedto bondan autocuringacrylicresin, Sevriton,to dentin. Workat the EastmanDentalHospital, London,showedthat glycerophosphoricacid dimethacrylateincreasedadhesionto dentinby penetratingthe surfaceandformingan intermediatelayer, nowcalledthe hybrid zone . This was detectedbecausethe dentinexhibitedan intenseaffinityor hematoxylinstaining,and

the zoneof altereddentinhadaffinitiessimilarto thoseof calcifieddentinin an exaggeratedform. It is interestingto note that, despitethe use of a methylmethacrylateresin as the restorativematerial, the pulpalreactionto Sevritonpluscavityseal wassimilarin intensityto that recordedfor otherautocuredresins. AlthoughSevritonwascapableof causingan acuteinflammatoryreactionwhenplacedin moderatelydeep,unlined cavities,the usualoutcomeof this reactionwasresolution. Materialsintroducedin the early 1980s,suchas Gluma,Tenure,and ScotchBondII, representedthe first generationof dentinbondingsystemsthat createdsufficiently strongbondsto dentin. Buonocoreet al reporteda dentinbondingagentusinga cavityprimercontaining glycerphosphoricacid dimethacrylatewith bondingbeingachievedprimarilyby the interactionof the phosphategroupwith the calciumionson the dentinsurface. Designedfor restoringcervicallesionswithoutmechanicalretention,the process consistedof conditioningthe dentinalsurfacewith citric acid. Theprocedureremoved the smearlayerandopenedthe dentinaltubules,permittingthe influxof the resin restorativematerial to a depthof 50 - 100 microns.Thecompositecontaininga chelating agenthad the potentialto bondto the dentin'scalciumcomponent. However,the bondstrengthswhichwereachievedwerefoundto decreasefrom58 2 2 kg/cm (5.7 MPa)to 28 kg/cm (2.7 MPa)after 5 monthsof waterimmersion.This was thoughtto be due to the linkagebetweenphosphateand monomerbeingeasily hydrolyzed,with a consequentreductionin bondstrengths. The principalbarrierto effectiveadhesionto dental tissueis water. Waterwill compete with a potentialadhesivefor the surfaceof a substrateand can alsohydrolyzeadhesive bonds.Moderndentinalbondingagentshaveevolvedfromthe originalconceptof increasingdentinalpermeabilityand wettabilityand promotingbondingto the smear layer, to the partial removalof the smearlayer, andfinallyto the use of stronger etchantsto modifyor removethe smearlayer and obtainsomeformof micromechanical retention. The next generationof dentinbondingagentsdifferedfromtheir predecessorsby the use of a solution,or seriesof solutions,whichwereappliedto the dentinsurfaceto modifyit prior to applicationof the resin. In manysystems,theseprimerswereapplied to the surfaceand not washedoff, whilesomealso requiredthe use of conditioners whichwereappliedand subsequentlywashedoff. The additionalstagesrequiredfor primingand conditioningmadethe chairsideuse of thesematerialsmorecomplicated and timeconsumingthanpreviousmaterials,but the bondstrengthsto dentinwere generallyhigherandmorereliablein the oral environment.

