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The Current State of Adhesive Dentistry:

A Guide for Ciinicai Practice
FRANCIS K. MANÎÊ, DM0, PHD; FUSUN OZER, DDS, PHD; RICARDO WALTER, DDS, MSC; ALAN M. ATLAS, DMD; NAJEED SALEH, DMD;
DIDIER DiETSCHI, DMD, PHD; AND MARKUS ß. BUTZ, DMD, PHD

Abstract Learning Objectives

Adhesive cJerntistry is key to minimally invasive, esthetic, and tooth- After reading this article, the readers
preserving dental restorations. These are typically realized by bonding should be able to:
variocjs restorative materials, such as composite resins, ceramics, or
» Discuss the use of composite resins for direct
even metal alloys, to tooth structures or other materials with composite
restorations.
resin luting agents. For optimal bond strengths and long-lasting ciinicai
» Explain the nature of the adhesive resin bond
success, however, these materiai and tooth substrates require their
to dental materials.
respective pretreatment steps, based on their natures and compositions.
» Describe the most common clinical problems
Today, dental adhesion is used in almost all dental specialties. This article
with bonded indirect posterior restorations.
summarizes key aspects and guidelines for clinical success with adhesive
dentistry and summarizes information presented at the 5"" International
Congress on Adhesive Dentistry.

Introduced to restorative dentistry in the mid igsos,' adhesion by matrix metalloproteinase (MMPs), which has been
to tooth structures and particularly dentin has evoived the recent focus of extensive research.'' Application of
significaritly in recent decades. Yet, the complexity of the chlorhexidine, benzalkonium chloride, or the antibacterial
dentin substrate continues to challenge researchers in the monomer methacryloyloxydodecylpyridinium bromide to
development of the ideal dental adhesive systenn. One prevent such degradation has not proven effective in the
significant milestone was the introduction of the total-etch long term. [Meanwhile, self-etch adhesives seem not to be
technique in the late 1970s.^ Despite initial concerns about affected by MMPs to the same extent, which may be due
potential damage of puipal tissues by phosphoric acid, this to the fact that collagen is exposed to a lesser depth and is
technique is still used today. better infiltrated by the adhesive system. Self-etch adhe-
Current adhesive systems are divided into two main sives, particularly two-step systems, have shown excellent
categories: etch-and-rinse (total-etch) and self-etch (etch- bonding performance to dentin through implementation
and-dry). Etch-and-rinse systems comprise two or three of functional monomers such as 10-methacryloyloxydecyl
steps and typically involve the use of phosphoric acid dihydrogen phosphate (MDP), which provides some
pretreatment of the dentin with subsequent infiltration of chemical adhesion to hydroxyapatite. Without the use
the demineralized coiiagen to form a hybrid layer.^ Self- of phosphoric acid, however, the bond—especially to
etch systems are one- or two-step solutions of different pH uncut enamel—may be compromised.' Therefore, self-
levels that interact with the tooth structures via functional etch adhesives are recommended particularly for cavities
monomers.'' Nakabayashi et aP introduced the hybrid layer predominantly in dentin, while etch-and-rinse systems
concept in 1982: its formation and quality is key in the are preferred for indirect restorations and cavities that
establishment of proper adhesion. are mostly in enamel.^
Both concepts have advantages and disadvantages in The performance of bonding agents in the laboratory
different ciinicai situations. Phosphoric acid with etch- and even in controlled clinical trials may not necessarily
and-rinse adhesives not only removes the layer of debris translate to the clinical situation in the dental office. One
from tooth preparation (smear layer) but also opens the influencing factor is operator experience and familiarity
dentinal tubules and exposes the underlying collagen with a specific adhesive system.**'^ Recent multimode (uni-
mesh. Exposed dentinal tubules are sealed by the adhesive versal) adhesive systems may help minimize this problem
resin. However, neither acetone nor ethanoi—vehicles in as they can be used in both etch-and-rinse and self-etch
etch-and-rinse adhesive systems—provide complete infil- modes. This feature can simplify the process and familiar-
tration of the demineralized dentin. The exposed collagen ize clinicians with new bonding systems.
fibrils may consequently suffer hydrolytic degradation Another key factor for the successful implementation of

