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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.

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

The additionalstagesrequiredfor primingand conditioningmadethe chairsideuse of thesematerialsmorecomplicated and timeconsumingthanpreviousmaterials.suchas Gluma. However. In manysystems. Theprocedureremoved the smearlayerandopenedthe dentinaltubules.and ScotchBondII. to the partial removalof the smearlayer.the bondstrengthswhichwereachievedwerefoundto decreasefrom58 2 2 kg/cm (5. the pulpalreactionto Sevritonpluscavityseal wassimilarin intensityto that recordedfor otherautocuredresins.whichwereappliedto the dentinsurfaceto modifyit prior to applicationof the resin. Materialsintroducedin the early 1980s.unlined cavities. representedthe first generationof dentinbondingsystemsthat createdsufficiently strongbondsto dentin.Tenure.with a consequentreductionin bondstrengths.This was thoughtto be due to the linkagebetweenphosphateand monomerbeingeasily hydrolyzed. andfinallyto the use of stronger etchantsto modifyor removethe smearlayer and obtainsomeformof micromechanical retention. AlthoughSevritonwascapableof causingan acuteinflammatoryreactionwhenplacedin moderatelydeep.the usualoutcomeof this reactionwasresolution. Buonocoreet al reporteda dentinbondingagentusinga cavityprimercontaining glycerphosphoricacid dimethacrylatewith bondingbeingachievedprimarilyby the interactionof the phosphategroupwith the calciumionson the dentinsurface.Thecompositecontaininga chelating agenthad the potentialto bondto the dentin'scalciumcomponent. despitethe use of a methylmethacrylateresin as the restorativematerial.7 MPa)after 5 monthsof waterimmersion. The principalbarrierto effectiveadhesionto dental tissueis water.the process consistedof conditioningthe dentinalsurfacewith citric acid.Moderndentinalbondingagentshaveevolvedfromthe originalconceptof increasingdentinalpermeabilityand wettabilityand promotingbondingto the smear layer. whilesomealso requiredthe use of conditioners whichwereappliedand subsequentlywashedoff. It is interestingto note that. Designedfor restoringcervicallesionswithoutmechanicalretention.or seriesof solutions. Waterwill compete with a potentialadhesivefor the surfaceof a substrateand can alsohydrolyzeadhesive bonds.7 MPa)to 28 kg/cm (2.but the bondstrengthsto dentinwere generallyhigherandmorereliablein the oral environment. . The next generationof dentinbondingagentsdifferedfromtheir predecessorsby the use of a solution.100 microns.the zoneof altereddentinhadaffinitiessimilarto thoseof calcifieddentinin an exaggeratedform.theseprimerswereapplied to the surfaceand not washedoff.permittingthe influxof the resin restorativematerial to a depthof 50 .

Amalgambond. whenusedwith the 10%maleicacid etchantprovidedby the manufacturers.The applicationspeedof thesematerialsmayhavereachedthe ultimatefromthe viewpointof operationalfeasibility.0 MPaand 25. eachof whichis characterizedby its user-friendlinessin comparisonwith the previoussystems. one is tryingto bondto shiftingsandratherthanto solid rock. RecentlyintroducedmaterialsincludePertacUniversalBond.and sinceearly generationdentinbondingsystemsdid not producesufficientlyhighbond strengthstheywereplaguedwith the problemof microleakage.and the etchantsolutionandprimerof ScotchbondMP require applicationof 15 and 5 secondsrespectivelyand the resinrequirescuringfor 10 seconds. The latest or fourthgenerationof dentinbondingagentsdifferentiatefromthe previous systemsin threeways:minimaltechniquesensitivity. It will be brokenas the substrate changesand mustbe capableof beingre-formed.Mirage Bond.7 MPa.the primerand Solution2 of the Gluma2000systemsrequireapplicationtime of 30 secondseach. Thereis a goodcorrelationbetweendentin/resinbondstrengthand microleakage. Undersuchconditions.the problemsof marginaladaptionand microleakagehavebeenreduced.2 MPa(to dentin)and 26. Manylater generationdentinbondingsystemsuse mechanicalmeansof adhesion ratherthanthe unreliablechemicalbondingseenin previousmaterials. similarbondstrengthsto enamel and dentin.suchas All-Bond.Thosesystems whichutilizethe hybridor resinreinforcedconcepthavebeenconsideredto perform betterthanthosewhichattemptto achievechemicalbonding.bondstrengthsto dentin andenamelof 23.becausethe adhesionto dentinis nearlythe sameas to enamel. This doesnot meanthat the dentistshouldallowthe cavitiesto be contaminatedwith salivaduringrestorationplacementas it decreasesbondstrength.Prisma UniversalBond.ScotchbondMPand Gluma2000.9 MPa(to enamel)with the substitution of a phosphoricacid etchant.Thesestrengthswere foundto increaseto 26.Clearfil LinerBond. Experimentalworkusingthe ScotchbondMPsystemhas shownthan.Tenure. The fourthgenerationdentinbondingagents.showsatisfactoryor evenenhancedadhesionto visiblymoistdentin. Furthermore.Dentinaladhesivesmayfail for this very reason. Thetotal applicationtimewith PertacUniversalBondis 100 secondscomparedto 130 secondswith the previous materials.respectivelywereachieved.covalentchemical bondscannotbe re-formed.In this respect.ScotchbondMP.the microleakageof six dentinbondingsystems(Optibond.but the development of a systemthat functionsin a slightlymoistenvironmentwithoutreductionin its propertieshas a definiteclinicaladvantage. and no reductionin bondstrengthwhenappliedto a moistsurface. Gluma2000and ImpervaBond)has beenassessedby . the adhesivebondmusthavea dynamiccharactertoo.Becauseenamelis an ion exchangerand dentinis a livingmaterial subjectto change.Oncebroken.