Becauseenamelis an ion exchangerand dentinis a livingmaterial subjectto change, one is tryingto bondto shiftingsandratherthanto solid rock. Undersuchconditions, the adhesivebondmusthavea dynamiccharactertoo. It will be brokenas the substrate changesand mustbe capableof beingre-formed.Oncebroken,covalentchemical bondscannotbe re-formed.Dentinaladhesivesmayfail for this very reason. Manylater generationdentinbondingsystemsuse mechanicalmeansof adhesion ratherthanthe unreliablechemicalbondingseenin previousmaterials.Thosesystems whichutilizethe hybridor resinreinforcedconcepthavebeenconsideredto perform betterthanthosewhichattemptto achievechemicalbonding. The latest or fourthgenerationof dentinbondingagentsdifferentiatefromthe previous systemsin threeways:minimaltechniquesensitivity, similarbondstrengthsto enamel and dentin, and no reductionin bondstrengthwhenappliedto a moistsurface. Furthermore,becausethe adhesionto dentinis nearlythe sameas to enamel,the problemsof marginaladaptionand microleakagehavebeenreduced. RecentlyintroducedmaterialsincludePertacUniversalBond,ScotchbondMPand Gluma2000, eachof whichis characterizedby its user-friendlinessin comparisonwith the previoussystems.The applicationspeedof thesematerialsmayhavereachedthe ultimatefromthe viewpointof operationalfeasibility. Thetotal applicationtimewith PertacUniversalBondis 100 secondscomparedto 130 secondswith the previous materials;the primerand Solution2 of the Gluma2000systemsrequireapplicationtime of 30 secondseach,and the etchantsolutionandprimerof ScotchbondMP require applicationof 15 and 5 secondsrespectivelyand the resinrequirescuringfor 10 seconds. Experimentalworkusingthe ScotchbondMPsystemhas shownthan, whenusedwith the 10%maleicacid etchantprovidedby the manufacturers,bondstrengthsto dentin andenamelof 23.0 MPaand 25.7 MPa,respectivelywereachieved.Thesestrengthswere foundto increaseto 26.2 MPa(to dentin)and 26.9 MPa(to enamel)with the substitution of a phosphoricacid etchant. The fourthgenerationdentinbondingagents,suchas All-Bond,Amalgambond,Mirage Bond,Tenure,showsatisfactoryor evenenhancedadhesionto visiblymoistdentin. This doesnot meanthat the dentistshouldallowthe cavitiesto be contaminatedwith salivaduringrestorationplacementas it decreasesbondstrength,but the development of a systemthat functionsin a slightlymoistenvironmentwithoutreductionin its propertieshas a definiteclinicaladvantage. Thereis a goodcorrelationbetweendentin/resinbondstrengthand microleakage,and sinceearly generationdentinbondingsystemsdid not producesufficientlyhighbond strengthstheywereplaguedwith the problemof microleakage.In this respect,the microleakageof six dentinbondingsystems(Optibond,Clearfil LinerBond,Prisma UniversalBond,ScotchbondMP, Gluma2000and ImpervaBond)has beenassessedby

Fortin& Swift, whoseresultsindicatedsignificantlyless microleakagewhenusing Optibond. Compositionof recentlyintroduceddentinbondingsystems. Gluma2000 Conditioningsolution:4.3%organicacids, 2.6%aluminiumsalts, in aqueoussolution Bondingsolution:28.9%monoand polyfunctionalmetacrylicacid PertacBond Bondingresin: Methacrylatedcarboxylicacid; hydrophillicand hydrophobicimethacrylates;camphorquinoneand activator ScotchbondMulti-Purpose Etchant:10%maleicacid Primer:Aqueoussolutionof HEMA;polyalkenoicacid copolymer. Adhesiveresin: Bis-GMA;HEMA;proprietaryphotoinitiator
Source:BurkeFJ, McCaugheyAD. The four generationsof dentingbonding.A J Dent1995;8: 88-92.

In additionto providingexcellentbondingto dentinalsurfaces,the newgeneration bondingsystemspermitclinicallyacceptablebondingof compositeresinsto materials otherthantoothstructure.It is nowpossible,for example,to bondresinsystemsto surfacesof basemetal alloys,hardenedamalgam,set composites,and, of course, fracturedporcelain.Finally, throughthe use of self-curingadhesiveagentsit is also possibleto bondamalgamto the walls of the cariespreparation.Undoubtedly,future researchwill broadenevenfurtherthe potentialusesof dentinadhesivesystems.

DentinalBondingagentsversusGlassionomerCements JohnW. McLean HonorarySemiorResearchFellow EastmanDental Institute, London,England. Abstract The long-term bonding of dental materials to dentin remains an area of