November/December 2013 • Volume 34 Special Issue 9

adhesive dentistry in clinical practice is the understanding and are often applied as flowable base materials veneered
that any type of bonding surface contamination from with more viscous hybrid composite resins or inserted in
saliva, blood, sulcus, or other fluids significantly affects 4-mm to 5-mm thick increments and cured in one step to
resin bonds in a negative way.'° Isolation of the operating eliminate time-consuming layering techniques. To date,
field through use of a rubber dam or similar means is, scant evidence is available to validate material placement
therefore, a necessity. in one layer. The recommended placement technique
it is fair to say that the search for the "ideal" dental adhe- continues to be small increments to allow for flow of the
sive system is ongoing. Based on the current literature, an composite material away from free space and toward a
adhesive should: 1) minimize phosphoric acid pretreatment bonded substrate."* This technique ensures an optimal
of dentin and only require selective etching of enamel; 2) be conversion rate upon photopolymerization and a restora-
a mild self-etch with a universal adhesive monomer such as tion with superior physical properties.
MDP; 3) be solvent free; and 4) have antibacterial properties. An advanced system for evaluating the clinical perfor-
mance of contemporary composite materials and bonding
COMPOSITE RESINS FOR interfaces applies noninvasive, nondestructive, high-resolu-
DIRECT RESTORATIONS tion cross-sectional light-wave imaging technology called
Composite restorative materials have been steadily evolv- swept-source optical coherence tomography (SS-OCT).'^'^^
ing since R.L. Bowen introduced them in the last century." With this technology, Nazari et aP' demonstrated superior
Their applications include anterior and posterior restora- cavity adaptation of a new stress-decreasing composite
tions both direct and indirect, and luting agents for all resin placed up to 3 mm in depth compared with conven-
types of indirect restorative materials. tional flowable composite.
Patient demand for tooth-colored esthetic and minimally Rapid developments in resin composite technologies
invasive restorations, as well as environmental concerns and formulations have made direct composite restorations
about mercury, are slowly reducing the use of amalgam highly predictable, as long as materials and application
for direct posterior restorations and replacing amalgam techniques are properly selected and applied.
with composite resin.
However, questions remain about the clinical long-term THE ADHESIVE RESIN BOND
performance of direct composite-resin restorations; clinical TO DENTAL MATERIALS
trials to evaluate novel dental composites are expensive and Composites
arduous to complete." Underperforming composite materi- Adhesion between two composite resin layers is achieved in
als, patient noncompliance, and operator error are main the presence of an oxygen-inhibited layer of the unpolymer-
reasons for failure, leading to secondary caries, fracture, ized resin. Successful bonding depends on establishing
marginal deficiencies, wear, and postoperative sensitivity.'^ a surface with a high number of unreacted vinyl groups
For anterior composite restorations, loss of retention is (C=C) that can then be cross-polymerized to the resin in
no longer a main reason for failure, provided dependable the bonding composite.^^ Because already polymerized
adhesive systems are used correctly.^^ Instead, marginal composites contain fewer free radicals on their surfaces,
deterioration and discoloration have become primary rea- several methods have been suggested to improve the
sons for replacement. They are mainly caused by improper composite-composite adhesion. Surface roughening with
adhesive technique, subgingival placement on root dentin airborne particle abrasion, etchants such as acidulated
or cementum, overfinishing of the restoration, incorrect phosphate fluoride, hydrofluoric acid, or phosphoric acid
material selection, and inadequate oral hygiene. with the use of intermediate adhesive resins (lARs) either
Posterior composite restorations are subject to greater in a siiane and/or an adhesive system have been recom-
failure due to masticatory forces, difficulty of placement, mended. The preferred method is a combination of air
and secondary caries, especially in the long term." Caries abrasion, application of a siiane coupling agent and an lAR.^^
risk plays a significant role in restoration survival. A 12-
year prospective study concluded that large four- to Ceramics
five-surface composite restorations have better survival The popularity of all-ceramic restorations has increased
than amalgam restorations of the same size in patients significantly in recent years due to better esthetics and
with low risk for caries." Patients at high risk for caries and durability. The two major categories of all-ceramic materials
bruxism have significantly higher failure rates in shorter are: silica-based (ie, feldspathic, leucite-reinforced, and
periods than patients with low risk.''' The effect of oral lithium disilicates) and non-silica-based (ie, zirconia or
hygiene and nutrition has not been sufficiently studied yttria stabilized zirconia, alumina) high-strength ceram-
but may also play a significant role in restoration survival. ics. The clinical success of either resin-bonded or repaired
Current trends suggest simplification of the placement ceramic restorations depends on the quality and durability
technique with low-shrinkage-stress bulk-fill composite of the bond between the composite resin and ceramic.
'' These new materials have varying properties This bond typically depends on the surface topography

