REVIEW

Australian Dental Journal 2004;49:(3):112-121

Adhesive restorative materials: A review

MJ Tyas,* MF Burrow†

Abstract The basic bonding mechanism was an ionic attraction

‘Adhesive’ restorative dentistry originated with the between two carboxyl (COO-) groups in the cement to
work of Buonocore in 1955 in bonding resin to the calcium (Ca++) in enamel and dentine. Further work
etched enamel. Since then, adhesive materials and by Wilson’s team4 resulted in the introduction of glass-
techniques have developed at a rapid rate. The first ionomer (glass polyalkenoate) cements, based
chemically adhesive material (zinc polycarboxylate essentially on the liquid of the polycarboxylate
cement) was marketed in the late 1960s, and glass- cements. Polycarboxylate cements are now little used,
ionomer cements and dentine bonding agents have
since become available. as the glass-ionomers have a wider range of
This review focuses on the latter two products.
applications and are easier to use.
Glass-ionomer cements have a particular role in Glass-ionomer cement is water-based, and therefore
adhesive dentistry because of their reliable chemical compatible with dentine, which is a water-containing
adhesion to enamel and dentine, and because of their tissue as well as commonly having a film of odontoblast
apparent ability to promote the remineralization of tubular fluid on the cut surface. In contrast, resin
‘affected’ dentine. Dentine bonding agents have
undergone marked changes in presentation over the
composite is a hydrophobic material and thus is
last 15 years, but all have an essentially similar relatively incompatible with dentine. The problem of
bonding system, that of hybrid layer formation. bonding hydrophobic resin to dentine was largely
However, the most recent systems have limited resolved by the work of Nakabayashi.5,6
clinical data supporting their use. This review will focus on the two adhesive systems
Key words: Dentine, adhesion, bonding, resin, glass- most relevant for today’s dentistry: glass-ionomer
ionomer, review. cements, and dentine bonding agents (DBAs) for resin
(Accepted for publication 15 April 2004.) composite. Bonding of resin composite to etched
enamel will not be discussed further as it is a well-
established technique and has changed little for several
years. In contrast, there is increasing interest in glass-
INTRODUCTION ionomers, and DBAs are constantly evolving.
The pioneering work of Michael Buonocore nearly
50 years ago1 marked the beginning of successful Glass-ionomer cements
‘adhesive’ dentistry. Buonocore1 was able to The original glass-ionomer cements (GICs) were
demonstrate that the treatment of enamel with water-based materials which set by an acid-base
phosphoric acid resulted in a porous surface, which reaction between a polyalkenoic acid and a
could be infiltrated by resin, to produce a strong
fluroaluminosilicate glass.4 Since these were brittle
micromechanical bond. However, the clinical
materials, attempts were made to enhance the physical
application of acid etching was not realized until 15
properties by the addition of either metal particles
years later when resin composites became available as a
(silver or gold), by a fusion process resulting in a
result of the work of Bowen’s group.2
‘cermet’ (ceramic-metal),7 or amalgam alloy particles by
In contrast to micromechanical bonding to tooth a simple addition (‘admix’). The use of ‘metal-
tissue, chemical bonding was developed by Smith3 and reinforced’ GICs appears to be diminishing following
resulted in the introduction of polycarboxylate cement. the introduction of high powder:liquid ratio products,
which are described below, and will not be discussed
further.
Further modification of water-based (‘conventional’)
GICs took place in the early 1990s by the addition of
*Professor, School of Dental Science, The University of Melbourne, water-soluble resin,8 to produce the ‘resin-modified’
Victoria.
†Associate Professor, School of Dental Science, The University of GICs. The purpose of adding resin was to enhance the
Melbourne, Victoria. physical properties and to reduce the sensitivity to
112 Australian Dental Journal 2004;49:3.
water balance of the conventional GICs. The first of the
‘resin-modified’ GICs (RM-GICs) was Vitrabond
(3M Dental Products, St Paul, Minnesota, USA), now
called Vitrebond (3M/Espe Dental). Vitrebond is a
liner/base material, and several restorative RM-GICs
are now available, including Vitremer (3M/Espe
Dental), Fuji II LC (GC International, Tokyo, Japan)
and Photac-Fil (3M/Espe, Seefeld, Bavaria, Germany).
