Adhesive Cementation

Article by : M.Aly / E.Abdelmoniem

This article based on studies and research articles by W. Devoto / F. Ferraris /
John W. Nicholson
This article used AI in
Adhesion In Dentistry

Adhesion in dentistry involves a living substrate that may show considerable

variation
The structure of a tooth consists of enamel and dentine, which have different
compositions and anatomies
Adhesion to enamel and dentine presents different problems due to their
different properties
The cut surface of dentine consists of exposed ends of tubules, which can
interfere with the development of an adhesive bond
Adhesive Dentistry
Adhesive dentistry is a key component of minimally invasive, esthetic, and tooth-
preserving dental restorations.
It involves bonding various restorative materials to tooth structures or other
materials with composite resin luting agents.
Adhesive dentistry is used in almost all dental specialties and is essential for
optimal bond strengths and long-lasting clinical success.
History And Evolution
Adhesion to tooth structures and dentin has evolved significantly since its
introduction in the mid-1950s.
The total-etch technique was introduced in the late 1970s, and current adhesive
systems are divided into etch-and-rinse and self-etch categories.
The hybrid layer concept was introduced in 1982, and its formation and quality
are key to establishing proper adhesion.
Clinical Applications And Challenges
Adhesive dentistry is used in direct restorations, bonding orthodontic brackets,
endodontic posts, crowns to implant abutments, and composite and ceramic
veneering materials to metal and ceramic frameworks.
Clinical challenges include operator experience and familiarity with adhesive
systems, surface contamination, and the need for isolation of the operating field.
The search for the ideal dental adhesive system is ongoing, with requirements
including minimizing phosphoric acid pretreatment, being a mild self-etch, being
solvent-free, and having antibacterial properties.
Composite Resins
Patients at high risk for caries and bruxism have higher failure rates in shorter
periods than patients with low risk.
Simplification of the placement technique with low-shrinkage-stress bulk-fill
composite resins is a current trend.
The recommended placement technique is to use small increments to allow for
flow of the composite material away from free space and toward a bonded
substrate.
Ceramics
The clinical success of resin-bonded or repaired ceramic restorations depends on
the quality and durability of the bond between the composite resin and ceramic.
Silica-based ceramics require hydrofluoric acid etching followed by application of
a silane coupling agent.
High-strength ceramics, such as alumina- and zirconia-based ceramics, require
unique surface treatment methods, including air-particle abrasion and
application of a special ceramic primer.
Posts And Adhesion
Prefabricated fiber-reinforced polymer (FRP) posts are popular due to satisfactory
clinical results and reduction in treatment time and cost.
The effectiveness of the adhesive cement and luting procedure plays an
important role in the retention of FRP posts.
Silane coupling agents are typically applied to the post surface to enhance
adhesion.
Resin-based self-adhesive cements eliminate the multiple and technique-
sensitive tooth- and material-pretreatment steps.