England. Abstract The long-term bonding of dental materials to dentin remains an area of .the newgeneration bondingsystemspermitclinicallyacceptablebondingof compositeresinsto materials otherthantoothstructure.hardenedamalgam. whoseresultsindicatedsignificantlyless microleakagewhenusing Optibond.polyalkenoicacid copolymer.Fortin& Swift. McCaugheyAD.Finally. McLean HonorarySemiorResearchFellow EastmanDental Institute.9%monoand polyfunctionalmetacrylicacid PertacBond Bondingresin: Methacrylatedcarboxylicacid.It is nowpossible.HEMA.8: 88-92.to bondresinsystemsto surfacesof basemetal alloys. DentinalBondingagentsversusGlassionomerCements JohnW.and. throughthe use of self-curingadhesiveagentsit is also possibleto bondamalgamto the walls of the cariespreparation. 2. The four generationsof dentingbonding.set composites. Compositionof recentlyintroduceddentinbondingsystems. of course.A J Dent1995. Adhesiveresin: Bis-GMA.6%aluminiumsalts.3%organicacids.for example. In additionto providingexcellentbondingto dentinalsurfaces.Undoubtedly.proprietaryphotoinitiator Source:BurkeFJ.camphorquinoneand activator ScotchbondMulti-Purpose Etchant:10%maleicacid Primer:Aqueoussolutionof HEMA. Gluma2000 Conditioningsolution:4. hydrophillicand hydrophobicimethacrylates. London. in aqueoussolution Bondingsolution:28. fracturedporcelain.future researchwill broadenevenfurtherthe potentialusesof dentinadhesivesystems.

Moderndentinalbondingagents Nakabayashiet al havedescribedmonomers. (QuintessenceInt 1996.27:659667.werenot of a lasting natureand werehydrolyticallyunstable.great controversy and the results of in vitro testing do not always reflect those found in' vivo.the materialwasbasedon their novel developmentof the lowviscosityepimineresinsand marketedunderthe tradename. although having a longer history of good adhesion to dentin.a problemthat can still arisewith the current resinbondingagents. Morerecently.) Historyof DentinalBonding Buonocoreand Quigleyusedglycerophosphoricacid dimethacrylatein their early experimentsand concludedthat the phosphategroupsin Sevritoncavityseal seemed ideallysuitedfor chemicalcombinationwith constituentsof the dentin. lowerviscosity. Subsequently. 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. Subsequentclinicaltrials showedthat the phosphatebonds. Thisresinimpregnationcreatesa . The selection of materials for specific clinical situations has become more and more difficult. Bowen filed his first patentin the UnitedStateson his nowfamousbis-GMAresin and produced a dentalrestorativematerial containingvinyl silanetreatedfusedsilica.Althoughthis workappearedto usherin a newera in dentinalbonding.propertiesthat wereless thanideal for securinglong-term bondingto dentin.and a certaindegreeof toughnessin the urethanemoiety.basedon 4-methacryloxyethyltrimellitate anlydride. 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. madea urethanedimethacrylateresin for use in resincompositedental materials. supposedlyformedwith calciumionsof the dentinalsurface. Thesenewresinshavethe advantageof highermolecularweight.that containbothhydrophilicand hydrophobicchemicalgroupsthat can penetrateetcheddentinandpolymerizein situ. Glass-ionomer cements. the urethanedimethacrylates(ICI Dental) weredevelopedby Knightet al for industrial use.whichstarteda newera in restorativedentistryand madepossiblethe modern methodsof dentinalbondingwith low viscosityphotocuredresins.Furtherworkby ICI resultedin the introductionof the first visiblelight-curing systems.and they confirmedthe earlier findingsof Kramerand McLean.P-Cadurit.workingat the AmalgamatedDental Company. In 1959. togetherwith less stainingthanbisGMA. It wasnot until 1958that the first low-shrinkageresin wasproducedby Schmidtand Purrmannin Germany.ForsterandWalker. are not suitable for use in high-stress bearing areas.the idealay dormantfor a longperiodbecause the restorativematerialsusedin the 1950swereall basedon methylmethacrylatesof relativelyhighviscositythat containedfree monomersandexhibitedhighshrinkage duringpolymerization.