great controversy and the results of in vitro testing do not always reflect those found in' vivo. The clinician is faced with a large number of dentinal bonding agents that have had limited testing in vivo and are frequently replaced before any long-term clinical testing has been completed. Glass-ionomer cements, although having a longer history of good adhesion to dentin, are not suitable for use in high-stress bearing areas. The selection of materials for specific clinical situations has become more and more difficult. This paper gives a personal view of the history and evolution of both resin bonding agents and glass-ionomer cements and their potential in clinical use. (QuintessenceInt 1996;27:659667.) Historyof DentinalBonding Buonocoreand Quigleyusedglycerophosphoricacid dimethacrylatein their early experimentsand concludedthat the phosphategroupsin Sevritoncavityseal seemed ideallysuitedfor chemicalcombinationwith constituentsof the dentin,and they confirmedthe earlier findingsof Kramerand McLean.Althoughthis workappearedto usherin a newera in dentinalbonding,the idealay dormantfor a longperiodbecause the restorativematerialsusedin the 1950swereall basedon methylmethacrylatesof relativelyhighviscositythat containedfree monomersandexhibitedhighshrinkage duringpolymerization,propertiesthat wereless thanideal for securinglong-term bondingto dentin. Subsequentclinicaltrials showedthat the phosphatebonds, supposedlyformedwith calciumionsof the dentinalsurface,werenot of a lasting natureand werehydrolyticallyunstable,a problemthat can still arisewith the current resinbondingagents. It wasnot until 1958that the first low-shrinkageresin wasproducedby Schmidtand Purrmannin Germany;the materialwasbasedon their novel developmentof the lowviscosityepimineresinsand marketedunderthe tradename,P-Cadurit. In 1959, Bowen filed his first patentin the UnitedStateson his nowfamousbis-GMAresin and produced a dentalrestorativematerial containingvinyl silanetreatedfusedsilica. Morerecently, the urethanedimethacrylates(ICI Dental) weredevelopedby Knightet al for industrial use. Subsequently,ForsterandWalker,workingat the AmalgamatedDental Company, madea urethanedimethacrylateresin for use in resincompositedental materials. Thesenewresinshavethe advantageof highermolecularweight, lowerviscosity,and a certaindegreeof toughnessin the urethanemoiety, togetherwith less stainingthanbisGMA.Furtherworkby ICI resultedin the introductionof the first visiblelight-curing systems,whichstarteda newera in restorativedentistryand madepossiblethe modern methodsof dentinalbondingwith low viscosityphotocuredresins. Moderndentinalbondingagents Nakabayashiet al havedescribedmonomers,basedon 4-methacryloxyethyltrimellitate anlydride,that containbothhydrophilicand hydrophobicchemicalgroupsthat can penetrateetcheddentinandpolymerizein situ. Thisresinimpregnationcreatesa

transitionallayer that is neitherresin nor tooth, but a hybridof the two. Sevritoncavity seal wasthe first commercialmaterialto use this approach.Chemicalbondingcould furtherenhancethe bond,but, at the presenttime, thereis evidencethat evenwhen established,the bondis of a transitorynature. Althoughmeasurementsof bondstrengthsrevealmuchlowervaluesfor glassionomer cementsthanfor dentinalbondingagentsusedwith resin composites,whenthesetwo materialswerefirst usedfor the restorationof erosion/abrasionlesionswithoutcavity preparation,the glassionomermaterialshad betterlong-termretentionrates. It is thoughtthat glassionomermaterialsare not affectedby scleroticdentinas muchas are somedentinalbondingagents.Also, the settingstresscharacteristicsfavorthe glassionomermaterials.Davidsonconsideredthat the ability of glassionomercementsto withstandstresscan be explainedby an internalfracturemechanismby whichmaterial can easilyreshapeto enforcednewforms. It seemslogical that the ideal methodof clinicallytestingthe retentionof bondedresin compositeandglassionomerrestorationsshouldbe in ClassV erosionlesionswithout cavitypreparationover a periodof at least 3 years. Unfortunately,clinical trials are difficult and takeyearsto complete,so that eachgenerationof dentinalbondingagents tendsto be supersededbeforelongtermclinical trials can be undertakenandproduce meaningfulresults. Thereforethe professionhas had to rely mainlyon short-termin vitro testingof bondstrengthsas a measureof a material'ssuccess. Fig 1 Evolutionof dentinalbonding,fromthe early attemptsto bondto the smearlayer to total removalby acid etchingand bondingto intertubulardentin. Fig 2 Formationof the hybridlayer in intertubulardentin. Fig 3 Failureof wettingby resin primersin the dentinaltubules. Fig 4 Penetrationof dentinalbondingagentsto formtagsin the dentinaltubules.The primershouldwet the surfaceof the tubuleprior to the applicationof the bondingagent. Moderndentinalbondingagentsusedwith acidetchingproceduresproducehighbond strengthvalues,but thesefiguresshouldnot be confusedwith long-termresistanceto microleakage,whichhas beenshownto occurevenin the absenceof gapsundera resincompositeplacedin ClassV cavitieswith an adhesiveresinsystem.Thedentinal surfaceand the smearlayerafter toothpreparationshowmanyvariations,with the result that short-termin vitro studiesof the strengthof dentinalbondscannotalways give the clinicianan accuratepictureof the futureclinical situation.Paul and Scharer believedthat therehas beena discrepancybetweenthe resultsof laboratorytestingand the in vivo performanceof the dentinalbondingsystems;they attributedthe difference to dentinalfluid, that underpressure,leakedout of numerouscut tubulesand changed the conditionsof the chemicalreactionof the adhesiveresin to the dentin(Fig 3). The interlockingof the bondingagentwith the collagennetworkof the intertubulardentin

(see Fig 2), and not the tag formationinto the tubuli (Fig 4), wasconsideredto be the mainsubstratethat yieldshighbondstrengthsto dentin. It is nowgenerallyagreedthat wherethe areaof intertubulardentinis maximal,as in outerdentin, betterbondstrength figurescan be obtained.

