Adhesion Students Word New

Ass. prof.
Rasha Afifi
Adhesion in Dentistry
Operative 5
Definitions:
Adhesion: The force that binds two dissimilar materials together when
they are brought into intimate contact.
Adherend: Substrate to which the material adhere.
Adherent: Adhesive material used to produce adhesion.
Adaptation: maximum degree of proximity between two adjacent
surfaces.
Mechanisms of adhesion involved in dentistry

A. Mechanical adhesion.
It occurs when the solidified adhesive interlocks micromechanically with
the roughness and irregularities of the surface of the adherend (substrate)
B. Chemical adhesion
It is the bonding of dissimilar materials by the interaction of atoms or
molecules at an interface that holds two phases together.
C. Electrostatic adhesion
Involves electrostaticinteractions that are relatively weak.It may be the
only type of adhesion if surfaces are smooth and chemically dissimilar.
Requirements for adhesion:

To produce good bonding, the adhesive or adherent should be able to
flow easily over the adherend to produce good wetting.
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Ass. prof. Rasha Afifi
Wettability is: Spontaneous flow and full spread of a liquid phase

(adhesive) over a solid phase (substrate surface),and is measured by the
contact angle.
The contact angle is: the angle between the liquid and the solid surface.
0 or 180 degrees ---> maximum adhesion
Less than 90 degrees ---> moderate adhesion
More than 90 degrees ---> poor adhesion
In addition, sufficient wetting of the adhesive will only occur if its

surface tension is less than the surface energy of the adherend.
Surface energy is: The inward attractive forces of the molecule

of a solid.
The surface energy of a liquid is known as the surface tension.
Thus, the requirements for successful wetting of adhesive are:

1. Intimate molecular contact between adhesive and tooth tissues
(adherend).
2. Cleanliness, smoothness and dryness of the tooth tissues.
3. High surface energy of the tooth tissues to be able to attract the atoms
of the adhesive.
4. Low-surface tension of the adhesive material (adherent) to be able to

properly wet the adherend.
5. Low viscosity of the adhesive to penetrate into the microporosities
6. To be able to displace air and moisture during the bonding process.
Advantages of adhesive techniques:

Bonded restorations have a number of advantages over traditional non-
adhesive methods:
• Ultra conservation of tooth structure: through elimination of

macromechanical preparations and excessive removal of tooth structure.
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• Long term restoration retention: strong bond provides longevity of the

restoration and prompted patient acceptance.
• Adhesive restorations better transmit and distribute functional stresses

across the bonding interface to the tooth thus provide better resistance.
• Reinforcement of the remaining tooth structure: (still a controversy) due

to the ability of bonding between the restoration and tooth that participate
in its load carrying ability.
• Expanded the range of esthetic restorative dentistry.
Indications for adhesive dentistry:
• Conservative restorations of class I, II, III, IV, V, VI carious or

traumatic defects
• Change shape and color of anterior teeth
• Fractured tooth reattachment
• Bond all indirect restorations
• Seal pits and fissures
• Bond orthodontic brackets
• Periodontal splints
• Repair of restorations
• Dentin desensitization
Fundamental principle of adhesion to tooth substrate:
The fundamental principle of adhesion to tooth substrate is based upon an

exchange process; as the inorganic tooth material is exchanged for
synthetic resin. This process involves two phases:
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a. Removal of calcium and phosphate content to expose

microporosities in both enamel and dentin surfaces.
b. The second phase (hybridization phase) involves infiltration and
in situ polymerization of resin within the created surface
microporosities.
This results in micromechanical interlocking that is primarily based
upon mechanism of diffusion.
Challenges in bonding to dental substrates:
1- Enamel is formed of 96% inorganic materials and only 4% of organic

and water while dentin is formed of 75% inorganic and 25% organic
substances and water by weight.
-Bonding to enamel (nearly homogemous structure) is a relatively simple
process; however; bonding to dentin, on the other hand, presents a much
greater challenge.
2. Obstacles in bonding to dentin
• Several factors account for this difference between enamel and dentin
bonding:
1. Heterogeneous composition of dentin:
The Inorganic and organic constitutes are unevenly distributed in
the intertubular dentin and peritubular dentin.
2. Complex histological structure of dentin

Peritubular dentin hypermineralized
Intertubular dentin high collagen and organic components
Intratubular dentin odontoblastic process and fluid.
3. Inherent dentin wetness

Dentinal tubules are filled continuously with dentinal fluid by the
capillary attraction which renders dentin under constant wetness. In
addition, the dentinal fluid is under a slight, but constant, outward
pressure from the pulp.
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4. Dentin is considered as Dynamic tissue

Mineral content of dentin increases in different situations,
including aged dentin, dentin in the vicinity of a carious lesion, and
dentin exposed to the oral cavity in non-carious cervical lesions, in which
the tubules become obliterated with tricalcium phosphate crystals.
The dentin that undergoes these compositional changes is called
“sclerotic dentin” and is much more resistant to acid-etching than
“normal” dentin. Consequently, the penetration of a dentin adhesive is
limited. Increase etching time is recommended with sclerotic dentin.
Classifications for the adhesive systems:
1. Scientific Classification (Van Meerbeek et al, 2001).

