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AL-AZHAR UNIVERSITY- GAZA

FACULTY OF DENTISTRY
OPERATIVE DEPARTMENT

: PREPARED FOR
DR. MOHAMMED ABU HASSIRA

: SUBMITTED BY
TASNEEM SAFI

LAMEES BAROUD

HANEEN AL SMMAK

BASEL AL KRONZ

2017 - 2016

ADHESIVE DENTISTRY
The Past decade has seen increased use of bonding agents in concurrence with
traditional dental materials. The availability of adhesive techniques permits the
placement of aesthetic restorations like composite resins, aesthetic inlays and
veneers, etc. Though a wide range of adhesives is available but there are some
.requirements which a dental adhesive should possess
Following factors have shown to be responsible for boost
:in adhesive dentistry
The development of tooth colored restorative materials 1
The introduction of new composite resins with superior properties .2
.Advances in the development of adhesive systems .3
Increased concern among patients for aesthetics and tooth colored .4
restorations
Indications for Use of Adhesives
.To treat carious and fractured tooth structure
.To restore erosion or abrasion defects .n cervical areas
To correct u.naesthetic contours, positions, dimensions, or shades of teehh .
.To treat dentinal hvpersensitivity
For the repair of fractured porcelain, amalgam and resin restorations .
For pit and rissure sealants .
To bond composite restorations .
To bond silver amalgam restorations
To lute crowns
To bond orthodontic brackets
Advantages of Bonding Techniques
:The following are advantages of bonding systems
.Adhesion of composite resin restorations to enamel and dentin .1
.Minimizes removal of sound tooth structure .2
.Management ot dentin hypersensitivity .3
.Adhesion reduces microleakage at tooth restoration interface .4
.As a part of resin cements for bonding cast restorations .5
.Adhesion expands range of aesthetic possibilities .6
.Bonding ot Porcelain restorations, e.g. porcelain inlays, onlavs and veneers .7
.Reinforces weakened tooth structure .8
.Reduction in marginal staining .9
For repair of porcelain or composite .10
.Bonding amalgam restorations to tooth .11
.Repair of amalgam restorations .12
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.To bond orthodontic appliances .13

:Adhesion can occur by


Chemical means .1
Physical means .2
Mechanical means .3

Adhesion forces across different materials depend on


Physical and chemical properties of both adhesive and the adherent .Homogeneity.Thickness of interface .Oral environment with its moisture .Chewing habits -.
Factors Affecting Adhesion
wetting
Wetting is an expression of the attractive forces between molecules of adhesive
and adherent. In other words, it is the process of obtaining molecular attraction .
:wetting ability of an adhesive depends upon two factors
.Cleanliness of tle adherend: Cleaner is the surface, greater is the adhesion
Sar face energy of the adherend: More the surface energy, greater is
.adhesion

Contact Angle (Fig. 1.2)


Contact angle refers to the angle formed between the surface of a liquid drop
and its adherent surface. The stronger the attraction of the adhesive for the
adherent, the smaller will be the contact angle The zero contact angle is the
.best to obtain wetting

Fig. 1.2: Lesser is the contact angle,


better is the adhesion

Surface Energy
Generally, harder the surface, higher is the surface energy, higher is the
adhpsive property of material. The surface tension of the liquid and the surface
.energy of the adherend, ultimately detemime the degree of wetting that occurs

Surface Contamination
Substrate surface should be clean as the contamination prevents the adhesion
Adhesive should be able to fill the irregularities making the surface smooth
. allowing proper or intimate contact
water Higher is the water content, poorer is the adhesion water can react with
both materials by the high polar group and hydrogen bond which can hamper
.the adhesion

