M Braem

A Critical Review of the Durability of Adhesion to Tooth Tissue: Methods and Results

The immediate bonding effectiveness of contemporary adhesives is quite favorable, regardless of the approach used. In the long term, the bonding effectiveness of some adhesives drops dramatically, whereas the bond strengths of other adhesives are more stable. This review examines the fundamental processes that cause the adhesion of biomaterials to enamel and dentin to degrade with time. Non-carious class V clinical trials remain the ultimate test method for the assessment of bonding effectiveness, but in addition to being high-cost, they are time- and labor-consuming, and they provide little information on the true cause of clinical failure. Therefore, several laboratory protocols were developed to predict bond durability. This paper critically appraises methodologies that focus on chemical degradation patterns of hydrolysis and elution of interface components, as well as mechanically oriented test set-ups, such as fatigue and fracture toughness measurements. A correlation of in vitro and in vivo data revealed that, currently, the most validated method to assess adhesion durability involves aging of micro-specimens of biomaterials bonded to either enamel or dentin. After about 3 months, all classes of adhesives exhibited mechanical and morphological evidence of degradation that resembles in vivo aging effects. A comparison of contemporary adhesives revealed that the three-step etch-and-rinse adhesives remain the ‘gold standard’ in terms of durability. Any kind of simplification in the clinical application procedure results in loss of bonding effectiveness. Only the two-step self-etch adhesives approach the gold standard and do have some additional clinical benefits.

Morphological Aspects of the Resin-Dentin Interdiffusion Zone with Different Dentin Adhesive Systems

Cross-sections of resin-dentin interfaces were etched with an argon-ion beam to make their substructure detectable by scanning electron microscopy. The dentin adhesive systems were categorized morphologically into three groups, and an attempt was made to clarify their adhesive mechanism. The first group of products removed the smear layer. The argon-ion bombardment clearly disclosed a hybrid or resin-impregnated dentin layer. It is hypothesized that conditioning with acidic or chelating agents demineralized the dentin surface-layer to a certain depth, leaving behind a collagen-rich mesh-work. Hydrophilic monomers are then believed to alter this collagen-fiber arrangement in a way that facilitates penetration of the adhesive resin, resulting in a mechanical, intermingled link between collagen and the adhesive resin. The second group preserved the smear layer. In this case, the dentinal tubules were obliterated with globular particles at their orifices and remained patent underneath these smear plugs. This type of adhesive system aims at the incorporation of the smear layer into the hydrophilic monomers, which have an affinity for the organic and/or inorganic components of the underlying dentin. Finally, a third, small group only partly dissolved the smear layer, creating a thin resin-impregnated dentin layer and a resin-impregnated smear plug. This study clearly showed that the application of recent adhesive systems induced structural changes in the dentin surface morphology, creating a retentive interface, called the interdiffusion zone, between the deep, untouched dentin layers and the composite filling material. This resin-dentin interdiffusion zone offers bonding sites for copolymerization with the resin composite and, concurrently, might have protective potential for the pulp tissues.

A classification of dental composites according to their morphological and mechanical characteristics

The on-going search for a biologically acceptable restorative material has brought a confusing variety of composites on the dental market. In the present study, commercially available composites are categorized as a function of their mean particle size, filler distribution, filler content, Youngs modulus, surface roughness, compressive strength, surface hardness, and filler morphology. Out of this information, it can be concluded that the materials of choice for restoring posterior cavities at present are the Ultrafine Compact-Filled Composites because their intrinsic surface roughness, Youngs modulus and, indirectly, their filler content, compressive strength, and surface hardness are comparable to the same properties of enamel and dentin. The Ultrafine Midway-Filled Composites seem to be very satisfactory materials for anterior use.