Other names for RM-GIC which have been used
include ‘resin-ionomers’, ‘resinomers’, ‘hybrid ionomers’
and ‘light-cured glass ionomers’. The last should not be
used as some products are not light-cured (see below);
‘resin-modified glass-ionomers’ is preferred.9
Fig 1. Restorations (arrowed) using a high powder:liquid ratio
Setting reactions conventional glass-ionomer cement (Fuji IX GP, GC Corporation,
Conventional GICs set by a complex reaction Japan) in 74 disto-occlusal and 75 mesio-occlusal surfaces.
between the (acidic) liquid and the (basic) powder.
(Some products have the polyalkenoic acid freeze dried
in the powder, and the liquid is either water or tartaric
acid.) A simplified description10,11 of the setting reaction
is adequate for this review.
On mixing powder and liquid, the acid attacks the
glass resulting in surface degradation of the glass and
release of metal ions (e.g., strontium, calcium,
aluminium), fluoride ions and silicic acid. The metal
ions react with the carboxyl (COO-) groups to form a
polyacid salt, which becomes the cement matrix, and
the surface of the glass becomes a silica hydrogel. The
unreacted cores of the glass particles remain as a filler.
Although the clinical set is completed within a few
minutes, a continuing ‘maturation’ phase occurs over
subsequent months. This is predominantly due to the
slow reaction of the aluminium ions,11 and is the cause
of the set material’s sensitivity to water balance. The set
material needs to be protected from salivary
contamination for several hours, otherwise the surface
becomes weak and opaque, and from water loss for
several months, otherwise the material shrinks and
cracks and may debond.11
The RM-GICs also undergo an acid:base reaction
(which is a pre-requisite for any material to be
described as a glass-ionomer cement). However, there is
an additional resin polymerization phase. Depending
Fig 2. Restorations (arrowed) after two years clinical service.
on the product, the resin polymerization may be self-
cure, light-cure or both. On mixing powder and liquid,
the acid:base reaction, and if present, the self-cure resin
polymerization reaction, begin and setting commences.
Restorative RM-GICs (in contrast to luting RM-GICs) Classification
undergo photopolymerization on exposure to light, The most practical classification of the GICs is on
resulting in clinical set. However, the acid:base reaction their clinical usage.11,13 Type I GICs are the luting
continues, albeit much more slowly. Although the set cements, characterized by low film thickness and rapid
material can be contoured and polished under water set; when available as an RM-GIC, the
spray immediately following polymerization, delayed photopolymerization reaction will be absent. Type II
polishing has been recommended.12 However, GICs are restorative cements, with sub-types 1 and 2.
dehydration remains a potential problem.10 All GICs Type II-1 GICs are aesthetic cements (available in both
show an increase in translucency at seven days conventional and resin-modified presentations) and
compared to that at placement, resulting in an aesthetic Type II-2 GICs are ‘reinforced’ (however, despite their
improvement.11 description, are not necessarily stronger than Type II-1
Australian Dental Journal 2004;49:3. 113
 thickness of the ion-exchange layer appears to be in the
order of a few micrometres,17,19 and merges into the GIC
on one side and into the enamel/dentine on the other.
Unfortunately there is some confusion in the literature
regarding the ion-exchange layer. Other terms have
been proposed such as ‘zone of interaction’,17 ‘inter-
diffusion zone’,20 ‘hybrid layer’,21 ‘interphase’,22 and
‘intermediate layer’.19 In particular, the notation ‘hybrid
layer’21 causes confusion with the ‘hybrid layer’ formed
between resin composite and dentine (see below). The
term ‘ion-exchange layer’ should be used, since it
accurately describes its nature. It has been shown that
this layer is resistant to acid and base treatment, and
has thus also been referred to as the ‘acid-base resistant
layer’ (Fig 3).
Fig 3. A bonded specimen of a conventional glass ionomer cement Ionic bonding between the carboxyl ions from the
to demineralized dentine. The ‘acid-base resistant layer’ can be
observed at the interface (arrows). This has also been referred to as cement acid and the calcium ions from the tooth
the ‘ion-exchange layer’. structure has been confirmed using X-ray photon
spectrometry,23 and ionic bonding to the collagen of
dentine has been proposed24 but not investigated.