2. Chronological classification (by bonding generation).
3. Classification according to the clinical application steps.
There are many classifications for the adhesive systems the most simple
and reliable one is the scientific classification. Many others found the
chronological classification confusing and generations available in the
market nowadays are starting from the fourth generation. So the
chronological classification will be discussed later.
1. Scientific classification Van Meerbeek et al, 2001;

- It is a scientifically based classification with three main groups of
adhesives based on the smear layer handling mechanism:
• Etch and Rinse Approach.
• Self-Etch Approach.
• Glass-ionomer Approach.
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Etch-and-rinse adhesives
3 or 2 step adhesives
Smear layer removing adhesives
Self-etch adhesives
2 or 1step adhesives
Smear layer dissolving adhesives
Glass ionomer based adhesives

1 or 2 step adhesives
Smear layer modifying adhesives
:
Scientific Classification (Van Meerbeek et al, 2001)
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1. Scientific Classification (Van Meerbeek et al, 2001)
I. Etch and Rinse Approach;involves either
- Three steps etch and rinse adhesive system: application of conditioner or

acid etchant, followed, by the primer & then application of the bonding
agent.
- Two steps etch and rinse adhesive system that combine the second and
the third steps, but still have a separate etch & rinse phase.
• Clinical steps
3-steps 2-steps
1. Isolation with rubber dam 1. Isolation with rubber
2. Acid Etching with phosphoric dam
st
1
acid 37% for 15 seconds 2. Acid Etching with
step
3. Washing with water for 10-20 phosphoric acid 37% for
1st
seconds 15 seconds step
4. Air Drying 3. Washing with water for

10-20 seconds
2nds 5. Application of primer for 20 4. Air Drying
tep
seconds
6. Air drying 5. Application of primer &
the bonding agent in one 2nds
tep
7. Application of the bonding agent step for 20 seconds
3rd
for 20 seconds 6. Air thinning
step
8. Air thinning 7. Light curing for 20
9. Light curing of the bonding agent seconds
for 20 seconds 8. Application of resin
10. Application of resin composite composite
N.B :Conditioners: Any material that could lead to alteration of tooth surface.
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Etching: Selective removal/demineralization, i.e. stripping of calcium from its

phosphorus.
The importance and objectives of the three steps for bonding is as follow
1.Etching
A- Enamel conditioning:
Objectives:
1. Removal of organic pellicle and prismless enamel
2. Removal of the smear layer
3. Creation of enamel microporosities (5-50μm)
4. Increase Enamel surface energy from 32 to 72 dynes/cm2
Methods:
1. Chemical conditioners:
a. Phosphoric acid 37% for 15 seconds: the most widely used etchant.
b. Nitric acid 2.5%.
c. Citric acid 10%.
d. Maleic acid.10%.
e. Oxalic acid.1.6-3.5%
f. EDTA: it’s a strong decalcifying agent (Chelator) but prompted low
bond strength to enamel.
g. Hcl acid 15% may be used for deeper enamel etching, followed by
resin infiltration (Icon) to modify the refractive spectral of enamel white
lesions.
2. Physical conditioners (LASER):

- laser can alter the surface of enamel and dentin through microscopic
explosions caused by thermal transients.
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- Laser leads also to a desensitized dentin due to occlusion of

dentinal tubules.
- Still under research and many researches claim that it causes cracks
and damage to the surface.
3. Mechanical conditioners (Air Abrasion):

- It is based on applying aluminum oxide particles of different sizes and
velocities to the enamel and dentin surfaces.
- Some authors claim that it causes surface alterations very favorable to
etching while others refuted that.
- It has been suggested that air abrasion could be useful with self-etch
adhesive systems.
Factors affecting successful enamel acid etching:
1- Type of acid: phosphoric acid is the most commonly used.
2- Acid concentration; higher concentration will lead to formation of
acid monophosphate dehydrate, which precipitate on the surface
thus, no micropores will be formed.
3- Time of etching; 15 seconds was found to be as efficient as 60
seconds.
4- Form of etchant: gel form etchants are preferred in upper teeth
and they are easy applied. Liquid etchant is used in deep grooves
and fissure.
5- Rinsing time: at least 10 seconds to remove acid remnants and
dissolved calcium phosphates.
6- Instrumented or non -instrumented enamel
7- Chemical composition and condition of enamel: Increase of
fluoride content of enamel needs increase period of acid
application.
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8- Primary or permanent teeth:

Primary teeth have thicker layer of prismless enamel than
permanent teeth. On the other hand permanent teeth have higher
mineral content.
9- Enamel is prism-structured or prismless: The enamel surface of
70% of permanent teeth is prismless.
Patterns of etching:
Three enamel-etching patterns have been described:
- Type I etching pattern: preferential removal of enamel prism
cores.
- Type II etching pattern: preferential removal of prism
peripheries.
- Type III etching pattern: not related to prism morphology.
Or simply enamel etching patterns could be in the form of interprismatic
(10-20μm) and intraprismatic pattern (2-5μm) of etching.
Clinical features: etched enamel appears white frosted (chalky white).
Type I
Type II
Type III
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B- Dentin Conditioning:
Objectives:
1. Total removal of the smear layer and smear plugs
2. Demineralize the superficial dentin surface
3. Exposes a microporous layer of organic collagen fibers thus increasing
the microporosity of the intertubular dentin (0.05-0.1μm)
4. Demineralizes the peritubular dentin producing more funneling of
dentinal tubules (1-3μm)
• Rinsing:
Using copious amount of water for 10-20 seconds to remove acid
remnants and dissolved calcium phosphates.
• Air Drying or Blotting:
- Mineralized dentin contains 50% minerals, 30% collagen and 20%
water by volume, whereas demineralized dentin is 30% collagen
and 70% water. With the removal of the mineral phase, the
collagen fibers are suspended in water.
- If there is a substantial zone of demineralization and the water
supporting the collagen network is removed, either by air drying or
the action of an air syringe, the collagen will collapse.
- Thus drying of dentin could be done by using air syringe or
minisponge or cotton pellet. Excessive dryness should be avoided
to avoid collagen collapse. Air-drying leads to decrease in volume
of collagen by 65% that could be regained by rewetting.
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Collapsed
collagen
fibers
Problems encountered dentin after etching:

1. Decrease surface free-energy (44.8 dynes/cm2) due to high proteins
(collagen) exposed.
2. Increased permeability and wetness of dentin hinder adhesion.
Thus, To overcome these obstacles (problems), an
adhesion-promoting agent (Primer) has to be used.
2. Application of Primer
• Primers:
They contain hydrophilic monomers (HEMA) and hydrophobic
part dissolved in solvents such as acetone, ethanol, and/or water. Because
the volatile characteristics of solvents, they displace water from dentin
surface and moist collagen network, promoting the infiltration of
monomers through the nanospaces of exposed collagen network.
Effective primers contain:
• Hydrophilic monomers having a high affinity for the exposed
collagen fibril arrangement
• Hydrophobic properties for copolymerization with the adhesive
resin.
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Objectives
• To transform the hydrophilic dentin surface into a hydrophobic and
spongy state that allows the adhesive resin to wet and penetrate the
exposed collagen network.
• To induce denaturation and precipitation of proteins from dentinal
fluid and decrease dentinal permeability
N.B.: After conditioning the demineralized collagen network is
susceptible to collapse when water was removed by drying.
Depending on the primer, two techniques (wet and dry bonding) have
been proposed
Wet versus Dry Bonding:

- Surface moisture is an important factor in optimal bonding.
- On enamel, a dry condition is theoretically preferred.
- On dentin, a certain amount of moisture is needed to avoid
collapse of exposed collagen, which insures best penetration of
adhesive monomers. Consequently, in the treatment of enamel and
dentin, it is difficult to achieve the optimal environment of
substrates.
✓ One way to achieve this goal is to keep the substrate dry field (dry
bonding technique) and use adhesive systems with water based
primers to rehydrate and thus re-expand, the collapsed collagen
network, enabling the resin monomer to interdiffuse efficiently.
✓ A balance should be present between the amount of water needed
to allow collagen re-expansion and the amount of water in the
primer. Low water concentration leads to stiffness of the collagen
network and lesser degree of re-expansion. On the contrary, too
much water would rapidly expand the collagen network but also
dilute the monomer concentration leading to decrease in the formed
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bond strength.
✓ The alternative is to keep the acid-etched dentin moist (wet
bonding technique) and to rely on the water-chasing capacity of
alcohol based primers. This clinical technique referred to as Wet
Bonding introduced by Kanca 1992.
The role of acetone and ethanol could be summarized as follows:
1. When applied to the substrate surface, acetone or ethanol diffuses
into the moist dentin, while water diffuses into acetone or ethanol.
2. They occupy the spaces previously filled by water, then evaporate
rapidly leaving behind sufficient room for the coming infiltrating
resins.
3. Acetone and ethanol are also characterized by having higher
vapour pressure than water and also generate less surface tension
forces in collagen fibrils with ultimate increase in bond strength
Disadvantages of wet bonding technique:

1. Over-wet condition: if water inside the collagen network is not
completely displaced, the polymerization of resin inside the hybrid layer
may be affected or the remaining water may compete for space with resin
inside the demineralized dentin.
In such condition, excessive incompletely removed water during priming

appeared to cause phase separation of hydrophobic and hydrophilic
monomer components, resulting in blister and globule formation at resin
dentin interface.
2. Acetone quickly evaporates from the primer bottle so that after the
primer solution is dispensed in a dish, the primer bottle should be closed
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at once and the primer solution should be immediately applied to the

