Adhesive Dentistry and Endodontics: Materials, Clinical

Strategies and Procedures for Restoration of Access

Cavities: A Review
Richard S. Schwartz, DDS, and Ron Fransman, DDS
Abstract
The complexity of restorative dentistry has increased
greatly in recent years, with the myriad of products
used in adhesive dentistry. So too has the simple
matter of restoring access cavities after completion of
endodontic treatment. This review discusses current
methods of bonding to tooth structure, ceramic ma-
terials, and metals, with emphasis on those aspects
that are important to endodontics. Specific materials,
procedures and major decision making elements are
discussed, as well as how to avoid problems in com-
patibility between endodontic and restorative materi-
als.
Key Words
Access cavities, adhesive dentistry, endodontics, restor-
ative dentistry
Dr. Schwartz runs a private practice limited to Endodon-
tics, and is Clinical Assistant Professor, UT Health Science
Center at San Antonio, San Antonio, TX. Dr. Fransman runs a
private practice limited to Endodontics, Amsterdam, Nether-
lands.
Address requests for reprints to Dr. Schwartz, San Antonio,
TX 78257; E-mail: sasunny@satx.rr.com.
Copyright 2005 by the American Association of
Endodontists
A
t the tomb of the unknown endodontist, there is a plaque that reads Root canal
treatment is not complete until the tooth has been restored. A recent article
reviewed the overall topic of restoration of endodontically treated teeth (1). This review
will address in detail the important issues when restoring access cavities through nat-
ural tooth structure and restorative materials with emphasis on major decision making
elements, material selection and clinical procedures. It will focus on those aspects of
adhesive dentistry that are important and unique to endodontics.
Contamination of the Root Canal System
One of the primary goals of root canal treatment is to eliminate bacteria from the
root canal system to the greatest possible extent (2, 3). Bacteria have been shown to be
the etiology for apical periodontitis (4) and to be the cause of endodontic failure (2, 3,
5). One of the goals in restoring of the tooth after root canal treatment should be to
prevent recontamination of the root canal system. Gross contamination can occur
during the restorative process from poor isolation or poor aseptic technique. Contam-
ination can also occur from loss of a temporary restoration or if leakage occurs. The
same things can occur with a permanent restoration, but permanent materials tend
to leak less than temporary materials (6). Exposure of gutta-percha to saliva in the pulp
chamber results in migration of bacteria to the apex in a matter of days (2, 79).
Endotoxin reaches the apex even faster (10).
The importance of the coronal restoration in successful endodontic outcomes is
widely accepted and has been supported by studies by Ray and Trope (11), Hommez et
al. (12), Tronstad et al. (13), Iqbal et al. (14), and Siqueira et al. (2). However, studies
by Riccuci et al. (15), Ricucci and Bergenholz (16), Heling et al. (17), and Malone et
al. (18) indicate that contamination may not as important a factor in failure as is
commonly believed. Therefore, it must be concluded that the significance of bacterial
contamination as a cause of endodontic failure is not fully understood. Because there is
clearly no benefit to introducing bacterial contamination into the root canal system, and
since it may be a contributing factor in endodontic failure, a basic premise of this review
will be that every effort should be made to prevent contamination.
Temporization
To minimize the likelihood of contamination, immediate restoration is recom-
mended upon completion of root canal treatment (1921).
When immediate restoration is not possible, and the tooth must be temporized, a
thick layer of temporary material should be used, preferably filling the whole chamber.
The majority of restorative dentists prefer a cotton pellet in the chamber, however (22).
If a cotton pellet or sponge is to be use, orifice barriers are recommended, to provide
a second layer of protection against contamination in addition to the temporary material
at the occlusal surface.
Recommended procedure for placing orifice barriers:
1. Countersink the orifice with a round bur.
2. Clean the orifices and floor of the pulp chamber thoroughly with alcohol or a
detergent to remove excess cement and debris. Air abrasion provides a dentin
surface that is free of films and debris.