ENAMEL BONDING
Enamel, the hardest tissue in the human body consists of 95% mineralized
inorganic substance, hydroxyapatite arranged in a dense crystalline structure
and a small amount of protein and water (Figs 1.3 A and B). To bond to enamel,
it is very important to focus on the mineral component (hvdroxvapatite) of
enamel. thionocore, in 1955, was first to reveal the adhesion of acrylic resin to
add etched eiiairiel. He used 85% phosphoric acid for etching, later Silverstone
revealed that optimum concentration of phosphoric acid shoald range behveen
3O-4O% to get a satisfactory adhesion in the enamel. Usually 37% phosphoric
acid is used for 15 to 30 seconds. If the concentration is greater than 50
percent, then monocalcium phosphate monohvdra te may get precipitated while
at concentrations lo'ver than 30 percent, dicalcium phosphate monohydra te is
.precipitated which interferes with adhesion

Figs 1.3A and B: Composition


. of enamel
By weight (B) By volume (A)

Several changes have taken place regarding the acid etching of enamel
:surfaces. These include
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Developmen t of phosphoric acid gels: Gels provide the clinician a greater


control and precision in the placement of etching agents. Earlier most gel
etchants used to contain silica as a thickening agent. But recently available gels
employ polymeric thickening agents which have better wetting abilities and
.rinse off more easily than silica containing gels
Percentage of etchants used: Currently used etchants employ the
concentrations of phosphoric acid that ranges from 10 to 50%. Studies have
shown no difference in etching of enamel using higher concentration or lower
concentrations of acid. Use of lower concentrations of phosphoric acid and
reduced etching time has shovn to give an adequate etch of the enamel while
.avoiding excessive demineralization of the dentin
Decrease in the acid application time: The standard treatment protocol for the
etching of enamel has been application of 37% phosphoric acid for 60 seconds.
But studies show that enamel should not be etched for more than 15-20
seconds. If enamel is etched for more than required time, deeper etch of the
enamel surface occurs. Since a bonding agent has a high viscosity, the surface
tension effect of the agent would not allow full penetration of the etched
enamel. This will result in a dead space' beyond the bonded area . When
enamel bends, or the weak resin based bond breaks off, the dead space
becomes exposed to oral fluids which has lower surface tension and thus
penetrates the dead space. This may result in secondary caries or discoloration
.of the margins
use of acid conditioners (i.e. nitric, citric, oxalic, maleic acids) other than
:traditional phosphoric acid
Many acids have been developed recently for conditioning like nitric acid, citric
acid and oxalic acids. These acids cause mild etching/conditioning, so for total
.etching it is advisable to use Phosphoric acid
Conditioning
It is the process of cleaning the surface and activating the calcium ions, so as to
.make them more reactive
Etching
It is the process of increasing the surface reactivity by demineralizing the
superficial calcium layer and thus creating the enamel tags. These tags are
.responsible for micromechanical bonding between tooth and restorative resin
steps for Enamel Bonding
Perform oral prophylaxis procedure using non- fluoridated and oil less
.prophylaxis pastes
Clean and wash the teeth with water. Isolate to prevent any contamination
.from saliva or gingival crevicular fluid
Apply acid etchant in the form of liquid or gel for 10 to 15 seconds. Deciduous
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teeth require longer time for etching than permanent teeth because of presence
.of aprismatic enamel in deciduous teeth
.Wash the etchant continuously for 10 to 15 seconds
Note the appearance of a properly etched surface. It should give a frosty white
.appearance on drying
.If any sort of contamination occurs, repeat the procedure
Now apply bonding agent and low viscosity monomers over the etched enamel
surface. Generally, enamel bonding agents contain BiSGMA or UDMA wilh
TEGDMA which is added to lower the viscosity of the bonding agent. The
bonding agents due to their low viscosity, rapidly wet and penetrate the clean,
dried, conditioned enamel into the microspaces forming resin tags. The resin
. tags which form between enamel prisms are known as Macrotags
The finer network of numerous small tags are formed across the end of each
rod where individual hydroxvapatite crystals were dissolved and are known as
microtags. These microtags are more important due to their larger number and
greater surface area of contact. The formation of resin micro and macro tags
within the enamel surface constitute the ftuidainental mechanism of enamel.resin adhesion
Mechanism of Etching
:Etching of enamel produces a number of effects
.Cleanses debris from enamel .1
Produces a complex three-dimensional microtopography at the enamel .2
surface
.Increases the enamel surface area available for bonding .3
Produces micropores into which there is mechanical interlocking of the resin .4
(Fig. 1.3 )
.Exposes more reactive surface layer, thus increasing its wettabilitv .5