etched surface
3. Keeping the cavity walls wet after conditioning will not allow white
frosted appearance of properly etched enamel to be detected
For successful priming:
1. Dentin surface must not be over dried or over wet.
2. Avoid excess water as it may dilute the primer renders it less effective.
3. In dry bonding, air dryness for 5-10 seconds is required while for wet
bonding, moisture should be removed by short air blast (gentle air drying
for 2 seconds) or blotting or wiped off with a dry sponge or small tissue
paper.
4. In dry bonding technique, air drying of demineralized dentin reduces
its volume by 65% but the original dimensions could be regained by
rewetting or re-moisten with water or antibacterial solution such as
chlorhexidine.
5. Apply multiple coats: this insures total covering of the substrate and
allow for more penetration of the hydrophilic monomer.
6. Primer application time should be at least 15 seconds to allow
monomers to inter-diffuse to complete depth of surface demineralization
and evaporation of the solvent.
7. The primer should be actively rubbed into the dentin surface with a
disposable brushes or sponge applicators to improve the inter-diffusion
process.
8. Enamel and dentin must appear glossy, shiny and hydrated with visibly
moist surface after priming.
9. Acid-etched enamel does not need a separate primer application to
achieve effective bonding to air dried enamel
10. In wet bonding technique, primers should always be applied on acid-
etched enamel to displace residual moisture.
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11. Short and gentle air-drying after primer application should be done.
C- Adhesive Resin:
• The bonding agent consists primarily of:
- Hydrophobic monomers as Bis-GMA or UDMA.
- Hydrophilic monomers such as TEGDMA to regulate viscosity
and HEMA as a wetting agent.
• Adhesive resin could be chemically or photo cured. For the photo
cured, resin polymerization is done prior to packing of the composite
resin.
• The main goal is to totally seal all the micro pores created previously
by resins and achieve a biologic tissue that is formed of resins
encapsulating and hydroxyapatite crystals and collagen totally to form
an elastic intermediary joint to link resin composite to tooth tissues.
• Requirements for an ideal dentin bonding agent:
1. It should be hydrophilic in order to bond to wet dentin.
2. It should contain hydrophobic part to copolymerize with the
subsequently applied resin.
3. It should have low viscosity for better diffusion.
4. It should be biocompatible
5 It should possess minimum film thickness for better wettability.
6. It should possess high bond strength to both enamel and dentin
immediately after placement.
7. It should minimize microleakage to nanoleakage.
8. It should be easy to be applied.
9. It should have good shelf life.
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Resin/enamel interface:
Adhesive resin absorbed by capillary attraction within the created
etched enamel surface enveloping individually exposed hydroxyapatite
crystals followed by in situ polymerization of resin to create two types of
resin tags:
• Macrotags fill up the space surrounding the enamel prisms
• Microtags result from resin infiltration/polymerization within the tiny
etch pits and at the cores of etched enamel prisms. They are thought to
be the major contributors to enamel retention.
Resin/enamel interface
Dentin Hybridization and Resin Tags formation:

✓ Hybrid layer The part of the resin that impregnates into the
intertubular dentin.
✓ Resin tags. The part that enters the dentinal tubules is called
Hybridization: is the formation of resin interlocking in the
demineralized tooth surface; providing micromechanical retention.
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• N.B: Concerns have been raised that aggressiveness etching of dentin

may cause demineralization to a depth that might be inaccessible to
complete resin impregnation. Incomplete resin penetration (also
called hybridoid layer), causes a microporous dentinal zone at the
base of the hybrid layer; thought to be a pathways for nanoleakage
fluids, causing hydrolysis of collagen.
Etch and rinse approach
Diagram illustrating the concepts of microleakage ( right side) and

nanoleakage (left side) when bonding dental resins (R) to dentin (D
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II Self-Etch approach
(Smear layer dissolving)

• Self-etching primers contains acidic monomer contains carboxilic
or phosphoric acid groups to create micromechanical retention, which
are not rinsed off, simplifying the procedure.
• When applied onto the tooth it will demineralize and penetrate
simultaneously, it is not rinsed away to leave dentinal tubules open and
exposed.
• Depending on the etching (added acid groups) aggressiveness, they
can be divided into strong (Ph≤1), intermediary strong (pH=1.5)
and mild (pH≥2) self-etch adhesives.
• To simplify the procedure it includes:

- 2 steps self etch systems:
Which is formed of self etching primer, hen application of adhesive resin.
- One step self etch systems: Incorporation of the self etching primer and
adhesive into one bottle.
• Clinical steps:
2 steps 1 step
1st Application of self etching • Application of the self-

step primer for 20 seconds etching primer together
Air drying with the bonding agent in
Application of the bonding one step
2nd
step agent for 20 seconds • Air thinning
Air thinning • Light curing
Light curing for 20
seconds
Application of resin
composite
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Advantages of self-etch adhesive:
1- Reduced the clinical application time,
2- Reduces the possibility of overwetting or overdrying,
3- Reduces the risk of errors during application and manipulation (less

technique sensitive).
4- Less postoperative sensitivity.

5- They are less likely to result discrepancies between the depth of
demineralization and depth of resin infiltration as both occur simultaneously.
• Self-etching primer is applied for 15-20 seconds etch through the

dentinal smear layers and into the underlying dentin, creating
acceptable dentin bond strengths.
However The degree of etching of enamel seems to be
minimal. Thus,
• On enamel: The self-etching primer should be applied for at least
30 seconds and actively applied by rubbing with repeated
application of fresh material. Or, separate conventional etchant
can be applied before application of the self-etching primer
(selective etching to enamel).
• Most self etch adhesive ( mild and intermediate strong self etch
adhesives) require a separate phosphoric acid etch on enamel only to
maximize adhesion to the ;highly mineralized enamel in what is called
“selective enamel etching”.
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Self-etch approacch
III Glass-ionomer approach

One-step or two-step
• Glass ionomers are the only materials that are self-adhesive to
tooth tissues
- One step or direct application of the material
• Two steps application involving pre-treatment with a weak
polyalkenoic acid conditioner.
• The application of Polyalkenoic-acid conditioner for 10-to-20
seconds increases bonding efficiency due to:

1. Cleaning effect
2. Partial demineralization by which the surface area is increased
and micro porosities for micromechanical interlocking are
exposed.
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3. Chemical interaction of polyalkenoic acid with residual

hydroxyapatite.
• The auto-adhesion of glass ionomer has recently been determined
to be due to:
1. Micromechanical interlocking.
2. True chemical bonding occurs between the carboxyl groups of the
polyalkenoic acid and calcium of hydroxyapatite.
II. Chronological “Generational” classification of adhesives:

Only adhesives from fourth to eighth generation are currently on the
market.
The First, second and third Generation adhesives no etching

of dentin (etching of enamel only) showed many disadvantages and
and low bond strength to the tooth structure so they are not available
in the market any more.
Fourth-Generation Adhesives:
- In the 1990’s, significant advances were made in adhesive dentistry
with the development of multistep dentin adhesive systems
- That involves the pretreatment of dentin with conditioners and
primers that make heterogenous and hydrophilic dentin more
receptive to bonding.
- Manufacturers used the term conditioner instead of etchant as
these conditioners were to be applied to both enamel and dentin
following the total-etch approach.
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- Fourth generation adhesives are referred to as three-step etch

and rinse adhesives.
- A final step in these adhesives involves the application of unfilled
or semifilled low viscosity adhesive that copolymerizes with the
primed dentin and simultaneously offers bonding receptors for
copolymerization with the restorative resin composite.
Fifth-Generation Adhesives:
• The fifth generation adhesive systems were introduced in
attempts to sum up the steps of bonding into two-step application
(etch-and-rinse), “Fewer bottles and/or less time”;
• They utilized a separate etch-and-rinse (total-etch) phase followed
by the application of a combined primer-adhesive resin solution.
• Bond strength of these adhesives has been comparable to those of
the fourth generation systems.
Sixth-Generation Adhesives:
• Further demand for simplification has urged manufacturers to develop

adhesives with even fewer clinical steps.
•The sixth-generation consists of self-etch adhesives. They are
characterized by the omission of a separate conditioning step and are
composed of two solutions.
They consist of two types of adhesives:
• Self-etching primer and a separate adhesive resin (two-step self-etch

adhesives)
• Those combine conditioner, primer, and adhesive resin but require

mixing(one-step, two-component self-etch adhesives)
• Sixth-generation adhesives use the smear layer on enamel and dentin as

bonding substrate.
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• Self-etch adhesives are more hydrophilic. Moreover, in order to ensure

etching capability of these monomers, water must be present to act as
ionizing medium.
Seventh-Generation adhesives:
• These systems are single-component, one-step self-etch adhesives and
combine conditioning, priming, and adhesive resin application without
mixing.
Disadvantages:
Due to the complex nature of the mixed solutions, they are:
• Prone to phase separation and formation of droplets within their
adhesive layers.
• Act as semipermeable membranes, permitting bidirectional water
currents.
• Lower bond strength than fourth- and fifth-generation adhesives.
Eighth –Generation adhesives:
-They are the nano-filled adhesive products or the self- adhesive resin
composite products.
Advantages:
- Bond strength too accepted clinically.
- Longer shelf life.
- Stress absorbtion.
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Bond Degradation
- Although the immediate bond strengths of contemporary

adhesives have been shown to be quite high, substantial
decreases in resin-dentin bond strength occurred after aging,
failure and continuous loss of bonded restorations over time for
both etch-and-rinse and self-etch adhesive systems.
- Bond durability is critical for the longevity of restoratives, because

degradation can weaken adhesion and lead to gaps between teeth
and restoratives.
Mechanism of dentin-adhesive interface degradation:
Degradation of the collagen Degradation of resin monomers

Degradation mechanism Degradation mechanism
- Acid-etching and disruption of the - Current adhesives include in their

tooth structure by drilling stimulates formulation hydrophilic and hydrophobic
proteolytic enzymes such as matrix components, that produce nanophase
metalloproteinases (MMPs), which separation.
can degrade the exposed collagen
component of the hybrid layer. - The hydrophilic elements 2-hydroxyethyl
methacrylate (HEMA), penetrates the
- The process proceeds with hydrolysis interior of the hybrid layer, while the
and consequent extraction of the hydrophobic monomers remain on the
adhesive resins that have infiltrated surface.
the demineralized dentin matrix.
- The camphorquinone do not penetrate,
- The previously resin-infiltrated leading to inadequate polymerization in
collagen matrix is exposed and the deepest zone of the hybrid layer.
vulnerable to attack by proteolytic
enzymes - Water initially enters the matrix by
diffusion into hydrophilic domains or
may be trapped within the matrix during
photo-polymerization in the moist
environment of the mouth.
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- The presence of water promotes the

chemical hydrolysis of ester bonds in
methacrylate materials and leads to
formation of water channels within the
hybrid layer.
- The action of esterase enzymes (from

saliva, pulp, and bacteria) break the ester
bonds present in the HEMA.
Factors affecting the interface durability.

