DENTAL MATERIAL II

Principles of bonding and adhesives in dentistry

DONE BY: EYAD MASSALHA

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What is adhesion? The force that binds two dissimilar materials together when they are brought into intimate contact. In dentistry, bonding refers to the process of attaching a restorative material to tooth structure (enamel and dentine) by adhesion. Basic principles in the bonding process Surface preparation to remove plaque & debris, we need some sorts of preparation to the tooth surface to make bonding process, and the surface of the cavity should be clean from any remnant of tooth structure. Some principle preparation should be done to remove any plaque and debris any contaminant on the surface. Acid etching with phosphoric acid IN CASE OF COMPOSITE, to remove mineral of the tooth structure, create porosity, enhance wettability. Wettability should be good enough to ensure good results. It will cover a larger surface area between the surface and the filling, we will have better bonding force. Wettability is the ability of a liquid to maintain contact with a solid surface, resulting from intermolecular interactions when the two are brought together. The degree of wettability is determined by a force balance between adhesive and cohesive forces. Phosphoric acid will create pores and roughness of the surface and increase the wettability, so anything you place on the top it, will flow much better. After that when the bonding agent is on the surface, the composite will stick with it with the tooth structure. Bonding agent applied and flows to fill the porosities and create resin tags (micromechanical retention). We dont need the material to be too viscose otherwise it will not flow well, and the morphology of the tooth structure is important, a rough surface provide better adhesion than the smooth surface. THE ROUGHNESS CREATED BY PHOSPHORIC ACID. Will remove part of the minerals in the enamel and dentin and also it will remove part of the mineral in the dentinal tubules open them create the micro-pores. Without the roughness there will be no good bonding. Resin applied and bonds chemically to underlying bonding agent (primary bonding).

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Adhesion For proper adhesion to occur, intimate contact between the adhesive and the substrate is needed. This intimate contact is affected by: Wettability of the substrate surface, should be good enough The viscosity of adhesive should be low viscosity to flow and cover much surface as possible. The morphology or surface roughness, as you know a rough surface provide better adhesion. Factors affecting adhesion This factors affecting the bonding between the restorative material and the tooth structure. We need to look about factors related to the tooth structure and the adhesive material itself (combination of factors) to make a bonding process. Wettability and surface energy Surface energy: the attraction of atoms to a surface (directed inward). In liquids, it is called surface tension. So its related to surface tension of the liquid (adhesive) and surface energy of the solid (tooth structure), when apply acid etching will modify the surface energy (enamel and dentin) making them good wetted. For good results, should be high surface energy and low surface tension. When the wettability is boor, the liquid form droplet and high contact angel. But when the wettability is good, the liquid flows better and able to wet the surface more and low contact angel. Viscosity of bonding agent Interpenetration (formation of hybrid zone), how the bonding agent penetrate inside the tooth structure. Micromechanical interlocking Chemical bonding

Clinical application ISOLATIN, ETCHING, BONDING. After a cavity preparation we need good isolation to the tooth from a surrounding environment like blood, saliva and any contamination. Following by etching to enhance the cavity surface by acidic material.

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Isolation Isolation done by cotton rows, rubber dam and retraction cord which will push the gingiva away, control bleeding and it will make the model visible to the dentist.

Enamel etching Introduced by Michael Buonocore in 1950s. Etching time 10 - 30 seconds (around 15 seconds), to be more exact 15 30 sec, and more time needed for enamel than dentine because is fully mineralized (96% minerals). Primary teeth and fluoride treated teeth require more time, because the enamel of the primary teeth isnt regular structure. Fluoride is acidic resistance material make the enamel stronger, so need more time for etching around 1 min. To know if the patient receives a fluoride treatment, simply ask him by taking a history. Etched enamel looks frosty white when dried, chalky color. Etching produces a rough surface (pits) into which resin flows and forms resin tags (micromechanical retention), after the enamel is etch we applied the bonding agent and it will flow to the micro pores and create resin tag. Then need the application of the light curing making the resin lock into the teeth structure. Inter lock with enamel provide micromechanical retention. Resin tags may penetrate to a depth of 10 - 20 microns in etched enamel. The depth of penetration depends on: Etching time Rinsing time, should be very well and clean from any remnant of the acidic material, if not cleaned, the acid will block the micro pores and prevent the bonding agent to take place. Rinsing by clean water without saliva then dry it. Saliva contains bacteria and debris will block the pores. These two factors determine how effective etching was, and how well debris was removed from enamel surface.