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of the substrate, surface energy, and chemical interaction oxide, which removes loose contaminated layers, and the
with the resin.^* roughened surface provides some degree of mechanical
interlocking with the adhesive material. Application of
Silica-Basecd Ceramics a special ceramic primer containing an acidic adhesive
F-lydrofluoric acid (FHF) etching followed by applicatiori monomer such as MDP provides superior bond strengths to
of a silane coupling agent is recommended for use with air-abraded high-strength ceramic surfaces.^^ Alternatively,
glassy matrix ceramics.^''•^^ FHF selectively dissolves the silica coating followed by silanization or chemical activation
glass or weak crystalline components of the ceramic and seems similarly successful.^*'^^
produces a porous, irregular surface of increased wettabil- The selective infiltration-etching technique by heat
ity. Application of a silane coupling agent on the etched treatment has been recently proposed to improve zirconia
ceramic surface increases the chemical adhesion between bonding. The surface is coated with a glass-containing
the ceramic and resin materials by coupling the silica (sili- conditioning agent (composed of silica, alumina, sodium
con oxides) in glassy matrix ceramics to the organic matrix oxide potassium oxide, and titanium oxide) and heated
of resin materials by means of siloxane bonds. above its glass-transition temperature. After cooling, the
Silica-based ceramics are brittle. Therefore, blunt glass is dissolved in an acidic bath, creating a porous
surface-roughening methods such as air-particle abrasion surface and achieving promising bond strengths.^'
or grinding, which cause microcracks and may ultimately
lead to fractures, should be avoided. METAL-FREE ENDODONTIC POSTS
A clinical example of a resin-bonded silica-based ce- The primary purpose of a post is to retain the coronal res-
ramic (porcelain laminate veneers) restoration is depicted toration in an endodontically treated tooth with extensive
in Figure T and Figure 2. loss of coronal structures. Prefabricated fiber-reinforced
polymer (FRP) posts have become very popular because of
High-Strength Ceramics satisfactory clinical results as well as reduction in treatment
Alumina- (AI^Oj) and zirconia-based (ZrOp ceramics are time and cost.^^'^^ They are usually luted with resin cements
typically used for copings and frameworks that are veneered to increase retention and mechanical performance of the
with feldspathic porcelains or composites, full-ceramic restored teeth while reducing the risk of root fracture.
restorations, or implant components due to their excellent The FRP posts are made of carbon or silica fibers
mechanical properties.^'*'^^ The high strength allows for ce- surrounded by a matrix of polymer resin, usually epoxy
mentation with conventional cements. If adhesive bonding is resin. Because fiber posts are passively retained in the
selected for final insertion, however, some unique properties root canal, the effectiveness of the adhesive cement and
have to be considered. The blo-inert high-crystalline and luting procedure plays an important role. Ideally, the in-
low-glass structure makes high-strength ceramics corrosion- tracoronal dentin is treated with etch-and-rinse adhesives
and acid-resistant, rendering adhesion protocols applied for and ethylenediaminetetraacetic acid (EDTA).^°
silica-based ceramics ineffective.^*^ The preferred surface The organic component of fiber posts, generally epoxy
treatment method is air-particle abrasion with aluminum resin, has a high degree of conversion and crosslinks.