Difference in appearance of :.( Fig. 1.3)


etched and unetched enamel rods

: when seen microscopicallv, three types of enamel etching patterns are seen
Type I preferential demineralization of enamel prism core leaving the prism
.peripheries intact. Here corresponding tags are cone shaped
Type II There is preferential removal of inter prismatic enamel leaving the prism
.cores intact. The corresponding enamel tags are cup shaped
Type III In this, the pattern is less distinct, including areas that resemble type I
.and II patterns and areas which bear no resemblance to enamel prism

Basically, acid etching creates a 5-50 micron deep microporous layer into which
adhesive resin flows. This result in a longlasting enamel bond achieved via
micro- mechanical interlocking between the resin and enamel. Bond strength of
.etched enamel to composite resin usually varies behveen 15-25 MPa
Among the factors that affect bonding of enamel are its fluoride content,
arrangement of crystals and impurities, e.g. presence of magnesium and
.carbonates in the hvdroxvapatite crystals

Factors affecting effects of acid etching on enamel


Form of acid used that is solution or gel
Concentration of acid used and time of etching
Type of acid used
Chemical nature of enamel .
Whether enamel is fluoridated or demineralized .
Type or dentition, i.e. primary or permanent
Dentin Bonding
Challenges in Dentin Bonding
Dentin is a heterogeneous structure with 50% volinorganic content, 30%
organic content (type I collagen) and 20% fluid.
Its high fluid content places stringent requirements on the materials.
Tubular structure of dentin provides variable area for fluid to traverse to
surface and affect bonding.
Formation of smear layer plugging the tubules.
Three steps involved are etching, priming, bonding.
Mainly dentin bonding concentrated on etching, priming, bonding.
On acid etching dentin the smear layer is removed exposes the collagen
increases dentin permeability.
On etching dentin is converted from a hard mineralized surface to a very
soft mineral free collagen rich surface that collapses when air dried.
Surface becomes porous with inter- and intrafibrillar pores through which
low viscosity monomers penetrate polymerize to form hybrid layer.

Dentin etching changes the surface energy, high protein content exposed
after etching is responsible for low surface energy (44.8 dynes/cm)
different from enamel.
This surface energy has to be increased by surface active primer
application
Objective of priming is to transform the hydrophilic dentin surface into a
hydrophobic surface, also to wet the surface, entangle with collagen fibers
on poly-merization, if possible react with functional groups of dentin for
chemical bonding.
Dental priming molecules has been mainly concentrated on bifunctional
molecules that bond to one end on tooth tissue and other end to
composite resin.

Current Strategies for Adhesion of Resins to Dentin


Three-step total-etch (E + P + B)
:Etchant (E)
- .Removes the smear layer
Exposes intertubular and peritubular.collagen
.Decrease surface-free energy.Opens the tubules in a funnel configuration :Primer (P)
Includes bifunctional molecules(simultaneously hydrophilic and
-hydrophobic)
- .Envelops the external surface of collagen fibrils
Re-establishes surface free energy surface-free energy to levels compatible .with a more hydrophobic restorative material
:Bonding Agent (B)
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
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One-bottle total-etch (E + [PB])