3. Place a temporary or permanent restorative material in the orifices and over
the floor of the chamber.
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JOE Volume 31, Number 3, March 2005 Restoration of Access Cavities 151
A bonded material such as composite resin or glass ionomer ce-
ment is preferred (2327). Temporary materials may also be used
(28). Mineral trioxide aggregate (MTA) may also be used (29). There
is probably some benefit to using a material that is clear so that the
restorative dentist can see the underlying obturating material if re-entry
is needed into the canal system (1) (Fig. 1).
Results varied in studies that evaluated temporary materials for the
access cavities (21, 3036). The most common materials tested were
zinc oxide eugenol (such as IRM, Dentsply Int.), zinc oxide/calcium
sulfate (Cavit, Premier Corp.) or resin based materials including com-
posite resin and resin modified glass ionomer materials. Generally, all
of the temporary materials were adequate if placed in a thickness of 3
mm or greater (21, 3336).
All temporary materials leak to some extent (20, 21, 3740). The
zinc oxide/calciumsulfate materials are more resistant to microleakage
than the zinc oxide eugenol materials (21, 34), probably because of
setting expansion and water sorption (33). Although the zinc oxide
eugenol materials tend to leak more, they possess antimicrobial prop-
erties, making them more resistant to bacterial penetration (21, 34,
41). Both materials are simple to use. One study reported less leakage
with the use of two materials in combination (42).
Resin based temporary materials must be bonded to provide an
effective seal, because they undergo polymerization shrinkage of 1 to
3% (30, 43). This is offset somewhat by the fact that they swell as they
absorb water (30). Generally, bonded resin materials provide the best
initial seal, but lack antimicrobial properties (30). They require more
steps and more time to place than materials such as IRM or Cavit.
Bonded resins are recommended for temporization that is likely to last
more than 2 to 3 wk (42, 44). Resin modified glass ionomer materials
are also a good choice for long term temporization, because they pro-
vide a bond to dentin and enamel, and many have antimicrobial prop-
erties (44).
Teeth requiring temporary post/crowns are a particular challenge,
because of the difficulty in obtaining a good seal (45, 46). To minimize
Figure 1. (A) The pulp chamber has been thoroughly cleaned. (B) There was 37% phosphoric acid applied to the orifices and floor of the chamber for 15 s. (C) The
floor and orifices are sealed with unfilled resin. (Courtesy of Dr. Fred Barnett, Philadelphia.)
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152 Schwartz and Fransman JOE Volume 31, Number 3, March 2005
the chances of contamination of the obturating material, a barrier may
be placed over it with a self-curing material. The post space should be
restored as soon as possible and it may be beneficial to flush the post
space with an antimicrobial irrigant when the temporary post is re-
moved.
Restoring Access Openings
When an access opening is made through an existing restoration,
several things should be considered. Removal of all existing restorations
is desirable if possible, because it allows more complete assessment for
the presence of cracks and caries (47). This is particularly recom-
mended for old class 1 and class 2 restorations, because they are likely
to be removed later anyway, in the process of preparing the tooth for a
crown. Magnification and caries detector are helpful in identifying
cracks and for complete removal of caries (48).
If the existing restoration is a crown or onlay that appears to be
clinically satisfactory and replacement is not planned, the chamber and
internal restorative materials should be examined carefully with mag-
nification. Caries detector should be painted on the internal tooth sur-
faces. Any areas stained by the caries detector, particularly adjacent to
restorations, should be examined carefully for softness or gaps (Fig. 2).
Caries detector may also stain sound areas of dentin that have decreased
mineral content (49). The key to the presence of caries is determined by
whether the stained areas are hard or soft. Many times caries can be
identified internally, necessitating replacement of the crown.
Access openings made through an existing restoration results in
loss of retention (5052) and strength (53). When the access opening
is restored, loss of retention is reversed (51, 52). If a post is added,
additional retention is gained (51).