Fig 5 Glassionomercementusedas a dentinsubstitutein a Class111 preparation Glassionomercements,beingwater-basedmaterials,are not as affectedby dentinal fluids,and, althoughtheyexhibit lowertensilebondstrengthsthando the resinbonding agents,the bondareagenerallyshowsa cohesivefracturethat reflectsthe low tensile strengthof the cementand not the actual strengthof the bond.Until a muchstronger cementis produced,it will not be possibleto measurethe true strengthof this bond.For this reason,currentuse of glassionomercementsas restorativematerialsshouldbe confinedto lowstressbearingareas;their greatestvaluelies in bondingto dentin. In cavitieswhereperipheralenamelbondingcan be achieved,the resin composite restorationusedwith a resin bondingagentis superiorin strength,surfaceintegrity, and esthetics. ClinicalUse Thereare two schoolsof thoughtwith regardto the clinical use of dentinalbonding agentsand glassionomercementliningsand bases.Onegroupadvocatesthe exclusive use of photocuredresin bondingagentsto forma hybridlayer in the dentinalsurface, whilethe proponentsof glassionomermaterialsrecommend,for the deepercavity, placementof glassionomerbasesas a dentinalsubstituteto whichcompositeor other restorativematerialscan be attached(Fig 5). The use of a singlebondingagentand restorativematerialthat can be attachedto the toothin one procedureappealsto the hard-pressedclinicianbut, as with mostdental materialsand techniques,a pricehas to be paid. Enameland dentinare very different substrates;to achievelongtermadhesion,the clinicianmustrecognizethis fact and not lightlydismisstechniquesthat maytake moretimebut take accountof these differences.The clinicianis facedwith innumerablebondingsystems,and makinga correctchoicefor eachclinical casehas becomemoreand moredifficult as the manufacturersmovefromonegenerationof bondingagentsto the next. DentinalBondingAgents Considerablesupportis emerging,bothin the clinical and researchfields, for the use of mild acid etchants,suchas maleicacid, to demineralizethe intertubulardentin, allowing hydrophilicprimersto infiltratethe collagennetworkandforma thin hybridlayer or zoneof resin-impregnateddentin.The only questionthat still remainsunansweredis howlongthis seal will last whenplacedunderstressandsubjectedto long-term exposureto oral fluids. As previouslydescribed,Sanoet al haveperformedexperiments usinga cryoscanningelectronmicroscopeanda silverion penetrationmethod. Microleakagewasobserved,evenin the absenceof gaps,undera compositeplacedin

