OBSERVATIONS GORDON J. CHRISTENSEN, D.D.S., M.S.D., Ph.D.

Bonding to dentin and enamel

Where does it stand in 2005?
onding to enamel and, subsequently, bonding to dentin have been among the most significant advancements in dentistry in the past 50 years. Nevertheless, bonding to tooth structure is a relatively new phenomenon. Amalgam, zinc phosphate cement and early resin-based composites of the 1960s and 1970s did not bond to tooth structure, and it may be a surprise to some younger scientific investigators that these clinical techniques had no major longevity problems. When reading current scientific reports on dentin bonding, one easily might be misled to conclude that a few additional megapascals worth of bond makes a restoration with dentinal bonding material superior to a restoration completed with a bonding agent that has fewer megapascals bonding. Using similar logic, one may ask why the amount of micro-

leakage of dental materials, which can be decreased by some bonding agents, has become of high importance. This concern seems peculiar to many mature practitioners, who know that the most microleakage among all types of dental restorations occurs with two of the longestlasting types: gold-alloy restorations cemented with zinc phosphate cement and gold foil restorations. Have our concentration on bond and microleakage and the endless publications on these subjects gone too far? How much bonding is enough bonding, and when is bonding not important at all? Is the microleakage reduction effected by bonding agents really so vital clinically? These are important questions that appear to have defied answers. Clinicians, including me, were astonished to see success with enamel bonding in the early 1960s. The next anticipated

bonding advancement was producing bonds to dentin of strength similar to that of bonds to enamel. However, the success of bonding to dentin has required far more creative chemistry than merely etching tooth structure with phosphoric acid. Dentinal bonding has evolved through several generations of chemistry to arrive today at in vitro bonds reasonably comparable with those achieved with enamel bonding. Where are we today with regard to bonding to enamel and dentin? Some of the statements in this article will attempt to make clinical sense out of the many confusing allegations made by in vitro projects on bonding. I will address the current state of the art in enamel and dentinal bonding, make suggestions about the importance of achieving bonds to tooth structure and suggest when various bonding techniques should be used.
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ENAMEL BONDING TODAY

Experienced dental clinicians know that when resin-based composite is placed on properly etched enamel, regardless of how long the resin has been in service in the mouth, it is nearly impossible to remove the resin from the tooth without cutting it off. This fact is even more clearly evident if a clinician attempts to remove a ceramic veneer that has been bonded with resin cement to properly etched enamel. The veneer cannot be removed by force, irrespective of whether or not it has been in place for years. It must be cut away from the enamel with rotary instruments. Enamel bonding is one of the most significant advancements in dentistry in the 20th and 21st centuries, and it is the main reason for the clinical success of several restorative procedures. Such procedures include the bonding of ceramic veneers to etched enamel, the use of resinbased composite to close diastemas, the placement of sealants, the extension of Class V restorations onto beveled enamel surfaces and the placement of orthodontic brackets. However, in my opinion, the alleged necessity for enamel or dentinal bonding for retention purposes has been highly overemphasized for procedures such as amalgam placement. While minor changes continue to be made by manufacturers on the basis of research findings, the technique for enamel bonding has not changed significantly in the past halfcentury. It is predictable and long-lasting, and the success of enamel bonding is well-known to experienced clinicians. Enamel bonding has signifi1300 JADA, Vol. 136

cantly improved the ability of clinicians to carry out many dental procedures not possible before its introduction.
DENTINAL BONDING TODAY