:Etchant (E)
- .Removes the smear layer
- .Exposes intertubular and peritubular collagen
- .Opens tubules in a funnel configuration
-.Decreases surface-free energy
Primer (P)+ Bonding Agent (B)
- .Penetrates into the dentin tubules to form resin tags
The first coat applied on etched dentin works as aprimer-it increase the .surface-free energy of dentine
The second coat (and third, fourth, and so on) acts as the bonding agent used in three-step systemsit fills the spaces between the dense network of collagen
.fibers
Two-bottle self-etch ([EP] + B)
:Etchant (E)+ Primer (P)
The SEP does not remove the smear layer, but fixes it and exposes about 0.5-1 .m of intertubular collagen because of its acidity(pH = 1.2-2.0)
.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
:Bonding Agent (B)
Uses the same type of bonding agent included in the three-step, total-etch .systems
The resin tags form on resin penetration into the microchannels of the .primer-impregnated smear plug
All-in-one self-etch (EPB)
:Etchant (E)+ Primer (P)+ Bonding Agent (B)
-.Etches enamel
.Incorporates the smear layer into interface 9

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 Stresses at Resin-Dentin Interface
Composites shrink as they polymerize, creating stresses of 7MPa within the
composite mass, depending on the configuration of the preparation. When the
composite is bonded to one surface only (e.g., for a direct facial veneer),
stresses within the composite are relieved by flow from the unbonded surface.
Stress relief within a three-dimensional bonded restoration is limited,
however,by its configuration factor. In an occlusal preparation, composite is
bonded to five surfacesmesial, distal, facial, lingual, and pulpal.The occlusal
surface is the only free or unrestrained surface. In such a clinical situation, the
ratio between the number of bonded surfaces and the number of unbonded
surfaces is 5, giving the restoration a configuration factor of 5.Stress relief is
limited because flow can occur only from the single free surface. Unrelieved
stresses in the composite contribute to internal bond disruption and marginal
.gaps around restorations that increase microleakage
It has been reported that immediate bond strengths of approximately 17MPa
are necessary to resist the contraction stresses that develop in the composite
during polymerization, to prevent marginal debonding. Water sorption by the
resin might compensate for the effect of the polymerization shrinkage,as the
resin might expand and seal off marginal gaps,but this occurs only over a
.relatively long time. Water sorption is directly proportional to the resin content
Enamel bond strengths usually are sufficient to prevent the formation of
marginal gaps by polymerization contraction stresses. These stresses might be
powerful enough to cause enamel defects at the margins, however. Extension of
.the enamel cavosurface bevel helps to improve the enamel peripheral seal
Each time a restoration is exposed to wide temperature variations in the oral
environment (e.g.,drinking coffee and eating ice cream), the restoration
undergoes volumetric changes of different magnitude than those of the tooth
structure. This occurs because the linear coefficient of thermal expansion of the
composite is about four times greater than that of the tooth structure.
Microleakage around dentin margins is potentiated by this discrepancy in linear
.coefficient of thermal expansion between the restoration and the substrate
Loading and unloading of restored teeth can result in transitional or permanent
interfacial gaps. Additionally, the tooth substrate itself might be weakened by
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cyclic loading. A study found that 71% of Class V composite restorations in third
molars with antagonists have significantly more microleakage than restorations
placed in teeth without opposing contact. Another study found that cyclic
loading and preparation configuration significantly reduced the microtensile
bond strengths of a self-etching primer (SEP). Also, when half of a wide occlusal
Class I composite restoration is fatigued for 100,000 cycles between 5N and
35N,while the other half is kept as control, the bond strengths of Single Bond
.(3M ESPE,St.Paul,Minn) decrease by 40% to 60%
Self-etch technique
Advantages
.Easy and time efficient application procedure
.No etching, post-conditioning rinsing, or drying
.Possibility for single-dose packaging
.Consistent and stable composition
."Possibility for particle- filled adhesive, act as "shock absorber
.Simultaneous demineralization and resin infiltration
.Less technique sensitivity