ClassV cavitieswith an adhesiveresinsystem.Theysuggestedthat the bonding monomerwasnot fully able to penetratethe demineralizeddentinafter phosphoricacid etching,thusleavinga porouszoneas a pathwayfor microleakagebeneaththe resinimpregnatedlayer. Theresistanceof the restorationto long-termmicroleakageshould be the mainconsiderationwhentechniquesand materialsare selectedfor adhesive bonding. Thereis generalagreementthat the largerthe bulk of the resin compositerestoration, the greaterthe effect of stressesproducedby polymerizationshrinkage.In the large posteriorrestoration,bondingto cervicaldentininvolvesgreaterrisksof microleakage becauseinnerdentinhas less intertubulardentinand becausethereis an increasein dynamicocclusalstresses.Wheneverpossible,the clinicianshouldretainan enamel margin,particularlyat the cervicalarea. At present,the use of compositesplacedon dentinalmarginsis betterconfinedto small cavitiesand low-stressbearingareas. However,the use of resinbondingagentsto seal dentinunderporcelain,gold, or amalgamrestorationsis enjoyinggreatersuccess,althoughas yet muchof the evidence for this is anecdotal.Pashleyet al consideredthe methodworthyof furtherinvestigation andexaminedthe ability of six differentdentinalbondingagentsto seal the dentinof crownpreparationsof humanteeth in vitro. Theyconcludedthat, althoughthe bonding agentstendto accumulateon chamfers,therebyincreasingtheir thicknessto 200 to 300 um, the methodcouldbe a simplewayto protectthe pulp fromthe consequencesof microleakage. Morerecently, photocuredresin bondingagentsbasedon glassionomertechnology havebeendeveloped(ScotchbondMultiPurpose,3M Dental; PertacUniversalBond, ESPE);carboxylicacid groupsthat becomeavailablefor attachmentto dentinare incorporated.In addition,thesematerialsare useful for attachingresincompositesto glassionomercementsurfaces.This line of chemistrymayhavea promisingfuture, becausethe introductionof carboxylicacid groupscouldfacilitatesomechemical bonding.Thesenewbondingagentscouldbe classifiedas glassionomer bonding agents, becausetheyhavea dual role in bondingto bothdentinand glassionomer cement. Swift and Triolo, in an in vitro studyon ScotchbondMultiPurposeUniversalDental Adhesive,foundthat dentinand evenenamelbondstrengthsare improvedwhenthe adhesiveis appliedto slightlymoistsurfaces,a findingthat mirrorsthe ideal surfacefor glassionomerbonding.Theyfoundthat improvedbondstrengthsare obtainedon enamelwhenthe stronger35%to 40%phosphoricacid is usedinsteadofthe10%maleic acid advocatedby the manufacturer.Themanufacturerhas startedto recommendthis procedure,which,as previouslydiscussed,illustratesthe difficultyof usingone material or etchantto conditionenameland dentin. In the pursuitof universality, maximalphysicalpropertiesare oftensacrificedon the altar of speed.Theclinicianis dealingwith two very differentsurfaces,and dentinis a vital tissuethat is bettertreated with mild etchantsor surfaceconditioners.Glassionomercements

The use of glassionomercementas a baseor dentinsubstitutefor attachingcomposite restorationsto toothstructurewasfirst describedby McLeanand llsonin 1977. The mainquestiontodayis whethercementbasesare obsoleteandhaveany valuein operativedentistry.To answerthis questionit is necessaryto againconsiderthe basic requirementof all restorations,resistanceto microleakage.Theefficacyof cavity sealingby glassionomerbaseshas hada longhistoryof successand has been confirmedin numerousclinical studies.In addition,becausethe glassionomercements liberatefluoride,they possesssomecariostaticproperties.Providedthat thesecements are placedon a cleandentinalsurface,their long-termresistanceto microleakagehas beenprovenoverperiodsof morethan15 years. A furtheradvantageis that, whenthesecementsare usedas dentinsubstitutesin the so-calledsandwichtechnique(see Fig 5), theyreducethe bulk of overlyingcomposite and subsequentpolymerizationshrinkage.In the caseof the ClassIII restoration,a glassionomerbasecan oftenimproveestheticsbecausethe cement'stransmissionof light is closeto that of dentin,preventingthe halo effect sometimesobservedwith the moretranslucentmicrofilledcomposites. Criticismis still leveled,however,at the laminate,or sandwich,techniqueand somein vitro studiesappearto showleakagearoundglassionomerbaseswherean acid-etched compositehas beeninserted.It is postulatedthat the polymerizationshrinkageof the compositerestorationbreaksthe seal of the glassionomercementto dentin. However,a recentstudyfoundno loss of seal in vital teeth, and microleakagewasmorerelatedto the atmospherein whichthe restorationwasplaced.In this in vivo test, the partially humidenvironmentfavoredthe applicationprocessand, as previouslydiscussed,the stressrelief exhibitedby glassionomercementsmaycontributeto this result. The use of glassionomerbaseshas enjoyedconsiderableclinicalsuccessover the last 20 years in countriessuchas the UnitedKingdomand Australia, and this anecdotalevidence shouldnot be lightlydismissed. In the shallowcavity, lossof seal in the sandwichtechniqueis oftenrelatedto the strengthand thicknessof the baseused,and thin liningsof less than1.0 mmare not alwayssatisfactory.Essentially, glassionomercementshouldbe usedas a dentinal substituteto protectthe dentinfromany acid penetrationduringinsertionofthe composite.The cementitself shouldbe protectedwith a glassionomerbondingagent, as previouslydescribed,prior to acid etching(Fig 6). In the shallowcavity, the clinician shouldcontinueto use direct dentinalbonding. Resinmodifiedglass-ionomercements The introductionof resin-modifiedglassionomercementsthat can be photocuredhas createdgreatinterest. Their advantagesare easeof placement,settingon command, andearly resistanceto moisturecontamination.It is not possibleto photocurea regular glassionomercement,and it is necessaryto modifythe polyacidby grafting methacrylategroupsontothe poly (acrylicacid) chain. Becausethe modifiedpoly (acrylicacid) is less solublein waterthanits parent, hydroxyethylmethacrylate(HEMA)