Properties Of Adhesive Cements

Low solubility in oral fluids to avoid dissolution and secondary caries.
High mechanical compressive and tensile strength to withstand masticatory
loads.
Reduced film thickness to ensure good margin accuracy and minimize spacer
requirements.
Good adhesion to mineralized tissues of the tooth and prosthetic restoration.
Low water absorption for dimensional stability and to prevent marginal cement
leakage.
Nontoxicity and insulation of the pulp for vital teeth.
Caries resistance and low solubility to prevent secondary carious lesions.
Adequate setting time for handling and placement.
Good esthetic integration and color stability.
Radiopacity for radiographic monitoring of excess cement.
Dental Adhesives classifications
* Dental adhesives are classified by generation or by their interaction with the
smear layer.
Etch-and-rinse (E&R) adhesives remove the smear layer and rely on
phosphoric acid etching of enamel and dentin.
Self-etch (SE) adhesives do not use a separate etching step and integrate the
smear layer residues into the adhesive interface.
Simplified adhesives, such as one-step SE and two-step E&R adhesives, are
popular due to their ease of use, but may compromise clinical outcomes.
* Universal Adhesives
Universal adhesives are one-step SE adhesives that can also be used as two-step
E&R adhesives with phosphoric acid etching.
They contain functional phosphate and/or carboxylate monomers that enable
chemical bonding to calcium in hydroxyapatite.
Universal adhesives are recommended for various clinical applications, including
direct and indirect restorations, core buildups, and dentin desensitization.
Composition And Properties
Universal adhesives contain hydrophilic monomers to enhance wettability to
dentin and hydrophobic groups to copolymerize with restorative materials.
Some universal adhesives contain silanes, such as 3-
methacryloxypropyltrimethoxysilane (MPS or γMPTS), to provide additional
chemical bonding to glass-matrix ceramics.
The application of a separate silane solution or a silane freshly mixed with the
adhesive is still recommended due to the incompatibility of silanes with acidic
solutions containing water.
Some universal composite resins exclude Bis-GMA from their organic matrix,
instead using alternative resin monomers such as DDDMA, UDMA, AUDMA, and
TEGDMA.
The composition of dental adhesives and composite resins has changed in
response to public opinion on BPA toxicity.
Clinical Performance
Clinical studies have demonstrated that universal adhesives, such as Scotchbond
Universal Adhesive (SBU), have excellent clinical outcomes, with high retention
rates and minimal marginal discoloration and marginal deterioration.
The clinical behavior of universal adhesives depends on enamel etching with
phosphoric acid, and selective enamel etching may provide micro-mechanical
retention and marginal sealing of etched enamel.
The application of universal adhesives to dry dentin does not result in worse
retention compared to application to moist dentin.
Challenges And Limitations
Intense marginal discoloration and marginal discrepancies have been reported in
several clinical studies.
The role of MDP in chemical bonding to hydroxyapatite is well-documented in
vitro, but some in vitro studies have questioned its potential in promoting
chemical bonding of universal adhesives to dentin and enamel.
The solvent evaporation time for universal adhesives may need to be extended
to ensure removal of residual water from the interface, and the application of an
extra hydrophobic bonding layer may be important for stable adhesion.
* Zirconia Restorations
MDP-containing universal adhesives and MDP- and silane-based ethanol solutions
are recommended as zirconia primers to increase the in vitro durability of bonds.
MDP-based primers are effective for translucent or cubic zirconia.
Examples of available primers include Monobond Plus, Clearfil Ceramic Primer,
and GC Ceramic Primer II.
Dental Adhesion
Matrix metalloproteinase (MMP) inhibitors have been advocated to prevent the
degradation of dentin bonds and improve the durability of restorations.
However, clinical trials have failed to provide evidence to support the use of MMP
inhibitors in clinical adhesive dentistry.
A meta-analysis reported scarce evidence to recommend or negate the
usefulness of MMP inhibitors applied prior to inserting adhesive restorations.
Adhesive Restorations
The adhesion strategy does not influence the development of postoperative
sensitivity after the insertion of posterior composite restorations.
Glutaraldehyde-based dentin desensitizers have been shown to be effective in
reducing dentin hypersensitivity, but there is no clinical evidence to support their
use underneath direct and indirect restorations to prevent postoperative
sensitivity.
The immediate dentin sealing technique has been popular among clinicians, but
there is no strong clinical evidence to recommend its use.
Universal Composites
Omnichroma composite resin demonstrated the ability to change shade as the
surrounding tooth structure became brighter.
Universal composites are easy to finish and have excellent polish retention.
However, the color stability of some universal composite resins is not ideal.
Clinical Recommendations
Etching enamel with phosphoric acid is still the most reliable method to achieve
durable and sealed restorations.
Simplified adhesives are subpar compared to adhesives that include an extra
hydrophobic resin.
Universal adhesives have the potential for chemical bonding to hydroxyapatite
as long as dentin is not etched.
More clinical studies are needed to document the long-term use of universal
composite resins.