Bonding to dentin has had a different, less successful and more erratic history than that of enamel bonding. Reports regarding the possibility of dentinal bonding 50 or more years ago were not optimistic. The early in vitro bonds achieved with then-available bonding agents were weak. In the ensuing years, research on bonding to dentin became the pet project of many scientists, and so-called adhesive dentistry evolved. Many generations of dentinal bonds were created, dentinal bonding products became better, dentinal bonds to tooth structure reported from in vitro studies were favorable and clinical dentists began awakening to the apparent value of dentinal bonding. Today, regardless of all the research showing effectiveness and longevity, the successful dentinal retention of restorations afforded entirely by dentinal bonding agents is suspect in the minds of experienced clinicians. It is a common experience to attempt to remove a restoration bonded to dentin, such as a veneer bonded almost entirely to dentin, only to find that the vibration of the cutting instrument shakes the bonded restoration from the tooth preparation and causes it to fly off the bonded surface. Why does this frustrating situation occur when the in vitro bond strengths of some dentinal bonding agents are reported to be as high as or higher than bond strengths reported with enamel bonds, and some bond longevity studies

show good in vitro retention of bonds to dentin? In my opinionwhich is based on my own clinical experience, observations in clinical study clubs and reports from practicing dentistsdentinal bonds depreciate during service in a way not observed with enamel bonds. In vivo longevity studies on the retention of dentinal bonds are sorely needed. Concomitant with the evolution of dentinal bonding has been the recognition that placing some direct and indirect dental restorations produced significant postoperative tooth sensitivity, in spite of being placed over the total-etching bonding agents available during the last decade. Examples of this unfortunate phenomenon have been the severe tooth sensitivity associated with resin cementation of ceramic or resin indirect restorations1 or the unpredictable postoperative tooth sensitivity associated with seemingly innocuous simple, shallow, Class I or II resinbased composites.2 Various techniques have been developed to prevent this sensitivity, including placing multiple coats of the dentin bonding agents, placing low-viscosity flowable resin restorative materials on top of the bonding agents, placing specially formulated desensitizing solutions, such as Gluma Densensitizer (Heraeus Kulzer, South Bend, Ind.) before placing the bonding agents, or placing a layer of resin-modified glass ionomer such as Vitrebond (3M ESPE, St. Paul, Minn.) or GC Fuji Lining LC (GC America, Alsip, Ill.) before placing the liquid bonding agent.3,4 The level of disagreement regarding scientific

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theories on how to prevent postoperative tooth sensitivity indicates the relative lack of consensus on dentinal bonding compared with enamel bonding. There appear to be well-founded reasons for clinicians obvious lack of confidence in some wellcontrolled, peer-reviewed, in vitro studies of dentinal bonding that often have beautiful microscopic photographs but little orientation on the researchers part toward clinical significance. The past 15 years have seen the appearance of many socalled self-etching dentinal bonding agents that have greatly reduced the incidence of postoperative tooth sensitivity.5 However, clinicians have found that both total-etching and selfetching bonding agents have significant uses (to be discussed later). In contrast to the dependability clinicians expect from enamel bonding, many clinical dentists have concluded that the primary reason to use dentinal bonding agents is to prevent postoperative tooth sensitivity. This empirical conclusion surely must antagonize and frustrate scientists involved primarily with in vitro testing of dentinal bonds, who have shown from their studies on extracted teeth that dentinal bonds are predictable over time when subjected to temperature changes ranging from 500 to 5,000 thermocycles. Yet, researchers should not be surprised that it appears that this level of thermocycling does not simulate clinical temperature change adequately. Again, clinical in vivo research is needed to substantiate or refute the longevity of dentinal bonding to teeth in the mouth. In the meantime, for many clinicians, any minor,

major or residual bond to dentin produced by dentinal bonding agents that remains over time is considered to be a bonus, not an assurance.
SUGGESTED USE OF BONDING AGENTS TODAY

Based on the clinical observations discussed in the previous narrative, the following suggestions appear to be appropriate. I expect that the suggestions will change as dentinal bonding studies move from primarily in vitro to in vivo for each specific clinical procedure. Resin-based composite restorations, Classes I through V. Total-etching dentinal bonds accomplished meticulously can be excellent,6

Many clinical dentists have concluded that the primary reason to use dentinal bonding agents is to prevent postoperative tooth sensitivity.