Without etching, bonding is weakened and this leads to microleakage. 4|Page

In amalgam corrosion products may seal any spaces between cavity and restoration, some elements of corrosion products can accumulate between the tooth structure and amalgam and close the gap, prevent the microleakage to occur. Corrosion means part of the amalgam will start to break down or dissolve. In GIC the release of fluoride provides protection, and also the GIC bind to the tooth structure chemically so no gap between the tooth and GIC and no microleakage. But in composite, good bonding is essential, while the composite sitting, shrinkage will occur then microleakage, so good bonding is very important for composite. Liquid or gel (the gel is made by adding colloidal silica to the acid) phosphoric acid 30 - 50% (usually 37%). How did they come up with this percentage? they tried different percentages, they examined the bond strength of the material with the enamel & dentine, and see which is better, which one gives you the better bond strength. Procedure Acid etch is applied using a brush or, if acid is supplied in disposable syringes, the acid maybe applied directly out of the syringe tip. The acid etching, blue or green in color, a gel is provided, a liquid also can be available, but the gel is better because it will not flow everywhere and it's easier to control it. Etchant is applied for 15 seconds, or longer as mentioned previously. Rinsing is done with water for 20 seconds then dried well, to ensure that you have removed all the acid. We use the water to rinse, but also we need to use some force to make sure that the surface is clean so we use water with air. It should have a frosty white appearance. Enamel should be kept clean and contaminant frees (saliva, blood, etc). If contamination occurs enamel should be re-etched for 10 seconds.

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Enamel bonding In the past, etching and bonding involved only enamel. Currently, total etch technique is done, and bonding agents are applied to both enamel and dentine. Today bonding agents are applied to both enamel and dentine so will provide a strong bonding with the restorative material. Bonding agents used for enamel bonding were made from resin combined with diluents to lower viscosity, (Bis-GMA & TEGDMA). The lower viscosity to ensure flow the material very well. Dentine etching and bonding What makes dentine a challenge when it comes to adhesive bonding? Dentine is a living tissue (50% Hydroxylapatite, 30% collagen, 20% fluid). Tubular nature of dentine (dentinal fluid). Branching patterns in tubules, may enhance retention, the tubules form a pathway to the pulp. Smear layer presence. Possible side effects on the pulp. Dentin is different from enamel, and it contains minerals, collagen, dentinal tubules, fluids, nerves extended into the pulp. So you need to be careful when you etch it or deal with it, and need special treatment. 1979 etching was done for dentine as well as enamel using 37% phosphoric acid. Research proved enhanced bonding (total etch technique). Total etch technique mean, the etching include both enamel and dentine. Over etching will remove more mineral than needed and open up tubules, and expose more collagen, making dentine more difficult to coat with bonding agent. Over etching dentine leads to weaker bond and sensitivity. When we come to etch the dentine, we should avoid over etching time, because we will remove more minerals and open the tubules more and more lead to irritation to tubular fluid by action of the acid, then will stimulate the nerve ending and cause sensitivity to the pulp and pain. So dont etch the dentine more than 15 sec.

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Over drying should be avoided to prevent collapse of collagen and occluding tubules. Making dentine more difficult to coat with bonding agent. To prevent over drying, after we finishing from etching, clean the surface then dehydrate it from any excess of water, then take small cotton put water on it and place it on the cavity surface to prevent collagen collapse. Over etching and over drying will weaken the bond and cause sensitivity to the patient. Another study showed how resin tags from bonding agents in dentine infiltrated a surface layer of collagen in demineralized dentine to form the HYBRID LAYER. This layer as intermediate layer thats bond composite to enamel and dentine. The hybrid layer should be covering all cavity surfaces to ensure a good bonding. So the hybrid layer attached to composite at one end and the tooth structure at another end. Its sticks to the tooth micromechanically and the composite attached to the hybrid layer chemically since both of them are made of resin. Bonding agents Several years ago, it was believed that bonding to dentine can be achieved by chemical bonding between resin and either collagen or mineral content of dentine. Molecules designed for these purposes had the following presentation MRX. M is a methacrylate group (hydrophobic and can attach itself to the resin). R is a spacer such as hydrocarbon chain (ensure mobility of M group when X is immobilized). X is a functional group that can bond to calcium in hydroxyapatite (usually an acidic group) which is hydrophilic. Earlier bonding agents based on silane coupling agents, as in composite we talked about something we called filler and matrix, it's called silane coupling agents, it has hydrophilic end that capture the filler and hydrophobic end that capture the resin matrix and we called it to the resin. Same thing in composite applied to bonding agents, so we want something to have an end or representation by X for example that will capture mineral content from hydroxyapatite and another end or another type of molecule that hold on collagen or organic component in dentine, so it can place both on enamel and dentine hold on to them then composite can be added and it can be chemically added.