Dental Materials
Zinc polycarboxylate cements were the first truly adhesive dental restorative
materials
Glass-ionomer cements were developed from previous studies on dental silicate
cements and zinc polycarboxylate cements
Glass-ionomer cements have been used in a variety of clinical procedures,
including lining cavities and restoring teeth
The development of glass-ionomer cements was assisted by the discovery of the
effect of (-)-tartaric acid, which improved the handling properties of the cement
Glass-ionomer cements are used as aesthetic restoratives, but are less widely
used than composite resins.
They have good compatibility with the tooth surface and can develop a strong
bond with enamel.
However, they are relatively brittle and sensitive to early moisture damage.
Resin-modified glass-ionomers have been developed to overcome these
problems and have been shown to adhere to enamel and dentine, release
fluoride, and have good aesthetics.
Composite Resins
Composite resins are the aesthetic material of choice for repairing teeth and are
used to repair damage caused by caries or trauma.
They are based on bis-GMA and cure by an addition process involving the
terminal methacrylate groups.
Bonding to enamel is achieved using micromechanical attachment, while
bonding to dentine is more complex and involves the formation of a resin-
dentine hybrid zone.
Composite resins have good durability in the oral environment, but their major
disadvantage is their lack of adhesion to dentine.
Dentine Bonding Agents
Dentine bonding agents have been developed to improve the adhesion of
composite resins to dentine.
Early examples include glycerophosphoric acid dimethacrylate and 2-
methacryloxyethyl phenyl phosphoric acid.
Modern agents have improved properties and are designed to interact with
either the mineral phase or the collagen of the dentine.
Examples include Gluma and Scotchbond, which have been shown to function
well when used following surface conditioning with citric acid or ethylene-
diamine tetra-acetic acid.
Compomers
Compomers are a type of material that combines aspects of composite resins
and glass-ionomers.
They do not set by neutralization, but only by polymerization, and lack the ion-
exchange bonding mechanism of true glass-ionomers.
Commercial examples include Dyract and Compoglass, which have different
compositions but share similar acid-functional molecules capable of both
neutralization and polymerization.
Properties And Performance
Fluoride release from compomers is lower than from resin-modified glass-
ionomers and unmodified glass-ionomers.
Compomers have been used in various applications, including Class V
restorations, but their wear resistance is inferior to that of conventional
composite resins.
Adhesion techniques for compomers are similar to those for conventional
composite resins, but the durability of these bonds is unknown, particularly in
the long term.

Material Conditioning
Silica-based materials, including glass ceramics and composites, can be treated
with surface conditioning and resin cements containing methacrylate monomers
to improve adhesion.
Glass ceramics can be treated with acid etching and silane-based promoters to
increase their surface roughness and improve adhesion.
Composites can be conditioned with blasting, acid etching, and silane treatment
to improve adhesion.
Metal alloys require special treatment, such as the use of a promoter solution or
tribochemical silicatization, to improve adhesion with resin-based systems.
Material Properties
Glass ceramics have high translucency and esthetic characteristics, making them
ideal for porcelain veneers and partial restorations.
Composites have improved wear resistance, physical properties, and color
stability compared to older materials.
Metal alloys are highly biocompatible and do not corrode easily, but they require
proper treatment and conditioning to achieve good adhesion with resin-based
systems.
Surface Preparation
Hydrofluoric acid application (2.5-10% for 2-3 minutes) is effective in creating a
suitable surface for adhesion
Etching gel should be rinsed completely with water to remove ceramic salts that
can affect adhesion
Immersion in pure alcohol in an ultrasonic cleaner for 2-4 minutes can be used to
remove residue
Sandblasting with aluminum oxide particles can be used, but may lead to
excessive material loss and fractures
Chemical Conditioning
Hydrofluoric acid pretreatment is followed by chemical conditioning with silane
application
Silane predisposes to covalent bonds and increases wettability of ceramics
Two-component silane is recommended to avoid hydrolysis or dissolution of the
solvent
Silane application may be followed by a warming phase to maximize its effect
Adhesive Bonding
Light-curing resin bonding agent is applied to the inner surface of the artifact
The adhesive is applied thinly and left to settle for 30 seconds before being
blown with an air jet
Only light-curing cement is recommended for glass-ceramic restorations,
especially when applied thinly
Conclusions
There are great changes taking place in dentistry. In-
creasingly, people are demanding aesthetic restorations
in teeth that they have retained, often well into old age.
There is also growing suspicion of silver amalgam as
a restorative, which though based on slender scientific