I) Dentin related factors
II) Adhesive system related factors
III) Micro mechanics of adhesive interface
IV) Extrinsic and intrinsic water sorption
V) role of saliva in bond degradation

VI) Miscellaneous factors
I. Dentin related factors;
1. Dentin smear layer:

• A layer of 2-5μm of calcific debris (hydroxyapatite crystals, collagen,
saliva and blood and microorganisms) produced by reduction or
instrumentation of dentin, enamel or cementum or as a contaminant.
• This tenaciously adherent layer is burnished on the cut surface by the

effect of heat and pressure of cutting and cannot be removed by rinsing.
Advantages of smear layer:

1- It reduces dentin permeability by about 86% through plugging the
dentinal tubules thus provides a drier surface for adhesion.
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2- Minimizes post-operative hypersensitivity and preventing the

ingress of irritants from the restorative material to the tubules.
• Disadvantages of smear layer:

It incorporates microorganism and is loosely attached to the
underlying dentin providing for a weak joint between the tooth
tissues and the restorative material.
So acids with a high reactivity rate with the mineral component of dentin
have been considered a good reagent for removing the smear layer.
2. Heterogeneous composition and complex histological structure
(as discussed before)
• Bonding to deep versus superficial dentin
- In superficial dentin, there are few dentinal tubules and large

amounts of intertubular dentin are available. Thus bonding the
mechanism is through hybrid layer formation.
- On the other hand, in deep dentin, the dentinal tubules are abundant
with limited amounts of intertubular dentin, so the resin tags
bonding is achieved.
• Bonding to the gingival marginal dentin
Clinical studies showed that the gingival margin in class II composite

restorations is the most common location for bonding failures. This was
explained by:
- The difference in the demineralization depth between dentin at the

gingival margin which is less mineralized than dentin at the
proximal walls. In addition, the density and size of dentinal tubules
at the gingival margin are greater than that at the proximal wall.
Thus, acids are expected to etch dentin at the gingival margin
faster and deeper than dentin at the proximal wall. This leads to a
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distinct difference in adhesive infiltration with considerably less

adhesive penetration at the gingival margin compared to proximal.
- The increase water content at the gingival dentin, which makes it

difficult bonding substrate. This is not only because of the water
already present within the demineralized dentin matrix, but also
because patent tubules contribute to the contamination of the
prepared surface with a great amount of dentinal fluids.
- The cumulative effect of the increased water led to reduced

adhesive infiltration and low monomer/polymer conversion of the
adhesive at the gingival margin as compared to the proximal wall.
• Bonding to altered dentin:
- In most of the clinical situation’s clinicians usually bond

adhesives to caries affected dentin or abraded sclerotic dentin.
Authors have reported nearly a 30%-40% drop in the bond
strength with both affected dentin substrates.
- The hybrid layer formed on caries affected dentin was thicker than
those formed on healthy dentin.
- The thick hybrid layer may be due to the fact that caries affected
dentin is partially demineralized and offers a more porous substrate
for acid etching than healthy dentin.
- Moreover there was also a dramatic reduction in monomer/polymer

conversion when the adhesive was used on carries affected dentin.
- Since caries affected dentin may be characterized by zones of

disorganized collagen, acid etching could promote phase transition
of this disorganized collagen to a gel. The gel could inhibit
adhesive infiltration.
- It was postulated that the lack of adhesive penetration in caries

affected dentin is due to a phase transition in the collagen that has
been disordered by caries.
28
II. Adhesive related factors
Etch and rinse adhesives

- Acid conditioners are used to demineralize the layer that is
smeared and the underlying intact dentin to create a microporous
surface with a rich collagen network providing room for resin
infiltration.
- The complete filling of the exposed space by subsequent
application of resin monomer is unattainable within the short time
available, and it is possible that an exposed demineralized dentin
zone remains within the bond structure. This leads to hydrolysis
and reducing long term bond strength.
- Moreover, it has been hypothesized that the dentin acid-etching
and disruption of the tooth structure by drilling stimulates
proteolytic enzymes such as matrix metalloproteinases (MMPs),
which can degrade the exposed collagen component of the hybrid
layer.
Self-etch adhesives:
- The market driven simplification of adhesive systems of self
etching primers that combines that conditioning and priming steps
are thought to overcome the shortcomings of the formation of an
exposed collagen network within the bonds of the total-etching
adhesives.
- Later similar morphological evidence of degradation was reported
by long term studies.
- Regions of incomplete resin infiltration or incomplete resin
polymerization within the hybrid layers or bonding resin may
represent pathways for fluids, a phenomenon termed nanoleakage.
29
All in one adhesive system:

- Water sorption of adhesive resin is proportional to its hydrophilic
characteristics compared to the hydrophobic based adhesives.
- The self-etching ability of one bottle adhesives is commonly

achieved by incorporation of water in resin monomers that enables
ionization of acidic monomers.
- The presence of such a more hydrophilic layer that induce water

sorption and water uptake, in turn, endangering the stability of the
polymer network.
III. Micro-mechanics of the adhesive interface:
Under clinical function dentin adhesives are subjected to both

chemical and mechanical stresses.
The interplay between the two forms of stress is expected to

result in an alteration of the properties of the adhesive with
time.
The mechanical property change results from a variety of

mechanisms including mechanical loads and exposure to
salivary esterase and changes the chemical nature of the
polymer.
Therefore, the change in the mechanical property of the

adhesive with time can result in a gradual loss of mechanical
integrity.
IV. Extrinsic and intrinsic water sorption.

Adsorption of extrinsic water leads to plasticization of the
adhesive and loss of interfacial adhesive dentin bond strength as
a result of water attack.
This increases water sorption after polymerization and/ or

extraction of water soluble unreacted monomers.
30
V. Role of saliva in bond degradation:
Human saliva contains a variety of enzymes which may

participate in the degradation of the adhesive as well as the
composite.
Human saliva samples have been shown to contain cholesterol

esterase and pseudo-cholinesterase activity in sufficient quantity
to degrade composite resin.
VI. Miscellaneous factors:
a. Clinical related factors.