Comparative SEM and TEM Examination of the Ultrastructure of the Resin-Dentin Interdiffusion Zone

The resin-dentin interdiffusion zone produced by a dentin-adhesive system that removes the smear layer and concurrently decalcifies superficial dentin was morphologically examined by both scanning and transmission electron microscopy. Cross-sectioned resin-bonded dentin discs were etched with an argon-ion beam to make the resin-dentin interface observable by SEM. For the TEM examination, the sections were partly decalcified by an aqueous EDTA solution to facilitate ultramicrotomy and to disclose the ultrastructure of the interdiffusion zone. Both SEM and TEM confirmed the presence of the resin-dentin interdiffusion zone as the junction between the deep unaltered dentin structure and the restorative resin. Within the interdiffusion zone, three sublayers with characteristic ultrastructure and staining were identified by TEM. An upper diffuse black layer contained few structural features. Underneath, partially-altered collagen fibrils were closely packed, mostly running parallel with the interface and perpendicular to the dentinal tubules. Their outline was electron-dense, forming tunnel-like structures. At the base of the upper layer, several stained projections were found to bulge out into the underlying collagen network and appeared to be confined by obstructive, parallel-running collagen fibrils. Finally, the third dense layer, containing hydroxyapatite crystals, demarcated the superficially demineralized dentin layer from the deeper unaltered dentin. Resin diffusion into the decalcified dentin surface layer was evident, but diminished with depth, presumably reducing deeper resin impregnation into the interfibrillar spaces. The citric acid dentin-pretreatment probably caused denaturation of the superficial collagen fibrils. Its decalcifying effect gradually weakened with depth, leaving behind hydroxyapatite crystals at the base of the interdiffusion zone. These crystals appeared to have been resistant to the EDTA TEM-sample decalcification procedure, which suggests that they were protected by resin encapsulation.

Comparative Physico-mechanical Characterization of New Hybrid Restorative Materials with Conventional Glass-ionomer and Resin Composite Restorative Materials

The recently developed hybrid restorative materials contain the essential components of conventional glass ionomers and light-cured resins. The objective of this study was to determine several physical and mechanical properties of eight such materials in comparison with two conventional glass ionomers, one micro-filled, and one ultrafine compact-filled resin composite. The two resin composites and two of the three polyacid-modified resin composites could be polished to a higher gloss than the conventional as well as the resin-modified glass ionomers. After abrasion, surface roughness increased for all materials, but not at the same extent, being the least for the conventional resin composites and one polyacid-modified resin composite, Dyract. In contrast to the latter resin composites, of which the surface roughness is principally determined by the presence of protruding filler particles above the resin matrix, roughness of conventional and resin-modified glass ionomers results from both protruding filler particles and intruding porosities. The mean particle size of the hybrid restorative materials fell between the smaller mean particle size of the resin composites and the larger one of the conventional glass ionomers. The micro-hardness and Youngs modulus values varied substantially among all eight hybrid restorative materials. For all the resin-modified glass-ionomer restorative materials, the Youngs modulus reached a maximum value one month after mixing and remained relatively stable thereafter. The Youngs modulus of the conventional and the polyacid-modified resin composites decreased slightly after one month. The conventional glass-ionomer materials undoubtedly set the slowest, since their Youngs modulus took six months to reach its maximum. The flexural fatigue limit of the hybrid restorative materials is comparable with that of the micro-filled composite. From this investigation, it can be concluded that the physico-mechanical properties vary widely among the eight hybrid restorative materials, indicating that these materials probably have yet to achieve their optimum properties. Their mechanical strength is inadequate for use in stress-bearing areas, and their appearance keeps them from use where esthetics is a primary concern.

Quantitative in vivo Wear of Human Enamel

In this study, the attrition wear, also called occlusal-contact-area wear, of human enamel was measured quantitatively with a computerized three-dimensional measuring technique over a period of four years. Tooth replicas from a clinical trial were used. A running-in wearperiod after restorative treatment, followed by steady-state wear, was suggested. The average steady-wear rate on occlusal contact areas was about 29 μm per year for molars and about 15 μm per year for premolars.