is addedas a cosolvent.Whenthis hydro philic speciesis included,the set cementwill act, to someextent, like a hydrogel, swellingin waterand becomingweaker.In general, the greaterthe amountof HEMA incorporated,the greaterthe swellingand reductionin strength. A proposedclassificationfor thesenewcementshas attemptedto differentiatebetween the true glassionomercementandthe newerhybridvarieties: 1. Theunqualifiedtermglass-iorzomer cement shouldbe reservedexclusivelyfor a material consistingof an acid-decomposableglassanda water-solubleacid that sets by a neutralizationreaction. 2. Materialsthat retaina significantacid-basereactionas part of their overall curing process,ie, theywill curein the dark, are classifiedas resin-modified glassionomer materials. 3. Materialsthat containeitheror both oftheessentialcomponentsof a glassionomer cementbut at levelsinsufficientto promotethe acid-basecuringreactionin the dark shouldbe referredto as polyacidmodif ed resin composites. Clinical use of resin-modifiedand regularglassionomercements Withthe introductionof the photocuredresin-modifiedglassionomercements,it might be thoughtthat the regularglass-ionomercementsthat set by an acid-basereaction couldbecomeobsolete.However,certainpropertiesof the photocuredmaterialsneed closeexamination.Theclinicalimplicationsfor the swellingin waterof the resinmodifiedmaterialshaveyet to be established,and their use as a baseor core for inlays or crownscouldresult in a misfit if the cementabsorbswaterand swellsafter the impressionis taken.In the caseof basesunderresin compositeor amalgamalloy restorations,the amountof swellingis unlikelyto affectthe stabilityof the restoration, providedthat the resin-modifiedglassionomercementthat is selectedhas a significant glassionomeracid-basereactionand will still curerapidlyin the dark. Knighthas describeda methodof overcomingthe stressesplacedon glassionomer basesby the polymerizationshrinkageof composites:the resin-modifiedglassionomer baseand resin compositeare curedsimultaneously.He postulatedthat the resin compositecuresbeforethe resinmodifiedglassionomermaterialand that shrinkage stressescouldbe absorbedby the moreplasticglass-ionomerbase. This is an interestingapproachand deservesfurtherstudy,particularlywhenconventionalglassionomerbasesare used. If the resin-modifiedmaterialsare usedas a total restorativein ClassIII and ClassV cavities,the implicationsof the wateruptakemustbe takeninto account,with regardto not only marginaladaptationbut also colorstability. The formationof hydrogelsin the resinmodifiedglassionomercementsand subsequentswellingin watermayresult in discolorationover time, and the resultsof long-termclinicaltrials are still awaited.It is

for this reasonthat researchaimedat producingfaster-settingand strongerregular glassionomercementsthat set by an acid-basereactionshouldbe continued,together with attemptsto introducealternativesto HEMAin the resin-modifiedmaterials. The polyacidmodifiedcompositematerialsalso requirelongertermclinical trials, becausealthoughtheyare strongerthaneitherglassionomeror resinmodified materials, theyare still significantlyweakerthanregularhybridor microfilled composites.Theyalso do not curein the dark, whichindicatesthe absenceof any significantdegreeof acid-basereaction.A clinicalquestionstill remainsas to their performancecomparedwith that ofthehybridor small-particlecomposites,particularly in posteriorrestorations.In addition,thereseemsto be little evidencethat these materialscan adhereto dentinby chemicalbonding,as occurswith the glassionomer acid-basereactioncements,andtheystill requirean acid-etchingprocedure,as usedfor conventionaldentinalbondingagents,to obtainhighbondingstrengths. Propertiesof polyacidmodifedresin compositeandresin-modifiedlutingcements The introductionof thesenewcementshas arousedconsiderableinterest, becauseboth materialsare strongerandare claimedto havebetterresistanceto earlysolutionthan the glassionomerlutingcements,althoughno resultshaveyet beenpublishedon their actuallossof cementformingionsor organicconstituentswhenexposedto moisture. The physicalpropertiesof bothtypesof materialappearto indicatethat theycouldmake a usefulcontributionto improvingthe retentionof crownsand inlayswhenconventional cementationtechniquesare used,and theyare worthyof furtherclinical study. However,a warningshouldbe givenwheredirectbondingof porcelaininlaysor crowns is contemplated.Evenin the caseof the polyacidmodifiedcompositecements,their mechanicalpropertiesare inferiorto thoseof the currentdual-curedor autocuredresin cements.The preventionof crackpropagationor debondingof porcelainrestorationsis dependenton the strengthof the bondbetweenthe porcelainsurfaceandthe tooth. Therefore,the strengthof the bondingresinplaysa vital part in securinglong-term resistanceto fractureor debondingof the restoration.At this stage,moreclinical evidenceis neededbeforeeitherresin-modifiedglassionomeror polyacidmodified resin compositecementsare usedfor purposesotherthanfor conventional cementation. ClassV restorationsand erosion/abrasionlesions The retentionrate of glassionomercementsin the erosion/abrasionlesionsolely involvingdentinis generallybetterthanthat of dentinbondedcompositerestorations. For this reason,otherquestionsof choicewill dependon estheticdemandsand the maintenanceof polishedsurfaces.Moderncompositerestorationshavegreat esthetic appeal, but boththe standardandresin-modifiedglassionomermaterialshavebeen considerablyimprovedwith regardto translucencyand color.