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Generations of bonding agents First generation (1950s): based on silane coupling agent model. Based on M-R-X model, success rate was low, due to high polymerization shrinkage and high CTE in unfilled resins used in those times. The CTE should be similar to enamel and dentine to prevent shrinkage or expand the material. The first generation is not good because this material shrink a lot when polymerize, high rate of CTE, so contraction and expansion is in high rate and the bonding is not good. Second generation (late 60s early 70s): similar concept to first generation agents low success rate. Attempts were made to deal with the smear layer Third generation agents: same as the previous generation, however attempts were made to modify or remove the smear layer. The smear layer is a layer of microcrystalline and organic particle debris that is found spread on root canal walls and the cavity surfaces after root canal instrumentation or cavity preparation. It is weakly bonded to dentine and if we use acid etching properly will be removed. Consist of: Dentine particles. Bacteria. Salivary constituents. We said the hybrid layer is good layer, it's made from bonding agent that attach to enamel and dentine and composite together, another layer is smear layer, it can flow up dentinal tubule and prevent good bonding, so smear layer is not good and hybrid layer is good, that's why when place the phosphoric acid, it is attendance to remove smear layer, open up dentinal tubule and clean the surface, so we want to clear smear layer. Before, they did not try to remove smear layer so the bonding was not good, now in second generation bonding agent they attempt to deal with smear layer and try to remove it. Procedure in 3rdgeneration, similar to previous generation, but tries to remove smear layer and modify it. Application of dentine conditioner (HEMA, or 2% nitric acid, or maleic acid) Application of primer (dentine bonding agent based on MRX), the primer like a bridge bond to tooth structure and to bonding agent. Application of adhesive (unfilled resin) Placement of resin composite

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So firstly generations were similar, bonding agent was not good enough, and they started improving the bonding between enamel and dentine and composite during fourth generation. Fourth generation procedure Total etch technique for enamel and dentine. Rinsing with water follows, then gentle drying without desiccating dentine to prevent collapse of collagen fibers. Rinse to remove etchant and demineralized debris. Dry to ensure enamel is etched. Slightly moisten dentine. Absorb excess water with cotton. Apply hydrophilic primer (contains resin that polymerizes within collagen and a solvent that evaporates to ensure drying of tooth surface). Apply adhesive (bonding resin) then cure. Composite applied and cured. As you see here we have extra step which is the primer, by this will make longer time to work, more chance for errors to occur and more chance for contamination. During fourth generation we start using what we talk about it last time the total etch technique for enamel and dentine, in previous application, they only want to make etching for enamel and this will not provide good bonding between a tooth and composite. Now they apply a material called the primer then followed by bonding agent and then composite, now the primer is hydrophilic, it can be flow over a surface and in the same time it has hydrophobic end that capture a bonding agent, nowadays we use only one bottle so we don't use a primer and bonding agent, the primer is added to bonding agent in one bottle.

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Fifth generation agents: fewer steps, better results. Rely on micromechanical retention involving: Penetration into partially opened dentinal tubules. Formation of hybrid layer (hydrophilic monomer penetrate and polymerize to form interpenetrating network with collagen fibrils. In fifth generation, fewer steps so better result because there is little chance of errors. They used similar material as in fourth generation but the primer was added to bonding agent in one bottle so they removed one step. So they tried to penetrate dentinal tubule, hybrid layer will be formed and potential was improving. Fifth generation bonding agents: Etching is achieved using phosphoric acid. Priming and bonding is combined in one step. Self etching primers, primer is added or incorporated with acid etching. Acidic groups are added to etch tooth surface. No need for rinsing and drying. May not be effective on unprepared enamel. Self priming adhesive: most commonly used now. Sometimes the primer is added or incorporated with acid etching, so it's another way for fewer steps, so again for fewer steps primer will be incorporated either in adhesive or with phosphoric acid. When the primer is added to acid and we applied it to the surface, there is no need for rinsing, so this is for example one advantage of self etching primer so we don't need for rinsing and drying, and there will be less dangerous of drying or over drying the tubule.