References
[1] Anusavice KJ. Skinner’s science of dental materials, W.B. Saun-
ders Co, Philadelphia, Pennsylvania, USA, 1996.
[2] Pitt Ford TR. The restoration of teeth, Blackwell Scientific, Ox-
ford, 1985.
[3] Nicholson JW. Educ. Chem. 1994;31:12.
[4] Rowe AH. (Ed), A comprehensive guide to clinical dentistry, vol 3,
Class, London, 1989.
[5] Pashley D. Scanning Microscopy 1989;3:161.
[6] Mjor I. in Dentine and Dentine Reactions in the Oral Cavity, (Ed.
A. Thylstrup, S.A. Leach, and V. Qvist), IRL Press, Oxford, 1987,
pp. 27—31.
[7] Stanley HR, Going RE, Chauncey HH. J. Am. Dent. Assoc.
1975;91:817.
[8] Brannstrom M, Nordenvall KJ. J. Dent. Res. 1977;56:917.
[9] Gwinnett AJ. J. Dent. Res. 1977;56:1155.
[10] Bowen RL, Cobb EN, Setz LE. Dentistry 1982;82:11.
[11] Bowen RL. Int. Dent. J. 1978;28:97.
[12] Nordenvall KJ, Brannstromm M. J. Prosthet. Dent. 1980;44:630.
[13] Douglas WH. J. Dent. 1989;17:209.
[14] Tao L, Pashley DH. Dent. Mater. 1988;4:371.
[15] Davidson CL, Abdulla AI, de Gee AJ. Oral Rehabil. 1993;20:291.
[16] Bowen RL. Int. Dent. J. 1985;35:155.
[17] Ali SAM, Williams DF. Clin. Mater. 1993;14:243.
[18] Buonocore MG. J. Dent. Res. 1955;34:849.
[19] Busscher HJ, Retief DH, Arends J. Dent. Mater. 1987;3:60.
[20] Smith DC. Brit. Dent. J. 1968;125:381.
[21] Greenwood NN. and Earnshaw A. The Chemistry of the Ele-
ments, Pergamon Press, Oxford, 1984.
[22] Paddon JM, Wilson AD. J. Dent. 1976;4:183.
[23] Hill RG, Labok SA. J. Mater. Sci. 1991;26:67.
[24] Akinmade AO, Hill RG. Biomaterials 1992;13:931.
[25] Akinmade AO, Nicholson JW. Biomaterials 1995;16:149.
[26] Mizrahi E, Smith DC. Brit. Dent. J. 1969;127:410.
[27] Wilson AD, Kent BE, Clinton D, Miller RP. J. Mat. Science
1972;7:220.
[28] Wilson AD, McLean JW. Glass Ionomer Cement, Quintessence
Publishers, Chicago, 1988.
[29] Wilson AD, Crisp S, Ferner AJ. J. Dent. Res. 1976;55:489.
[30] Crisp S, Ferner AJ, Lewis BG, Wilson AD. J. Dent. 1975;3:125.
[31] McLean JW, Wilson AD. Brit. Dent. J. 1974;136:269.
[32] McLean JW, Wilson AD. Aust. Dent. J. 1977;22:31.
[33] McLean JW, Wilson AD. Aust. Dent. J. 1977;22:120.
[34] McLean JW, Wilson AD. Aust. Dent. J. 1977;22:190.
[35] McLean JW. Quintessence International 1987;18:517.
[36] Mount GJ. Atlas of Glass—Ionomer Cements, Second edition,
Martin Dunitz, London, 1994.
[37] Billington RW, Williams JA. J. Oral Rehabil. 1991;18:163.
236 JW. Nicholson / International Journal of Adhesion & Adhesives 18 (1998) 229