Althoughthe compositerestorationmayexhibit superiorcolorin the earlyyears, the standardglassionomercementscan maintaingreatercolorstabilitybecauseof their chemicalstability. However,poorfinishingtechniquescan produceroughsurfacesthat stain, and preservationof the originalgel surfaceshouldbe the clinician'sprime objective,as describedby McLeanandWilsonin 1977. Providedthat this goal is achieved,glassionomercementsare very durablein cervicalrestorationsandcompete with the composites,particularlywherebondingto cervicaldentinis required.Sclerosed dentinremainsthe greatestobstacleto obtaininggoodbondingwith dentinalbonding agents,andfailureat the cervicalmarginas a result of microleakageis not alwayseasily detected. ClassV cavitiesmayalso be restoredwith glassionomercements,but esthetic considerationstake prioritywhenmoreextensivefacial areasare involved,andthe small-particleor microfilledcompositesare superior.Thesandwichtechniqueis only practicalin the deepercavityand shouldbe the first choicewherecariescontrolis a priorityfor the olderpatient.Shallowcavitiesare betterrestoredwith direct dentinbondedcomposites,but againthe area of cervicaldentininvolvedwill influence the longevityof the restoration.An alternativeis to placea conventionalglassionomer restoration,whichcan later be cut backand overlaidwith an acid-etchedcomposite. ClassII restorations Directbondingof compositesto dentinin the posteriorrestorationis generallyregarded as the mostchallengingoperationby the clinician.He or she has to contendnot only with moisturecontrolbut alsowith dentinalsurfacesthat are not as receptiveto hybridization.In addition,as describedpreviously,the bulk of the restorationwill determinethe amountof polymerizationshrinkageandsubsequentdistributionof stress. Unlessthe entirerestorationcan be bondedto peripheralenamel,a strongcasecan be madefor usinga glassionomerbase(conventional,cermetbased,or resin-modified)to act as a biologicseal andoffer protectionto the surroundingtoothstructurethroughthe releaseof fluoride.The glassionomerbasealsoavoidsthe risk of damageby acid etchingin the deepercavity, postoperativesensitivityis reduced,and bulk shrinkageof the compositerestorationis lessened. The sandwichtechniquehas beenmisappliedto this typeof restoration.Attemptsto use glassionomercementas a base,so that the cementis extendedto the surfaceat the cervicalmargin,mayresult in dissolutionof the cement.Glassionomercementsshould only be usedas internalbases.However,in a recent3-year clinical studycomparing direct compositeinlayswith conventionalrestorations,Wassellet al observedthat there wasno evidenceof dissolutionof a cermetbase, evenwhenit extendedto the cervical margin,in eithertypeof restoration,and no secondarycarieswasdiagnosed.It is possiblethat the fluoridereleaseand betterabrasionresistanceof this materialmay havecontributedto this result.