Disadvantages
Consists of both hydrophobic and hydrophilic components, together with water
.and high concentration of solvent
.Prone to phase separation and entrapment of droplets in adhesive layer
.Most self-etch systems contain water, it influences polymerization badly
.Reduced shelf life because of hydrolysis of monomers
.High hydrophillicity due to presence of acidic monomers
.Bonding effectiveness depends on composition of adhesive solution
.No long term clinical evaluation
.Impaired durability
.Incompatibility with autocuring composites
Total-etch technique
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Advantages
Separate application of conditioner, primer, and adhesive resin
Low technique sensitivity
Better adhesion to enamel and dentine
More effective and consistent result
"Possibility for particle-filled adhesive, act as "shock absorber
Disadvantages
Risk of over-etching dentine because of presence of highly concentrated
.phosphoric acid etchants, resulting in incomplete resin infiltration
.Three step application procedure
.Risk of surface contamination because post-conditioning rinsing required
.Sensitive to overwet or overdry dentine surface conditions
Weak resin-collagen interaction, this may result in nanoleakage and early bond
.degradation

:Bond generation

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Smear
layer

tion

Bond
strength

Preparation steps

1st
generatio
n

2_3mpa

3steps

2nd
generatio
n

5-6mpa

3steps

3rd
generatio
n

Modify
the
smear
layer(remov
e it without
distrusting
the plugs)

4th
generatio
n

Remove

5th
generatio
n

Remove

6th
generatio
n

Remove

7th
generatio
n

Remove

3steps

25mpa

3steps

2step
(Bond
+primer+
adhesive in )in the
same bottel+etching
2step
(Etch + primer)+
(adhesive+resine)
All in non bottel
Hybr
idiza

Hybrid composite was developed in an effort to obtain even better finish than small particle composite while still maintaining desirable properties of the
. latter
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It contain two kind of fillers,this bimodal distribution of filler loading and better .surface finish
Fillers are colloidal silica and ground particles of glass containg metal Smaller filler particle and greater amount of microfillers increase surface area .and thus filler loading will not be as high as small particle filled
: Layer of hybrid zone
.top layer amorphous electron dense phase.1
middle layer cross sectioned and longitudinally sectioned collagen fibril .2
. separated by electron lucent spaces
base layer is characterized by gradual transion to underlaying unaltered .3
.dentin
Role of hybrid layer :
This layer forms following initial demineralization of dentinal surface with an
acidic conditioner exposing a collagen fibril network with inter fibril
microporosities that subsequently become intediffused with low viscosity
monomers .this zone in wich resin adhesive system interlocks
micromechanically with dentinal collagen is termed hybrid layer or zone.
hybrid layer act as stress breaker or stress reliever eith youngs modulus of
3Gpa
sealing the surface against leakage and imparting a high degree of acid
resistance
Hybridoid layer is the region of demineralized dentin into which resin failed to
penetrate .concurrent to hybrid layer formation is penetration of primer into
open dentinal tubule.
Microtagd-formed within intertubular dentin.
Macrotags-within dentinal tubules.
Macrotags are generally of little value as these are under cured.
astudy using SEP showed that the dentin bond strength did not vary from 1
day to 6 monthes to 1 year on tooth subjected to occlosal function . it also
showed the porpsity in hybrid layer increase the significantly at 1 year , owing
to loss of resin between the collagen fibers.becouse these result obtained with a
hybrid layer being created by SET , they cant be generalized by to total etch
adhesion. They do support the theory ,however,that collagen may play an
important role in the strength of the resin dentin interface.
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Wet vs dry dentin :


*water has been considered an obstacle for attaining an effective adhesion of
resin to t occure on drying demineralized dentin
*the use of adhesive system on moist dentin is made possible by incorporation
of organic solvent acetone or ethanol in the primer or adhesive.
*the moist bonding technique prevent the spatial alternation that occure during
demineralized dentin.
*keeping dentin moist after etching prevents collapse of collagen which can
prevent resin monomer penetration.
*dentin should be kept with thin film of water and glistening appearance. No
pooling of water as it can dilute the primer .
*this thin film of water will be driven off by solvent in primer
*When etched dentin is dried using an air syringe ,bond strength decreased
especially for acetone based and ethanol based dentin adhesive
*the collapse of collagen fibers on drying may be result of changes in the
molecular arrangement .while in wet state wide gaps separate the collagen
molecule from eatch other , in dry the molecule are arranged more compactly.
Disadvantages of wet bonding:
Having cavity wall wet prevent to see frosted etched enamel surface.
Water based adhesive are recommended to be used after slight air drying of
etched tooth surface.
Role of protein in dentin bonding
(1)
The limited durability of resin-dentin bonds severely compromises
the lifetime of tooth-colored restorations. Bond degradation occurs via
A /- hydrolysis of sub optimally polymerized hydrophilic resin components .
b/- degradation of water-rich, resin-sparse collagen matrices by matrix
metalloproteinases (MMPs) and cysteine cathepsins.
so scientist include in their experimental studies : (1) increasing the degree of
conversion and esterase resistance of hydrophilic adhesives;