Measurement of the bond strength of GIC to enamel
products). However, they are more wear-resistant.7 and dentine is complicated by the brittle nature of the
Type III GICs are the lining cements and fissure GIC. Laboratory bond strength tests invariably result
sealants, characterized by low viscosity and rapid set. in cohesive failure of the GIC, rather than failure within
In the mid- to late-1990s, high powder:liquid ratio the ion exchange layer.22 Consequently, the true
conventional GICs were introduced, alternatively strength of the ion-exchange layer is not known;10,16
termed ‘packable’ or ‘high viscosity’ GICs.10 These values in the range 3-10MPa are commonly reported,
products (e.g., Ketac Molar, 3M/Espe, Seefeld, Bavaria, i.e., approximately the cohesive strength of GIC.
Germany; Chemflex, Dentsply, York, Pennsylvania, Additional bonding mechanisms have been explored
USA; Fuji IX and Fuji IX GP, GC International) are for the RM-GICs, since the presence of resin suggests
promoted principally for small cavities in deciduous that bonding analogous to resin composite may occur,
teeth (Fig 1, 2),14 temporary restorations, liner/base i.e., resin tags into enamel and establishment of a
applications, and in the ‘Atraumatic Restorative hybrid layer into dentine. However, the experimental
Treatment’ (ART) technique.15 evidence seems equivocal. Some workers25-27 have
demonstrated resin tags in the dentinal tubules, while
Bonding mechanism others28-30 did not appear to do so. The ‘hybrid layer’ of
The bonding mechanism of the GICs to the dental resin-dentine bonding was apparently observed by
hard tissues is very complex, and may be different for Pereira et al.,10,27 but could not be identified by Lin
RM-GICs compared to conventional GICs. et al.25 or by Ramos and Perdigão.28 Bonding by an ion
Simplistically, an ionic bond occurs between the exchange layer25 and ionically28 as for conventional
carboxyl (COO-) ions in the cement acid and the GICs has also been proposed.
calcium (Ca++) ions in enamel and dentine.
When freshly mixed conventional GIC is placed on Fluoride release
enamel or dentine, dissolution of any smear layer The release of fluoride ions is one of the notable
occurs but demineralization is minimal since the tooth characteristics of GICs. It is present originally as a flux
hydroxyapatite buffers the acid, and polyalkenoic is in the manufacture of the glass, and is released from the
quite weak.16 Phosphate ions (negatively charged) and glass particles on mixing with the polyalkenoic acid.
calcium ions (positively charged) are displaced from the The presence of fluoride also has benefits in increasing
hydroxyapatite, and are absorbed into the unset translucency and strength and improving handling
cement. This results in an intermediate layer between properties.31 The mechanism of release is complex and
the ‘pure’ GIC and the ‘pure’ hydroxyapatite; the so- not fully understood. However, it is maximum in the
called ‘ion-exchange’ layer.11 Problems of specimen first few days and decreases rapidly to a lower level
preparation of a water-based material have hindered over weeks, and maintains a low level over months.31 It
investigation of this layer, although better techniques has also been shown that GIC can be ‘recharged’ with
are now becoming available.17 fluoride, resulting in a subsequent short-term boost in
The ion-exchange layer appears to consist of calcium release.32,33 Most of the fluoride is released as sodium
and phosphate ions from the GIC, and aluminium, fluoride, which is not critical to the cement matrix, and
silicic, fluoride and calcium and/or strontium ions thus does not result in weakening or disintegration of
(depending on glass composition) from the GIC.18 The the set cement.34 Resin-modified GICs show similar