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Microleakage Occurs when the restoration does not completely seal the surrounding margins of the cavity preparation. Because of polymerization, shrinkage of the composite make it a serious problem. Possible outcomes of microleakage? Staining, sensitivity, and recurrent. What contributes to microleakage? If you don't cure bonding agent properly, or don't provide isolation from contamination and saliva during acid etching.

This picture about microleakage, They have the tooth, they present the composite properly in one side, and they also present composite to other side but there was contamination, they contaminate the tooth during procedure and then place it in solution contain dye to see if the dye can penetrate between the tooth and filling. And then they look it under microscope, they noticed in side that there was no contamination the composite dens properly, there was no dye around it, no microleakage, and where the filling was not made it properly for example the composite not cure properly, there will be penetration of dye, can you see the black area around composite, so there will be microleakage around filling and you may see bacteria and saliva around it, It's very common to see a black line around composite filling, and this represent staining due to microleakage. 11 | P a g e

Factors that prevent good bonding

ZOE remnants factor, because of the eugenol prevent proper setting of composite, if we have remnants from temporary filling, and we don't remove it or clean the surface properly, it will prevent good setting of composite and lead to microleakage. The most important factor is: moisture control Follow the instruction with regard to the time that should cure both bonding agent and composite. If we follow these steps with regard to acid etching, drying, bonding agent curing, composite layering, incremental and curing, you will minimize the chance of microleakage and minimize shrinkage.

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Measurements of bond strength Tests used: Shear bond strength Tensile bond strength Data were variable due to variability of tooth surface, and different testing methods Microtensile and microshear bond strength less variability. Either shear strength or microshear strength or tensile strength is applied to know the bond strength between composite or glass inomer cement and tooth surface. Tensile strength is stress that stretches the material, shear mean sliding the material from each other. So they use force to try and separate composite from tooth structure and to measure amount of force that need to separate them, the higher the force the better bonding strength. Amalgam bonding Older amalgam restorations leak less due to corrosion products. We try to use a bonding agent between amalgam and tooth structure to minimize microleakage, but this way is not acceptable because it will not make different. It is not commonly used because it will take a lot of time. Technique: Cavity preparation then isolation. Etching of enamel and dentine to remove smear layer. Primer applied and cured. Self-cure bonding resin applied then amalgam is applied. Clinical applications of bonding Porcelain bonding and repair involves: Sandblasting Special etchant (hydrofluoric acid) Silane applied for 30 seconds then dried to evaporate solvent (leaving a layer of vinyl that bonds resin to adhesive) Bonding agent applied Composite applied

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Crown and bridge which is made of porcelain, sometimes a small piece of it can be fracture because it's brittle material, now when small piece of it fracture, you don't have to replace the whole crown because it is very expensive, one way to solve this problem is repairing it by composite and correct the defect. Underneath porcelain there is a metal, so if part of porcelain is broken, the metal will be shown that's not esthetic, so to solve this problem you can use composite, so you need to use slightly different material, you need to etch the metal and remnants part of porcelain, but acid that we used here is different, it's not phosphoric acid, in case of porcelain repair they used hydrofluoric acid. Pit and fissure sealants Success depends on good wetting, intimate contact through etching which will also ensure longevity of the sealant. PRR: minimal cavity preparation, resin composite placement, sealant placement on top. Filled and unfilled resins, resin based pit and fissure sealant, it has good strength and very successful, it's very strong material so it can handle occlucal force. GIC Some of pit and fissure based on GIC, and some of them based on resin, similar to composite resin but a little amount of filler in order to be able to flow. PRR (preventive resin restoration) we need to use hand piece to open pit and fissure making very shallow cavity 1mm, then it filled with composite, on composite we can applied pit and fissure sealant. If you think the pit and fissure is not cleaned, or might have caries, so you can open it with hand piece, then filled with resin, and in the top we put the pit and fissure sealant, this procedure is called PRR.

Glass 12345-

ionomer cements bonding Cavity preparation. Conditioner, made from polyacrylic acid. Rinse and dry. GIC is placed. Varnish on top of GIC.

DONE BY: EYAD MASSALHA

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