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(2) the use of broad-spectrum inhibitors of collagen lytic enzymes, including


novel inhibitor functional groups grafted to methacrylate resins monomers to
produce anti-MMP adhesives;
(3) the use of cross-linking agents for silencing the activities of MMP and
cathepsins that irreversibly alter the 3-D structures of their catalytic/allosteric
domains;
(4) ethanol wet-bonding with hydrophobic resins to completely replace water
from the extrafibrillar and intrafibrillar collagen compartments and immobilize
the collagen lytic enzymes;
biomimetic remineralization of the water-filled collagen matrix using analogs (5)
of matrix proteins to progressively replace water with intrafibrillar and
extrafibrillar apatites to exclude exogenous collagen lytic enzymes and fossilize
endogenous collagen lytic enzymes. A combination of several of these
strategies should result in overcoming the critical barriers to progress currently
.encountered in dentin bonding
:Sensetivity of bond
It is common for dental bonding patients to wonder what they should expect
after treatment. Being aware of the possible risks and side effects, along with
how to properly care for the teeth after treatment, can alleviate any anxieties
.patients may have about undergoing the dental bonding procedure

Risk of dental bonding:


Allergic reaction: It is possible for patients to experience an allergic reaction
to the conditioning liquid, composite resin, or tools used during the dental
bonding procedure.
some patients, especially those that have undergone some removal of natural .
tooth enamel, will experience some discomfort in the few days following
treatment. This may include tooth sensitivity to hot and cold foods and drinks or
.discomfort when eating hard or crunchy foods

Infection: Before the dental bonding material is placed, infection, tooth


decay, and debris must be cleaned away and the tooth sterilized. If an infection
is still present after the composite resin material is placed, it will continue to eat

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away at the natural tooth structure, and will eventually result in the need for
root canal therapy or tooth extraction.

Discoloration of the bonding material: The composite resin material


is not completely resistant to staining; further, it will not respond to teeth
whitening treatment.
:To avoid sensitivity
To limit pain after dental bonding, patients can consume foods and drinks at moderate temperatures and eat soft foods. Pain medication can be taken to
.alleviate any discomfort

Dental bonding patients should follow these aftercare instructions to ensure that
:the composite resin bonding material lasts as long as possible

Brushing: Brush the teeth twice a day, ideally once in the morning and
once at night, using toothpaste that contains fluoride; Brush the outside, inside,
and top of each tooth, and then brush the tongue. Replace your toothbrush
every three to four months to ensure that your teeth are properly cleaned.

Flossing: Floss once a day; be sure to bring the floss all the way up to the
gum line and thoroughly remove all plaque before moving on to the next tooth.

Drink water after meals: Drinking water after meals will help flush out
food particles and reduce acidity levels in the mouth.

Avoid Products that stain the teeth: Use of tobacco products, such as

cigarettes or chewing tobacco, causes yellow and brown stains to appear on the
teeth and bonding material.
Avoid Foods and drinks that wear down the bonding
material: Acidic foods (such as citrus, soda, and wine) eat away at tooth
enamel and the composite resin; hard or crunchy foods such as candy, pretzels,
and beef jerky can wear down and even chip the bonding material due to the
force that is exerted while chewing on these foods.

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Avoid Habits that wear down the bonding material: Certain habits,
such as biting on fingernails, pen caps, pens, pencils, and other hard objects,
wears down the bonding material and tooth enamel over time.

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