114 Australian Dental Journal 2004;49:3.
dynamics of fluoride release,35 although for both types There have been numerous cytotoxicity tests of several
of material the dynamics of release and the amounts GICs.50 The trend has been that GIC is more cytotoxic
released depend on the particular material and the when freshly mixed, and that cytotoxicity decreases as
experimental design. the material sets. The equivocal nature of the results
The clinical significance of the fluoride release is indicates that direct pulp testing is necessary. However, in
controversial. Many laboratory studies using, for pulp and connective tissue studies the results are also
example bacterial and demineralization-remineralization equivocal, and appear to depend on the particular brand
models, have suggested that GIC will prevent secondary of GIC being evaluated. A further complication in
caries.36-42 Clinical studies have shown an effect of GIC interpreting human and animal studies is the generally
on salivary fluoride levels,43 acidogenic bacteria44 and on accepted theory that bacterial microleakage is
demineralized dentine restored with GIC and worn in responsible for the majority of pulp damage. The
removable appliances.45 There is anecdotal clinical contribution of material damage and bacterial damage to
evidence that secondary caries in association with GIC is overall damage is difficult to separate.50
at a very low level. This has been supported by one Glass-ionomer cement has been shown to have an
retrospective study,46 but significantly contradicted by a antimicrobial effect in several studies, and greater than
cross-sectional study,47 and one five-year prospective that shown by other materials such as amalgam and
study was inconclusive.48 However, using an evidence- resin composite. However, again it is difficult to do
based systematic review of the literature, there was no more than generalize, as the results depend on the
evidence for or against an anti-cariogenic effect of GIC.49 experimental method, the bacteria used and the
product tested.50 There are several theories regarding
Biological properties the antibacterial activity. Most workers propose that
The biocompatibility of the GICs has been fluoride is responsible, possibly acting synergistically
extensively reviewed by Sidhu and Schmalz,50 and the with pH. However, other released agents have been
reader is referred to this excellent paper for more detail. cited as possible antibacterials, including zinc55 and
polyalkenoic acid,56 acting alone or synergistically with
The term ‘biocompatibility’ is frequently misused,
pH and fluoride.57
and is assumed to mean ‘inert’. However, the accepted
definition is more complex: ‘the ability of a material to Additional studies have been carried out on the
elicit an appropriate biological response in a specific biological properties of RM-GICs.50 It might be expected
that a different pattern of pulp damage might occur
application.’50 Therefore, in the context of restorative
because of the presence of unreacted monomer.
materials it is important to identify the tissues with
However, the results are also equivocal. This issue has
which the material may come into contact. For GIC,
been explored in detail elsewhere,50 and the reader is
these tissues are dentine (and therefore pulp), gingivae,
referred there for more information. One of the principal
and oral mucosa.
reasons for the wide variation in results is the lack of
Sidhu and Schmalz50 have recommended that the standardization among testing protocols, even though
relevant issues regarding biocompatibility of GICs are standard tests have been available for some time.50
the release of degradation products, cytoxicity in
various situations, antibacterial properties, osteogenic Clinical performance
effects, long-term host and tissue response and the
One of the principal benefits of GICs is their
effect on dental personnel.
adhesion to the dental hard tissues, and this has been
Several metallic ions are released from GIC, as well confirmed in non-undercut non-carious cervical lesions
as fluoride. The highest release occurs from the unset (NCCLs) where dentine is the main substrate.46,58-60
material, and as described above, most research has However, because of the low fracture toughness of
been done on fluoride. Hydroxethylmethacrylate GICs (including RM-GICs), they are recommended
(HEMA) is released from RM-GICs and can diffuse principally for non-stress-bearing areas, e.g., carious
through dentine in laboratory studies. Since HEMA can and non-carious cervical lesions and approximal
induce allergic and toxic responses, the clinical anterior lesions. Nevertheless, the high powder:liquid
relevance of its release requires more investigation.50 ratio materials may be useful in the restoration of small
Nevertheless, to date there is no evidence that HEMA cavities in deciduous teeth14 (Fig 1, 2). Clinical studies
in dental materials is responsible for any local or on RM-GICs are less extensive because of their more
systematic adverse effects. recent introduction.61-69 However, the results are mixed
The pH of GIC increases as the cement sets.11 It has with respect to both brand comparisons and
been suggested that the initial low pH may be comparisons with polyacid-modified resin composites.