1- Position of the tooth
Adhesive restorations in Premolars showed better
performance than those in molars
2- Cavity size
3- Cavity type
4- The number of restored surfaces
5- C-factor or Configuration factor: Is the ratio of
bonded to free unbounded cavity walls.
- Resin restorations shrink as they polymerize, creating stresses of
up to 7MPa within the resin composite mass depending on the
configuration of the preparation.
- When the composite is bonded to one surface only, stresses within
the composite are relieved by flow from the unbonded surface.
- However, stress relief within a three-dimensional bonded
restoration is limited.
- Unrelieved stresses in the composite may cause internal bond
disruption as well as marginal gaps around restorations.
- The higher the ratio of bonded to free resin surface, the less the
flow that may compensate for contraction stress.
31
b. Operator related factors.
The operator qualification and employment status and experience affect

the longevity of the restorations.
The often mentioned problems of leakage related to posterior composite

restorations may be related to adhesive procedures having not been done
properly due to the inappropriate selection of adhesive materials and
techniques or the application of materials not in accordance with the
manufacturers' instructions.
1. Isolation
- Before of any bonding procedure begun, adequate isolation and
moisture control of the substrate to be bonded must be achieved.
-Salivary contamination is detrimental because saliva contains proteins
that may block adequate resin infiltration in enamel and dentin created
microporosities.
- Consistent use of a rubber dam remains the most effective method of
moisture control.
2. Dentin and pulp protection

-The use of non-adhesive liners and bases beneath adhesive restorations is
not recommended.
-Adhesive materials such as glass-ionomer cements can be used
(Sandwich technique), but in most cases the simple application of an
appropriate adhesive is effective.
-In deep cavity with remaining dentin thickness less than 0.5mm; calcium
hydroxide remains the material of choice however; it rapidly dissolves if
the cavity is not adequately sealed. Therefore, when calcium hydroxide is
used, it should be covered by less soluble materials as resin-modified
glass ionomer cement.
32
3. Temporization
Eugenol-containing temporary restorations must be avoided as eugenol
affects the polymerization of the resin material.
4. Post operative and post restorative care.
High level of good oral hygiene is required in order not to allow
plaque accumulation with subsequent bond degradation.
c. Patient related factors.
The type of patient and the oral environment play an important role in the
survival of dental restorations. The caries risk of patients has been shown
to significantly influence the durability of restorations.
d. Material related factors.
Difference in Flexural and compressive strength, Elastic modulus,

Fracture strength, toughness, hardness and wear resistance have been
shown to be significantly different among materials when laboratory
techniques were used to compare the restorations.
Potential preventional solutions for bond degradations:
1. Material dependant attempts:
a. Modifying the methacrylate side chains:

33
Modifying the methacrylate side chains with functional monomers in

“mild” SE adhesives, such as
- 10 methacryloyloxydecyl dihydrogen phosphate (10-MDP).
- 4 methacryloxyethyl trimellitic acid (4-MET).
- 2-(methacryloyloxyethyl) phenyl hydrogenphosphate (phenyl-P)
lead to a chemical bond to calcium ions of the hydroxyapatite crystals.
“Mild” SE adhesives interact only superficially with dentin, forming a
thin (even submicrometre) hybrid layer. The use of “mild” SE adhesives
is believed to minimize nanoleakage, leave a substantial amount of
hydroxyapatite around the collagen fibrils to mask the collagen cleavage
site. Thus, the collagen could not be degraded.
63
b. Photo-initiator incorporation:
To address the In-adequate monomer/ polymer conversion, but it should
be compatible with the hydrophilic components.
c. Crystallization by Resin Adhesive, Glass-Ionomer Cement, or

Bioglass:
A resin adhesive with glass-filler particles (i.e., a surface reaction type

pre-reacted fluoro-boroalumino-silicate glass) have recently been
developed and used for antibacterial effects or remineralization of the
hybrid layer by gradual release of various ions such as Na, B, Al, Si, or F.
This type of adhesive offers the potential to act chemically like

glassionomer cement releasing ions and acting as an adhesive with
high bond strength by functional monomers.
The ability to grow crystals between restorative compounds and dental

hard tissue may lead to protection of tooth surfaces in interfacial gaps and
may contribute to the longterm stability of restoration.
d. Addition of protease inhibitors:

- Specific and non-specific matrix metalloproteinase inhibitors (MMPIs)
e.g., Chlorhexidine (CHX), Galardin (GL), chemically modified
tetracycline (CMT), etc., Most are under development and have no
proven biocompatibility to be used on human subjects.
34
- CHX has proven biocompatibility and good anti-bacterial action both

in vivo and in vitro.
- Application of 2% CHX to the acid etched dentin has been found to

have MMP inhibitor and anti-enzyme properties even at this low
concentration.
ADHESION TO DENTAL TOOTH TISSUES

e. Collagen cross-linking agents:
- It is proposed to enhance mechanical properties of dentin matrix,
reduce biodegradation rates of collagen, increase the properties of
the dentin-resin bonds, and extend the life of adhesive restorations.
- Proanthocyanidins (PA) are natural biocompatible collagen cross-
linker.
- (PA) has ability to bind to proline rich proteins, such as collagen,