—236
[38] Reich E, Volkl H. J. Dent. Res. (Special Issue), 1994, 73, Abstract
1394.
[39] Tyas MJ, Beech DR. Aust. Dent. J. 1985;30:260.
[40] McLean JW, Nicholson JW, Wilson AD. Quintessence Interna-
tional 1994;25:587.
[41] Antonucci JM, McKinney JE, Stansbury RW. US Pat Appl.
160856, 1988.
[42] Mitra SB. Eur Pat Appl., 0 323 120 A2, 1989.
[43] Mitra SB. J. Dent. Res. 1991;70:72.
[44] Cortes O, Garci-Godoy F, Boj JR. Am. J. Dent. 1993;6:299.
[45] Mitra SB. J. Dent. Res. 1991;70:75.
[46] Forss H. J. Dent. Res. 1993;72:1257.
[47] Nicholson JW, Anstice HM, McLean JW. Brit. Dent. J.
1992;173:98.
[48] Anstice HM, Nicholson JW. J. Mater. Sci.; Mater. in Med.
1992;3:447.
[49] Croll TP. Dental Clin. N. Am. 1995;39:737.
[50] Smith BGN, Wright PS, Brown D. Clinical Handling of Mater-
ials, 2nd edition, Butterworth-Heinemann, Oxford, 1994.
[51] McCabe JF. Applied Dental Materials, 7th edition, Blackwells,
Oxford, 1992.
[52] McCabe JF. Brit. Dent. J. 1984;157:440.
[53] Anstice HM. Chem. & Ind., 1994, 899.
[54] Davidson CL, de Gee AJ, Feilzer AJ. J. Dent. Res. 1984;63:1396.
[55] Legler LR, Retief DH, Bradley EL, Denys FR, Sadowsky PL.
Amer. J. Orthodont. & Dentofacial Orthopedics 1989;96:485.
[56] Nakabayashi N, Kojima K, Masuhara ET. J. Biomed. Mater. Res.
1982;16:265.
[57] Pashley DH. Trans. Acad. Dent. Mater. 1990;3:55.
[58] Walshaw PR, McComb DM. J. Dent. 1995;23:281.
[59] Nakabayashi N, Ashizawa M, Nakamura M. Quintessence Inter-
national 1992;23:135.
[60] Wang T, Nakabayashi N. J. Dent. Res. 1991;70:59.
[61] Hagger O. Swiss patent 278946, 1951.
[62] Kramer IRH, McLean JW. Brit. Dent. J. 1952;93:291.
[63] Buonocore MG, Wileman W, Brudevold F. J. Dent. Res.
1956;35:849.
[64] Nicholson JW, Singh GS. Biomaterials 1997;17:2023.
[65] Fusayama T, Nakamura M, Kurosaki N, Iwaku M. J. Dent. Res.
1979;58:1364.
[66] Nakabayashi N. Int. Dent. J. 1985;35:145.
[67] Stanford JW, Sabri Z, Jose S. Int. Dent. J. 1985;35:139.
[68] Asmussen E, Munksgaard EC. Int. Dent. J. 1988;38:97.
[69] DeTrey Dentsply Company, Technical brochure for Dyract,
1993.
[70] Ivoclar Company, Technical brochure for Compoglass, 1995.
[71] Millar BJ, Abiden F, Nicholson JW. J. Dent. 1998; 26:133.
[72] Pospiech P, Rammelsberg P, Tichy H, Gernet W. Journal of
Dental Research, 1995, 74, 475, Abstract 600.
[73] Preston AJ and Mair LH. Journal of Dental Research, 1996, 75,
1177, Abstract 368.
[74] Jones DW. Brit. Dent. J. 1994;177:159