Mechanical properties and filler fraction of dental composites

Several mechanical properties of experimental composites and an unfilled resin were studied. The dynamic Youngs modulus was measured with a non-destructive dynamic method. The Youngs modulus and also the transverse strength were determined statically by means of three-point bending. The hardness was studied by means of Wallace indentation depth measurements, and in vitro wear resistance was assessed under stress-bearing conditions. An exponential regression of the results measured for each property as a function of the volumetric filler fraction was appraised. An excellent correlation was found with each property. This exponential mixture rule is proposed for the study of the mechanical properties of isotropic dental composites.

Clinical Status of Ten Dentin Adhesive Systems

Laboratory testing of dentin adhesive systems still requires corroboration by long-term clinical trials for their ultimate clinical effectiveness to be validated. The objective of this clinical investigation was to evaluate, retrospectively, the clinical effectiveness of earlier-investigated dentin adhesive systems (Scotchbond, Gluma, Clearf il New Bond, Scotchbond 2, Tenure, and Tripton), and to compare their clinical results with those obtained with four modern total-etch adhesive systems (Bayer exp. 1 and 2, Clearfil Liner Bond System, and Scotchbond Multi-Purpose). In total, 1177 Class V cervical lesions in the teeth of 346 patients were restored following two cavity designs: In Group A, enamel was neither beveled nor intentionally etched, as per ADA guidelines; in Group B, adjacent enamel was beveled and conditioned. Clinical retention rates definitely indicated the improved clinical efficacy of the newest dentin adhesives over the earlier systems. With regard to adhesion strategy, adhesive systems that removed the smear layer and concurrently demineralized the dentin surface layer performed clinically better than systems that modified the disorderly layer of smear debris without complete removal. Hybridization by resin interdiffusion into the exposed dentinal collagen layer, combined with attachment of resin tags into the opened dentin tubules, appeared to be essential for reliable dentin bonding but might be insufficient by itself. The additional formation of an elastic bonding area as a polymerization shrinkage absorber and the use of a microfine restorative composite apparently guaranteed an efficient clinical result. The perfect one-year retention recorded for Clearfil Liner Bond System and Scotchbond Multi-Purpose must be confirmed at later recalls.

The Impact of Composite Structure on Its Elastic Response

The non-destructive determination of Youngs modulus of dental composites by means of the fundamental period was found to be reliable and accurate. Post-polymerization effects could clearly be detected. Exponential regression analysis showed a correlation coefficient of 0.92, after logarithmic transformation, with volumetric filler content. The high accuracy and reliability of the measurements themselves are reflected in low standard deviations. The results are in excellent agreement with those of other investigations. Furthermore, the ease and speed of operation make this new procedure a powerful laboratory tool for material-testing and practical large-scale investigations.

Morphological characterization of the interface between resin and sclerotic dentine

Since dentine exposed to the oral environment undergoes important compositional and morphological transformations, bonding to it differs significantly from bonding to unaffected normal dentine. In this investigation, the interface between resin and sclerotic dentine, the dentine type clinically exhibited by cervical abrasive or erosive lesions, was morphologically characterized by scanning electron microscopy after an argon-ion-beam etching procedure. The microstructure of the resin-sclerotic dentine interface was compared with that produced to normal unaffected dentine in an attempt to find reasons for the reported less reliable bonding of adhesive resins to sclerotic dentine. A resin-dentine interdiffusion zone or hybrid layer with only a limited width was formed at the hypermineralized intertubular dentine. No or only short resin tags were developed in most dentinal tubules, since their orifices were obliterated due to increased peritubular dentine apposition, intratubular deposition of irregular minerals and formation of so-called sclerotic casts. Consequently, it is reasonable to predict that dentine adhesives with an adhesion strategy, which mainly involves micromechanical interlocking by the formations of a resin-dentine interdiffusion zone combined with resin-tag development into the dentinal tubules, will be less effective when applied to sclerotic dentine than to unaffected normal dentine. An adapted adhesive treatment may be necessary to make sclerotic dentine more receptive to bonding. Further research should be directed to develop adhesive systems that bond equally well to various kinds of dentine.