The imperfectionsof the largemesioocclusodistalcompositerestorationare well known,and, despitecurrentattemptsto ban amalgamalloyrestorations,the publicmust be madeawareof thesedeficiencies.Compositescan providegoodservicein small ClassI and ClassII preparationswith minimaldirect stress,becauseocclusalcontactis generallyconfirmedto the toothenameland the restorationis to someextentprotected. However,despiteimprovementsin the chemistryand particle-size distributionof the fillers, the hydrolyticstabilityof the filler-matrixinterfacestill remainsquestionableand mayresult in loss of material in functionalocclusion,whereocclusalstabilityis so vital. Wearin the contactareaalso remainsa problem.Governmenthealthdepartments shouldbe warnedthat compulsoryreplacementof amalgamalloyrestorationswith toothcoloredmaterialscouldprovean expensiveexercisein publichealthcare. Summary Dentinalbondingagentsand glassionomercementshavea usefulrole in adhesive dentistry,and neithersystemhas a monopolyon clinicalsuccess.It is importantto recognizethe optimalpropertiesof eachmaterialwhenit is beingselectedfor clinical use. Glassionomercements,becauseof their ability to renewbrokenbonds,havebetter cavity-sealingpropertiesand resistanceto microleakageover longperiods.In addition, becauseof their ability to leachfluoride,theypossesssomecariostatic properties.Theyare particularlysuitedto the restorationof erosion/abrasionlesions and as dentinalsubstituteswhenresin compositeor otherrestorationsare placedand longtermresistanceto rnicroleakageis a priority. Their excellentclinicalperformance has considerableclinicalandscientificbackingif confinedto lowstressbearingareas, and postoperativesensitivityis reducedparticularlywherestrongeracid etchingis employedor faultsin the dentinalbondingtechniqueoccur. In highstressbearingareasor whenthin sectionsof materialare required,glassionomercementslack strengthandare easilydamagedduringfunctionor by early finishingproceduresand contaminationwith moisture.The modernhybridand microfilledcompositesare superiorin esthetics,strength,andretentionof surface polishwherelargeareasof facial enamelare involved. Dentinalbondingagentshavebeenfirmlyestablishedfor bondinganteriorresin composites,porcelainveneers,inlays,and somemetal restorationsto toothstructure. Theypossesshigherbondstrengthsthando glassionomercementsbut requiregreater attentionto the preparationof surfacesfor bonding.Moderntechniquesare employing weakeracids, suchas maleicacid, to preventdamageto the pulpin the deepercavity, andtheseetchantsfacilitatethe formationof a hybridlayer. Thesuccessof dentinal bondingis still dependenton the morphologyof the dentin,and in areaslackinga high percentageof intertubulardentin, problemscan arise. Judgmentson the meritsof usingglassionomercementbasesor resindentinal bondingagentsthat are basedon short-termin vitro testingon extractedteeth are

contradictory.Longtermclinical trials are still neededto establishthe veracityof this testing. Futureresearchon dentinalbondingagentsemployingglassionomertechnologycould providesomechemicalbondingas well as materialswith increasedfracturetoughness, negligiblesettingshrinkage,and thermalexpansionsimilarto that of toothstructure. Longtermstabilityat the enameldentininterfacecan only be achievedwith restorative materialsthat havetheseproperties. REFERENCES 1. BowenRL. Bondingof restorativematerialsto dentine:Thepresentstatusin the UnitedStates.Int Dent J 1985;35: 155-159. 2. BuonocoreM, WilemanW, BrudevoldF. A reporton a resincapableof bondingto humandentinsurfaces.J Dent Res 1956;35:846851. 3. CaustonBE. Improvedbondingof compositerestorativeto dentine.BR Dent J 1984;156:9395. 4. BurkeFJT, McCaugheyAD: Thefour generationsof dentinbonding.AMJ Dent 8:8892. 5. ClinicalResearchAssociates.Dentingbonding.Stepby stepprocedures.Newsletter. 1991;15 (12; Insert) :2. 6. DouglasWH.Clinicalstatusof dentinebondingagents.J Dent1989;17:209215. 7. FortinD. Swift EJ, VargasMA. Microleakageof newdentinbondingsystems.Oper Dent 1992;Suppl5; 50-61. 8. JohnsonGH, PowellLV. GordonGE. Dentinbondingsystems;A reviewof current productsand techniquesJ Am Dent Assoc1991;122: 34-41. 9. KramerIRH, McLeanJW. Alterationsin the stainingreactionsof dentinresultingfrom a constituentof a newself-polymerizingresing.Br DentJ 1952;92:150153. 10. PhillipsRW,RygeG. Adhesiverestorativedentalmaterials. Proceedingsof a workshop.Spencer,Indiana:OwenLitho,1961. 11. TrioloPT, Swift EJ, BarkmeierWW.Shearbondstrengthsof six currentgeneration dentinadhesivesystems.J Dent Res 1994;73:199(Abst777).

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