Fig 1. Preoperative intraoral view of failing composite res- Fig 2. Postoperative intraoral view after restoration of all
torations in the two maxillary central incisors. In addition, maxillary incisors with minimally invasive adhesively bonded
the patient was dissatisfied with the esthetics of the maxil- porcelain laminate veneers. Clinics by Dr Markus B, Blatz;
lary incisors. dental technology by Cusp Dentai Laboratory, Boston, MA,

November/December 2013 • Volume 34 Special Issue 9

This poiymer matrix is virtually unable to react witin tine
monomers of resin cements.^' A silane coupling agent is
typically applied to the post surface to enhance adhesion.
The recently developed resin-based self-adhesive ce-
ments eliminate the multiple and technique-sensitive
tooth- and material-pretreatment steps. They have also
become popular for cementation of fiber posts.^^ Self-
adhesive resin cements contain multifunctional hydrophilic
monomers with phosphoric acid groups, which can react Flowable liner (CDO)
with hydroxyapatite and also infiltrate and modify the
smear layer. They can offer bond strengths comparable Dentin Sealing
(Dual Bonding/IDS)
to etch-and-rinse systems.

Flowable liner (CMR)

METAL ALLOYS
The development of techniques for adhesion of composite
resins to metallic substructures has greatly expanded re-
storative treatment options. Early techniques relied solely
on mechanical retention of composite resin to the metal-
lic substrate through retentive perforations or meshes.^^
Macro-mechanical retention techniques yielded unreliable
bond strengths, gap formation, and microleakage at the
bonding interfaces.^" Micromechanical retention tech-
niques began with pretreatment of metal-bonding surfaces
with air-particle abrasion,^" which became increasingly
successful when combined with resin cements containing
special adhesive monomers (MDP) to also provide true
chemical bonds.^=
Other efforts to improve metal-composite bonds have
included various etching techniques'^ and acidic adhesive
monomers^' that chemically bond to oxides on base-metal
alloys. The nonreactive surface of noble metal alloys pre-
sented a special challenge, which led to the development of
electrochemical plating of tin, oxidation, and acid pickling.
Treating metal alloy surfaces with silica intermediates Fig 3. Diagrammatic illustration of a modern concept for
and silane coupling agents began in 1984.^^ Silica was "Indirect Adhesive Restorations in the Posterior," present-
ed by Dr. Didier Dietschi, The different layers indicate the
introduced onto the metal surface from application of concepts of dual bonding/immediate dentin sealing (IDS),
silicon dioxide (SiO^) in a flame. Other systems embed cavity design optimization (CDO), and cervical margin
silica-coated aluminum particles into the metal surface relocation (CMR),
through air-particle abrasion.^^^o The silica coat is then Fig 4. Preoperative view of defective tooth-colored res-
treated with silane, which acts as a coupling agent be- torations. Improper adaptation and open margins neces-
tween the metal surface and resin. These techniques have sitate replacement.
proven successful to both base and noble metal alloys.
Current development of adhesion to noble dental alloys
has focused on the use of functional monomers, especially modern adhesive technologies to tooth structures and indi-
those containing sulfur."" Multifunctional adhesives for both rect dental materials. The most common clinical problems
nobie and base metal alloys typically contain monomers with bonded indirect posterior restorations include hard
with functional groups, such as sulfur, amino, and carboxyl, tissue conservation (cavity design might lead to signifi-
and have demonstrated high and durable bond strengths.^^ cant loss of sound tissue), impression taking, and adhesive
cementation (deep proximal preparations are a challenge
INDIRECT ADHESIVE RESTORATIONS and make working field isolation more difficult), as well
IN POSTERIOR TEETH as provisional restorations. Conventional acrylic provision-
Bonded indirect tooth-colored restorations for posterior als are time consuming and the cement contaminates the
teeth are excellent examples of the significant develop- interface, while simplified "soft" light-curing provisionals
ments and improvements that have been made in adhesive are lost easily and trigger sensitivity due to leakage. An
dentistry, as they combine distinct clinical protocols with original treatment protocol to overcome these problems

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Fig 5. Situation after removal of the failing restorations.