responsible for the early anecdotal reports of sensitivity One presentation of an RM-GIC is in a low
following crown cementation.51 However, laboratory powder:liquid ratio form (Fuji Bond LC; GC
studies indicate that the dentine buffers the hydrogen International), and is used in a similar way to a dentine
ions released from GIC, 52 and objective reports53,54 have bonding agent. Excellent five-year results have been
shown that GIC was not associated with post-operative obtained for the retention by this material of resin
sensitivity. composite in non-carious cervical lesions.70
Australian Dental Journal 2004;49:3. 115
 Evidence is accumulating that GIC may have an
important role in minimum intervention dentistry.11,71
Modern concepts of operative dentistry propose that
only the ‘infected’ dentine should be removed, leaving
the ‘affected’ dentine which has the potential to
remineralize.72,73 Recent evidence suggests that such
remineralization may be potentiated by GIC,74,75 and
this has special relevance in the ART technique.73,76

Types I and II glass-ionomer cements

Although the focus of this review has been on Type
II (Restorative) GICs, the important role of Type I
(luting) and Type III (liner/base and fissure sealants)
should not be ignored. The ‘cervical lining’ technique
(also known as the ‘open sandwich’, a term not
favoured by the first author) was described in 1984,7 Fig 4. Bonded specimen in which the dentine (mineral and protein)
has been removed. The infiltration of resin into the acid-etched
and clinical trials are supporting its usefulness, dentine can be seen with an associated permeation of resin
provided that an appropriate GIC is used.77-80 Glass- throughout the dentine tubular network and its lateral branches.
ionomer cements can be effective fissure sealants and
are useful when optimum moisture control for resin-
based sealants cannot be achieved.81 Although clinical
papers to first identify a layer between the resin and
retention appears less than for resin-based sealants,
dentine substrate referred to as ‘hybrid’ dentine, in that
prevention of fissure caries is comparable.81,82 it was the organic components of the dentine that had
been permeated by resin (Fig 4).90 The term ‘hybrid
Dentine bonding agents layer’ has now become synonymous with bonding of
The concept of bonding a restorative material to the resins to etched dentine. There has been a tremendous
dentine surface is by no means a new idea. Even at the amount of research done on the hybrid layer, its
time of Buonocore using phosphoric acid to bond to structure, formation and how it can be improved.
enamel, the idea of bonding to dentine was considered. Without a hybrid layer a bond will not be formed to the
However, due to limitations of materials and dentine. Therefore, it is essential for some modification
knowledge of the structure and nature of dentine the to be made to the dentine surface so a mechanical
dream remained just that until the late ’70s. In fact interlocking of resin around dentinal collagen can
Buonocore did try to introduce a dentine adhesive but occur. This layer has also been referred to as the ‘resin-
was unsuccessful.83 The earliest bonding agent which dentine interdiffusion zone’.91
showed some success was introduced by Fusayama.84,85
At the same time Bowen86 in the USA started Classification
investigating new formulations of resins that were more Dentine bonding agents have gone through many
water tolerant as well as methods of treating the changes over the last 10 years. This has led some people
dentine with oxalates to gain adhesion. The concern of to refer to the changes as ‘generations’ of material,
many clinicians at that time was the potential damage implying that there has been some chronological
phosphoric acid was going to cause the dental pulp if development. This is a falsehood — for example, the
dentine was etched. This led to the development of the first ‘self-etching’ type material was introduced by
first Scotchbond (3M Dental, St Paul, Minnesota, Coltène (Altstätatten, Switzerland) as ‘ART Bond’.
USA), a phosphate ester of Bis-GMA. This material Therefore, it is more logical to classify materials by the
could almost be considered as the first self-etching number of steps needed to complete the bonding
priming material for dentine, although it was process.
recognized the enamel needed to be etched.87,88
The first material to be truly successful in bonding to ‘Three-step’ or ‘Conventional’ systems
dentine was introduced as GLUMA (Bayer Dental, This group represents those materials that have
Leverkusen, Nordrhein-Westfeld, Germany). This separate etching, priming and adhesive steps. It just so
material used EDTA to etch or condition the dentine happens that this group of materials is also the oldest.
which was then primed with a solution of However, they are still widely used and have been
formaldehyde and 2-hydroxyethylmethacrylate shown to provide reliable bonding. The greatest
followed by a bonding resin of Bis-GMA.89 The problem with this group would seem to be that three
mechanism proposed for this material was to bond to distinct steps are needed, which gives rise to possible
the organic component of the dentine, namely the problems through contamination of the bonded surface
collagen. The first work to investigate the mechanism prior to placement of the resin composite filling
of bonding to the dentine was by Nakabayashi.90 His material; in other words, they are more technique
paper of 198290 has now become one of the classic sensitive (Fig 5).