and facilitate the enzyme proline hydroxylase activity, essential for
collagen biosynthesis.
f. Biomimetic remineralization of resin-dentin bonds:
- In dentin bonding, the mineral phase of dentin is intentionally removed

by acids, chelating agents, or acidic resin monomers to expose the
collagen for creating micromechanical retention of resins. Unfortunately,
it seems that contemporary etch- and- rinse and self-etch adhesives are
incapable of completely replacing water from the extrafibrillar and
intrafibrillar collagen compartments with resin monomers.
-Biomimetic mineralization is a proof-of-concept strategy that utilizes

nanotechnology principles to mimic what occurs in biomineralization.
35
-This strategy replaces water from resin-incompletely filled regions of the

hybrid layer with apatite crystallites that are small enough to occupy the
extrafibrillar and intrafibrillar compartments of the collagen matrix, and
has been adopted for remineralization of resin dentin bonds.
Resin Bonding to Dentine after Casein Phosphopeptide-Amorphous Calcium

Phosphate (CPP-ACP) Treatment.
2. Technique dependent attempts:
a. Ethanol-wet bonding:
- The problem of water hydrolysis of ester-bonds in adhesive
polymers and peptide bonds in collagen might be eliminated if
water could be excluded from the bonded interface.
- This has been the aim in ethanol wet bonding, where ethanol is
used to chemically dehydrate acid-etched demineralized dentin
matrices to reduce collagen hydrophilicity and facilitate the
infiltration of more hydrophobic monomers to dentin.
- Infiltration of hydrophobic monomers decreases water

sorption/solubility and resin plasticization, but it has been
suggested that the elimination of residual water also reduces or
eliminates enzyme-catalyzed hydrolytic collagen degradation.
- One problem with this method is that in the clinical setting, this
solvent may be diluted because of repeated exposure of the
material to the atmosphere or concentrated, because of separation
of the bonding liquids into layers within the bottle.
36
b. Rubber dam isolation to limit the impact of water or saliva

contamination, careful attention to handling, management
c. Extended adhesive application time with rubbing action, allowing

proper resin penetration and solvent evaporation
d. Warm air dryness to accelerate solvent evaporation.

67
IN SUMMARY: The success of clinical restorations depends on a
variety of factors including proper technique, appropriate materials, and
proper patient selection.
37

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Mechanisms of adhesion involved in dentistry

Requirements for adhesion:

Wettability is: Spontaneous flow and full spread of a liquid phase

In addition, sufficient wetting of the adhesive will only occur if its

Surface energy is: The inward attractive forces of the molecule

The surface energy of a liquid is known as the surface tension.

Thus, the requirements for successful wetting of adhesive are:

2. Cleanliness, smoothness and dryness of the tooth tissues.

4. Low-surface tension of the adhesive material (adherent) to be able to

5. Low viscosity of the adhesive to penetrate into the microporosities

6. To be able to displace air and moisture during the bonding process.

Advantages of adhesive techniques:

• Ultra conservation of tooth structure: through elimination of

• Long term restoration retention: strong bond provides longevity of the

• Adhesive restorations better transmit and distribute functional stresses

• Reinforcement of the remaining tooth structure: (still a controversy) due

• Expanded the range of esthetic restorative dentistry.

Indications for adhesive dentistry:

• Conservative restorations of class I, II, III, IV, V, VI carious or

• Change shape and color of anterior teeth

• Fractured tooth reattachment

• Bond all indirect restorations

• Seal pits and fissures

• Bond orthodontic brackets

Fundamental principle of adhesion to tooth substrate:

The fundamental principle of adhesion to tooth substrate is based upon an

a. Removal of calcium and phosphate content to expose

Challenges in bonding to dental substrates:

1- Enamel is formed of 96% inorganic materials and only 4% of organic

2. Complex histological structure of dentin

3. Inherent dentin wetness

4. Dentin is considered as Dynamic tissue

Classifications for the adhesive systems:

1. Scientific Classification (Van Meerbeek et al, 2001).

1. Scientific classification Van Meerbeek et al, 2001;

Glass ionomer based adhesives

Scientific Classification (Van Meerbeek et al, 2001)

1. Scientific Classification (Van Meerbeek et al, 2001)

I. Etch and Rinse Approach;involves either

- Three steps etch and rinse adhesive system: application of conditioner or

4. Air Drying 3. Washing with water for

Etching: Selective removal/demineralization, i.e. stripping of calcium from its

2. Physical conditioners (LASER):

- Laser leads also to a desensitized dentin due to occlusion of

3. Mechanical conditioners (Air Abrasion):

8- Primary or permanent teeth:

Clinical features: etched enamel appears white frosted (chalky white).

Problems encountered dentin after etching:

adhesion-promoting agent (Primer) has to be used.

Wet versus Dry Bonding:

Disadvantages of wet bonding technique:

In such condition, excessive incompletely removed water during priming

at once and the primer solution should be immediately applied to the

Dentin Hybridization and Resin Tags formation:

• N.B: Concerns have been raised that aggressiveness etching of dentin

Etch and rinse approach

Diagram illustrating the concepts of microleakage ( right side) and

(Smear layer dissolving)

• To simplify the procedure it includes:

1st Application of self etching • Application of the self-

Advantages of self-etch adhesive:

1- Reduced the clinical application time,

2- Reduces the possibility of overwetting or overdrying,