Recurrent caries involved proximal areas, leading to ex-
tensive proximal cavities. The remaining enamel is very
thin or even absent along the cervical margins. A direct
approach is not indicated due to cavity dimensions, mar-
gin position, and dentin quality.
. A curved metal matrix is placed and fitted precisely
along cervical margins. A highly filled flowable compos-
ite is applied to relocate the proximal margin and fill all
undercuts.
Fig 7. Ail cavities were lined (dentin bonding agent and
flowable composite). Enamel margins were refinished,
i cavities are ready for final imprr--'- -

was introduced by Dietschi and Spreafico''^ in 1998 and

includes four main concepts, which are illustrated in Figure
3 through Figure 10.
The first concept, dual bonding, relates to the substrate
treatment.'"''''^ It was later referred to as immediate dentin
sealing, which is to seal the dentin with a dentin bonding
agent after the cavity is isolated with a rubber dam.'"' This
prevents further tissue dehydration and contamination,
and protects the tooth against sensitivity while improving O
bond strength and stability of the adhesive interface.'"
Cavity design optimization (CDO)''^ limits removal of
sound tooth structure during preparation by applying a
flowable composite liner to fill all undercuts and create an
ideal cavity geometry. The third concept, cervical margin re-
location (CMR),^'"' is applied for deep proximal preparations
(intrasulcular), which complicate impression taking and
cavity isolation during cementation. After placing a matrix, a
first layer of flowable or restorative composite is applied to
reposition the margin more coronally (Figure 6 and Figure
7). A highly filled flowable composite or low-shrinkage flow-
able base is recommended. Cementation is performed with
a light-cure composite rather than a dual-cure composite
for optimal working time and control. Controlled adhesive
Fig 8. Pressed and stained lithium disilicate ceramic
cementation (CAC) has major advantages in complex cavity restorations on the master cast.
designs. Combined with the CMR technique, visual margin
Fig 9. Cementation with a light-cure composite materia
examination and proper cement removal are simplified. A (typically a microhybrid).
highly filled fine/microhybrid composite is recommended

November/December 2013 • Volume 34 Special Issue 9

 Fig 10. Definitive restora-
tions. The restorative ap-
proach ensures optimal
biologic and physical in-
tegration for predictable
and reliable results.

Clinics by Dr. Didier

Dietschi.

for cementation, and its viscosity is reduced during res- Ricardo Walter, DDS.MSc
toration placement with a special ultrasonic or sonic ce- Assistant Professor of Restorative Dentistry, Department of
mentation tip. Various studies have verified adequate light Preventive and Restorative Sciences, University of Pennsylvania
School of Dental Medicine, Phiiadelpiiia, Pennsylvania
transmission and conversion rates for light-cure composites
underneath ceramic inlays/onlays with proper curing lights Alan M. Atlas, DMD
and exposure times."** =° The reduced restoration thickness Clinical Professor, Department of Preventive and Restorative
(CDO concept) supports proper light transmission. Sciences, University of Pennsylvania School of Dental
These clinical concepts address the most frequent Medicine, Philadelphia, Pennsylvania
difficulties with indirect adhesive restorations in the NajeedSaleh,DMD
posterior, leading to more predictable and improved Professor of Clinical Restorative Dentistry, Director of
treatment outcomes.^''" Comprehensive Care Clinics, Department of Preventive and
Restorative Sciences, University of Pennsylvania School of
Dental Medicine, Philadelphia, Pennsylvania
SUMMARY
Today, offering patients minimally invasive dentistry is not Didier Dietsclii, DMD, PhD
just another treatment option, it Is an ethical obligation. Senior lecturer, Department of Cariology & Endodontics,
Adhesive dentistry facilitates minimally invasive, esthetic, School of Dentistry, University of Geneva, Switzerland;
and tooth-preserving dental treatment and applies to Adjunct Professor, Department of Comprehensive Dentistry,
Case Western University, Cleveland, Ohio
almost all dental materials and specialties. The various
tooth structures and dental materials, however, require Marl<usB.Biatz,DMD,PhD
specific bonding protocols for long-term clinical success, Professor of Restorative Dentistry, Chairman of the Department of
as discussed in this article. Adhesive techniques, technolo- Preventive and Restorative Sciences, University of Pennsylvania
School of Dental Medicine, Philadelphia, Pennsylvania
gies, and clinical concepts are constantly being updated
and improved, shaping the future of the dental profession.