116 Australian Dental Journal 2004;49:3.
 demineralization is identical to that of the self-etching
priming materials, but the bonding resin is also
incorporated. These systems also have the problem of
not etching the enamel as effectively as phosphoric
acid. In addition these systems are the newest and have
no long-term clinical data to demonstrate their
effectiveness, although early studies are showing some
variability in the success of these materials.96,97

Bonding mechanism
As already mentioned, the mechanism of bonding of
resin-based DBAs is via a hybrid layer. This is a
micromechanical interlocking of resin around dentinal
collagen fibrils that have been exposed by
demineralization. The interlocking occurs by the
Fig 5. SEM of conventional system showing a hybrid layer of diffusion of the resins in the primer and bonding resin.
approximately 3µm thick (arrows). The dentine has been partially
removed to show tags entering the tubules. The formation and structure of the hybrid layer has
been extensively studied, and has also been referred to
as the resin-impregnated layer, the resin-dentine
‘Two-step’ systems interdiffusion zone. This came about with the use of
This group has two subgroups; the first includes argon-ion beam etching introduced by Inokoshi98 and
those systems that have a separate etch and have later Van Meerbeek and his co-workers who provided
combined the priming and bonding steps. These some of the first detailed descriptions of the hybrid
systems are often referred to as ‘Single-bottle’ systems. layer.99-103 The thickness of the hybrid layer ranges from
In general, the problems experienced with the less than 1µm for the all-in-one systems to up to 5µm
Conventional Systems still exist with the Single-bottle for the conventional systems. The strength of the bond
systems. Although one step has been eliminated, the is not dependent on the thickness of the hybrid layer, as
great problem is ensuring good infiltration of the the self-etching priming materials have shown bond
priming-bond into the demineralized dentine. The other strengths greater than many other systems but exhibit a
subgroup combines the etching and priming steps thin hybrid layer. At the same time as Van Meerbeek
together and are referred to as ‘Self-etching primers’. et al.99 described the hybrid layer, Sugizaki104 showed
These systems also have not been without their that the etching, washing and drying process caused the
problems. The major concern has been their ability to dentine to collapse due to the loss of the supporting
etch the enamel to a great enough extent to ensure a hydroxyapatite. Further work showed that this collapse
good seal. This seems to be overcome now.92 The of the collagen was an impediment to the successful
problem of technique sensitivity also seems to have diffusion of the resin to the base of the region of
been significantly reduced with these systems compared
demineralization. To overcome this problem, Kanca105
with the Conventional and Single-bottle systems.93 This
introduced the ‘wet bonding technique’ which left the
is attributed to the fact that the self-etching priming
demineralized collagen fibres supported by residual
agent does not have to be washed off the dentine,
water after washing. This allowed the priming solution
therefore eliminating the need to maintain the dentine
to diffuse throughout the collagen fibre network more
in a moist state. The method of demineralization of
these materials is by the use of an acidic resin that successfully. However, when it comes to clinical
etches and infiltrates the dentine simultaneously (Fig 6). practice, it is very difficult to find the correct balance of
The dentine is an excellent buffer, so the acidity of the residual moisture. Sano et al.106 showed in their work
self-etching primer is rapidly reduced and after on nanoleakage that most resin-based DBAs allowed
polymerization is neutralized.94 A recent study the ingress of silver nitrate along the base of the hybrid
compared the 24-hour bond strengths of an etch and layer. However, the clinical significance of this is
rinse adhesive (Single-bottle) and a self-etching priming unclear. It may be a pathway for fluid to affect collagen
adhesive after enamel and dentine had been prepared not coated by resin, and the outcome may be
using different methods.95 It was shown that treating degradation of the bond over time. However, the degree
the enamel or dentine with an Er:Yag laser produced a of nanoleakage is very much material dependent rather
significant reduction in bond strength compared with than system dependent,107 meaning that there are
preparation using a diamond bur, diamond- conventional systems and self-etching priming systems
sonoabrasion or airbrasion. that show small amounts of nanoleakage whereas
others show more. For the self-etching systems, these
‘One-bottle’ or ‘All-in-one’ systems are able to solubilize the smear layer and demineralize
This fourth group is the simplest of all the DBAs. the underlying dentine, forming a quite thin hybrid
They combine all steps into one process. Their mode of layer.108
Australian Dental Journal 2004;49:3. 117
 ability of the resins to penetrate to the full depth of the
demineralized dentine. In the case of caries-affected
dentine treated with chemo-mechanical caries removal
solutions, there appear to be no adverse effects on the
bond with a DBA.117-121
However, the bond to radicular and pulp chamber
dentine does seem to vary quite a lot depending on the
DBA used.122-126 This perhaps provides a strong case for
being careful with the selection of a DBA for these
regions of the tooth. It is believed that it maybe
necessary to use different DBAs for different regions of
the tooth, or a system needs to be selected where it has
been shown to provide a reliable bond to all parts of
Fig 6. SEM of a self-etching priming system showing a 1µm thick
hybrid layer (H) between the arrows. These systems can remove
the tooth. Another alternative is the use of GIC
smear plugs allowing resin infiltration into the tubules and lateral restorative materials when then is a deep cavity on the
branches. radicular surface of a tooth, as it is known that a
reliable bond can be achieved and moisture control is
not such a problem.