but many of them require several steps that can be confusing in a busy practice. Self-etching products are easier to use and more predictable in reducing or eliminating postoperative tooth sensitivity.5 Placement of resinmodified glass ionomer liners before using either category of bonding agents provides predictable tooth sensitivity prevention. When only a small amount of enamel is present on tooth preparations, I suggest placing mechanical retentive features, such as pins, potholes, channels or undercuts. Every bonded restoration that falls out is a significant loss of time and reduces the patients trust

and acceptance. By using mechanical retention in addition to dentinal bonding, the clinician can prevent these complications. Crowns or fixed prostheses cemented with resin cement. In my opinion, based on in vitro research and my own clinical observations, totaletching bonding agents do not predictably preclude postoperative tooth sensitivity in these situations.1 Self-etching liquids applied before use of resin cements are more predictable, but even these products are associated with some postoperative tooth sensitivity. Only resin cements with self-etching bonding agents incorporated into them, such as RelyX Unicem (3M ESPE) and Maxcem (Kerr, Orange, Calif.), provide predictable elimination of postoperative sensitivity when used with resin cements, as I have observed from the responses of clinicians in continuing education courses. Depending on dentinal bonds for retention when cementing crowns or fixed prostheses with resin cements should be the secondary reason for using dentinal bonding agents. Currently, the primary reason for their use is to reduce or eliminate postoperative tooth sensitivity. A well-known and trusted retention method for crowns can be accomplished easily and predictably at the seating appointment: making scratches with a rotary diamond instrument on the tooth preparation and on the internal aspect of the restoration. It is my opinion that the prevention of postoperative tooth sensitivity is more important when considering selection of a resin cement than is the bond to tooth structure that has
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been created. Can one expect to achieve bonding to teeth with zinc phosphate cement? These nonbonded restorations served for decades. Veneers cemented over enamel surfaces, sealants or any other restoration placed primarily on enamel surfaces. The total-etch concept using phosphoric acid is the procedure of choice in this situation, and this bond is totally predictable. Indirect veneers or toothcolored inlays or onlays cemented on tooth surfaces that are mostly dentin with some enamel present. To control the extent of etching, I suggest etching the enamel surfaces with phosphoric acid gel; washing the phosphoric acid off the tooth surface and placing a self-etching bonding product over the entire tooth prepara-

tion, including the previously phosphoric acidetched surfaces; seating the veneer with resin cement; and curing the bond and resin cement through the veneer. Bonding amalgam. In spite of the fact that some practices no longer use amalgam, its use will continue for many years. Some amalgams, especially spherical amalgams, are wellknown to cause postoperative tooth sensitivity. Self-etching bonding agents prevent this sensitivity.
SUMMARY

subject and blends research and clinical observations to make some logical conclusions about how and when to use the various enamel and dentinal bonding materials that are available today. s
Dr. Christensen is co-founder and senior consultant, Clinical Research Associates, 3707 N. Canyon Road, Suite 3D, Provo, Utah 84604. Address reprint requests to Dr. Christensen. The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. 1. Clinical Research Associates. Filled polymer crowns: 1- & 2-year status reports. Clin Res Associates Newsletter 1998;22(10): 1-3. 2. Christensen GJ. Preventing postoperative tooth sensitivity in Class I, II and V restorations. JADA 2002;133:229-31. 3. Christensen GJ. Self-etching primers are here. JADA 2001;132:1041-3. 4. Christensen GJ. Resin cements and postoperative sensitivity. JADA 2000;131:1197-9. 5. Clinical Research Associates. Self-etch primer (SEP) adhesives update. Clin Res Associates Newsletter 2003;27(11/12):1-5. 6. Christensen GJ. Tooth sensitivity related to Class I and II resin restorations. JADA 1996;127:497-8.

Bonding to acid-etched enamel is well-known, effective, predictable and long-lasting. Bonding to dentin has had a less satisfactory history to date, but it has been highly recommended and researched. This article discusses the controversies in this

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