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November/December 2013 • Volume 34 Special Issue 9

CONTINUING EDUCATION QUIZ AEGIS Publications, LLC, provides 2 hours of Continuing Education credit
for this article. Course is valid from 12/03/2013 to 12/31/2016. Participants
must attain a score of 70% on each quiz to receive credit. Participants
receiving a failing grade on any exam wiil be notified and permitted to

The Current State of Adhesive Dentistry:

take one re-examination. Participants will receive an annual report docu-
menting their accumulated credits, and are urged to contact their own
state registry boards for special CE requirements.

A Guide for (iinicai Practice By visiting compendiumce.com/go/adhesion, you can take the quiz for
$16 and print your certificate immediately or you can fill out and mail the
Answer Sheet below for $32. Allow approximately 2-3 weeks for process-
FRANCIS K. MANTE, DMD, PHD; FUSUN OZER, DDS, PHD; RICARDO WALTER, DDS, MSC; ALAN M. ATLAS,
ing. For more information, call 877-4-AEGIS-l.
DDS; NAJEED SALEH, DHO; DIDIER DIETSCHI, DMD, PHD; AND MARKUS B. BLATZ, DMD, PHD
Address: AEGIS Communications CE Department. 104 Pheasant Run,
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Complete this CE examination oniine at compendiumce.com/go/adhesion or mail/fax this page to AEGIS Communications.

ANSWER SHEET

1. Self-etch adhesives are recommended particularly for 4. All-ceramic materials that are non-silica-based include; 8. The preferred surface treatment method for alumina-
cavities predominantly in: A. feidspathic. B. ieucife reinforced. and zirconia-based ceramics is;
A.deiitin. B. enamel. c. iifhium disiiicafes. D.zirconia. A. rinse wifh silane.
ccementum. D. deciduous teeth. B. rinse wifh hyaiuronic acid.
5. Hvdrofiuoric acid etching followed by application of c. rinse with phosphoric acid.
2. Adhesion between two composite resin layers is a silane coupling agent is recommended for what type D. air-parficie abrasion viifh aluminum oxide.
achieved in the presence of an; of ceramics?
A. oxygen-inhibited layer of the poiymerized resin. A. pressed B, high density 9.Prefabricated fiber-reinforced polymer posts
B. oxygen-inhibited layer of the unpoiymerized resin. Ciow density D. giassy matrix are usually luted with;
C, oxygen-enriched iayer of the polymerized resin. A- ZnPO, B. glass ionomer.
D. oxygen-enriched iayer of the unpoiymerized resin. 6. Silica-based ceramics are; c, resin cemenfs. o. eugenoi.
A. compliant. B. brittle.
3. Successful bonding depends on establishing a surface C. elastic D.siightiy flexible. 10. "Cavity Design Optimization" limits removal of sound
with a high number of unreacted; tooth structure during preparation by applying what to fill
A. yinyi groups. 7. Alumina- and zirconia-based ceramics are typically all undercuts and create an ideal cavity geometry?
B. calcium carbonate molecules. used for copings and frameviori(s that are; A. a hybrid glass ionomer B. IRM
c. esterine polymers. A, out of occlusion. B. veneered. c. a flowable composite iiner D. calcium hydroxide
D. hydroxyapatife chains. C. subgingival. D. supragingival.

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