Bonding substrate Clinical studies
Dentine is quite a variable tissue. Within the tooth There has been a considerable amount of work done
itself the dentine approaching the dentino-enamel to evaluate the success or otherwise of DBAs in clinical
junction is more highly mineralized and the area studies. However, one of the great problems has been
occupied by the tubules is less than that of dentine that many of the DBAs have been considerably changed
adjacent to the pulp.109 In addition to this, dentine or a new material introduced by the time these studies
should be considered as a dynamic tissue that changes are completed or published. Many of the studies have
due to ageing, in response to caries and restoration also been performed on NCCL, which means the
placement. Most changes relate to occlusion of tubules outcomes can not really be applied to restorations in
and also an increase in the mineralization of the other parts of the mouth because NCCL dentine is
dentine. The implication of this is that the dentine usually sclerosed and therefore different from that of an
becomes slightly more difficult to etch and exposure of intracoronal cavity. However, these outcomes will
collagen fibrils can also be reduced, hence there is a provide some indication as to whether the DBA is able
potential for the bond to be somewhat tenuous. This is to achieve a durable bond under very harsh conditions.
particularly the case for the highly sclerosed dentine of Since the early materials were introduced, the retention
non-carious cervical lesions. Laboratory studies rates of the DBAs to sclerosed cervical dentine have
indicate that the hybrid layer of the dentine surface of steadily improved to extent that retention rates are little
NCCLs is thinner than that of normal dentine.110,111 In different from GICs.
addition, it seems that some bonding systems do not With regard to clinical studies on posterior teeth
adhere as well to this surface and show a slightly restored with a DBA, there is still little evidence
decreased bond strength. available.127-131 It would seem though, that clinical
A considerable amount of work has also been done studies of resin composite restorations are showing
looking at the variation of the bond to caries-affected evidence that when placed in the correct manner and
dentine. Some of the early studies used artificial caries- the patient has a low caries rate, restoration survival is
like lesions. However, this does not reproduce the approaching that of amalgam.132
situation that occurs in the oral cavity since caries is a When it comes to the use of DBAs, it is important to
process of demineralization and remineralization follow the manufacturers’ directions carefully. Over-
associated with the damage of the supporting collagen etching can create a situation where there will
matrix.112,113 For those studies that have investigated the potentially be a region of poorly or uninfiltrated
bond strength to caries on extracted teeth, the hybrid dentine. This zone may be susceptible to acid or enzyme
layer tends to be thicker and the bond less, although attack from oral bacteria, hence leading to bond
this is bonding system dependent.114,115 The increased failure.133-135
thickness of the hybrid layer is mainly because the In the case of the self-etching priming materials, this
dentine is already partially demineralized from the is not believed to be a problem. However, the converse
caries and the action of the acid etch is therefore problem may occur: as mentioned, the dentine or smear
somewhat greater. This provides a clear basis for not layer may neutralize the etching primer if the primer
etching for longer than that recommended by the has a relatively high pH. The anecdotal evidence would
manufacturer.116 In addition, the water content of seem to indicate that gentle agitation of these solutions
caries-affected dentine is believed to be greater than may assist with the etching. However, there are no
normal dentine. This too will also have an effect on the research data to support this.
118 Australian Dental Journal 2004;49:3.
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chemical bonding at biomaterial-hard tissue interfaces. J Dent
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26. Friedl KH, Powers JM, Hiller KA. Influence of different factors
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