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

(see Fig 2).the resin composite restorationusedwith a resin bondingagentis superiorin strength.to achievelongtermadhesion. althoughtheyexhibit lowertensilebondstrengthsthando the resinbonding agents.as in outerdentin.and.For this reason.and makinga correctchoicefor eachclinical casehas becomemoreand moredifficult as the manufacturersmovefromonegenerationof bondingagentsto the next.beingwater-basedmaterials.evenin the absenceof gaps.for the deepercavity. In cavitieswhereperipheralenamelbondingcan be achieved.a pricehas to be paid.suchas maleicacid. and not the tag formationinto the tubuli (Fig 4). wasconsideredto be the mainsubstratethat yieldshighbondstrengthsto dentin. The use of a singlebondingagentand restorativematerialthat can be attachedto the toothin one procedureappealsto the hard-pressedclinicianbut.undera compositeplacedin . as with mostdental materialsand techniques.surfaceintegrity. placementof glassionomerbasesas a dentinalsubstituteto whichcompositeor other restorativematerialscan be attached(Fig 5). ClinicalUse Thereare two schoolsof thoughtwith regardto the clinical use of dentinalbonding agentsand glassionomercementliningsand bases.Until a muchstronger cementis produced.The clinicianis facedwith innumerablebondingsystems.currentuse of glassionomercementsas restorativematerialsshouldbe confinedto lowstressbearingareas.bothin the clinical and researchfields.Onegroupadvocatesthe exclusive use of photocuredresin bondingagentsto forma hybridlayer in the dentinalsurface. As previouslydescribed. Microleakagewasobserved. betterbondstrength figurescan be obtained.are not as affectedby dentinal fluids. It is nowgenerallyagreedthat wherethe areaof intertubulardentinis maximal. Fig 5 Glassionomercementusedas a dentinsubstitutein a Class111 preparation Glassionomercements. Enameland dentinare very different substrates.the clinicianmustrecognizethis fact and not lightlydismisstechniquesthat maytake moretimebut take accountof these differences. for the use of mild acid etchants.their greatestvaluelies in bondingto dentin. whilethe proponentsof glassionomermaterialsrecommend.it will not be possibleto measurethe true strengthof this bond. DentinalBondingAgents Considerablesupportis emerging. and esthetics. to demineralizethe intertubulardentin.Sanoet al haveperformedexperiments usinga cryoscanningelectronmicroscopeanda silverion penetrationmethod.the bondareagenerallyshowsa cohesivefracturethat reflectsthe low tensile strengthof the cementand not the actual strengthof the bond.The only questionthat still remainsunansweredis howlongthis seal will last whenplacedunderstressandsubjectedto long-term exposureto oral fluids. allowing hydrophilicprimersto infiltratethe collagennetworkandforma thin hybridlayer or zoneof resin-impregnateddentin.

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

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

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

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

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

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

1961.Indiana:OwenLitho. 50-61. WilemanW. FortinD. BurkeFJT. Insert) :2. 10. 2. 5. Bondingof restorativematerialsto dentine:Thepresentstatusin the UnitedStates.17:209215. McCaugheyAD: Thefour generationsof dentinbonding. BrudevoldF. BowenRL. McLeanJW.Stepby stepprocedures. Alterationsin the stainingreactionsof dentinresultingfrom a constituentof a newself-polymerizingresing.Newsletter. Proceedingsof a workshop.and thermalexpansionsimilarto that of toothstructure. KramerIRH.AMJ Dent 8:8892. 8. ClinicalResearchAssociates. BarkmeierWW.Int Dent J 1985. CaustonBE.Suppl5. Improvedbondingof compositerestorativeto dentine. Microleakageof newdentinbondingsystems. JohnsonGH.Shearbondstrengthsof six currentgeneration dentinadhesivesystems. PhillipsRW.35: 155-159. 9.15 (12. Swift EJ.A reviewof current productsand techniquesJ Am Dent Assoc1991.J Dent1989.73:199(Abst777). 3.122: 34-41. negligiblesettingshrinkage.35:846851.Oper Dent 1992.Br DentJ 1952. Swift EJ.Spencer.RygeG.Clinicalstatusof dentinebondingagents.Longtermclinical trials are still neededto establishthe veracityof this testing.Dentingbonding.J Dent Res 1956. Longtermstabilityat the enameldentininterfacecan only be achievedwith restorative materialsthat havetheseproperties.92:150153.BR Dent J 1984. Adhesiverestorativedentalmaterials. 7. DouglasWH. 4. PowellLV. A reporton a resincapableof bondingto humandentinsurfaces. Dentinbondingsystems. TrioloPT.contradictory. 1991. GordonGE. 6. VargasMA. .156:9395. Futureresearchon dentinalbondingagentsemployingglassionomertechnologycould providesomechemicalbondingas well as materialswith increasedfracturetoughness. BuonocoreM. REFERENCES 1. 11.J Dent Res 1994.