Ideally, we would like to restore access cavities with a restorative
material that provides a permanent, leak proof seal. Unfortunately, no
such material is available. All materials that we use and restorations that
we place leak to some extent. This includes intracoronal restorations
including bonded resin and glass ionomer materials (38, 54) as well as
the metal or ceramic extra-coronal restorations (55, 56). To minimize
leakage, bonded restorations are recommended, regardless of the re-
storative material (6, 57).
Access openings are made through a number of different restor-
ative materials, including gold alloys, base metal alloys and porcelain, as
well as enamel and dentin. Bonding to each of these substrates present
specific challenges which require specific strategies and materials. Of-
ten the access opening is prepared through two or three different sub-
strates. The structural integrity of the tooth may also influence the
choice of restorative materials. Each substrate will be addressed sepa-
rately.
Bonding to Enamel
Enamel is often present along the margins of access preparations
of anterior teeth. The resin bond to etched enamel is strong and dura-
ble. The technique dates back to 1955 (58). Etching of enamel with an
acid such as 30 to 40% phosphoric acid results in selective dissolution
of the enamel prisms and creates a surface with a high surface energy
that allows effective wetting by a low viscosity resin. Microporosities are
created within and around the enamel prisms that can be infiltrated with
resin and polymerized in-situ (59). These resin tags provide micro-
mechanical retention. Bond strengths are typically in the range of 20
megapascals (Mpa) (60). Megapascals are a measure of the force per
unit area that is required to break the bond. Self-etching adhesive sys-
tems, which will be discussed in the section on bonding to dentin, etch
ground enamel fairly well, but do not etch unground, aprismatic enamel
effectively (6163). Therefore, enamel margins should be beveled
when using self-etching adhesive systems. It is critical to prevent con-
tamination of etched enamel with blood, saliva or moisture (64). Poorly
etched enamel leads to staining at the margins of the restoration (65).
A good enamel bond protects the underlying dentin bond which is less
durable (66).
Bonding to Metal-Ceramic and All-Ceramic
Restorations
Access cavities are often made through metal-ceramic or all-ce-
ramic materials, so attaining an effective, durable bond is important
when restoring them. The literature is unambiguous that the best
method to bond to porcelain is to first roughen the surface by acid
etching and then apply a silane coupling agent, followed by the resin
(6770). Bond strengths of 13 to 17 Mpa have been reported, and
failure is often cohesive within the porcelain, meaning that the interfa-
cial bond strength exceeds the strength of the porcelain itself (7173).
Bonding to porcelain was initially developed as a method for repair of
fractured metal-ceramic crowns. Improvements in the technique al-
lowed porcelain veneers to become a common clinical procedure.
Etched ceramic materials form a strong, durable bond with resin (74).
Micro mechanical bonding can be attained by roughening the
porcelain with a bur, air-abrasion or etching with hydrofluoric acid.
However, acid etching is the most effective method (73, 75, 76). The
first to introduce acid etching of porcelain was Calamia in 1983 (77).
Adhesion between the resin and porcelain may be enhanced by the
use of a silane-coupling agent. Silane acts as a surfactant to lower sur-
face tension and forms double bonds with OH groups in the porcelain,
forming a siloxane bond. At the other end of the silane molecule is a
methacrylate group that copolymerizes with resin. The use of a silane-
coupling agent with porcelain was first described by Rochette in 1975
(78).
Hydrofluoric Acid
Hydrofluoric acid provides greater surface roughness to porcelain
than air abrasion or roughening with a bur (75). It works by dissolving
the glass particles (leucite) within the porcelain (Fig. 3). Most of the
porcelains used in metal-ceramic restorations are feldspathic porce-
lains that contain leucite. Some ceramic materials, such as low fusing
porcelains, do not contain leucite and are not etched effectively by
Figure 2. Caries detector was applied to the inside of an access cavity. Note how
the caries detector accentuates the caries under the composite buildup. (Cour-
tesy of Dr. Gary Carr, San Diego.)
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JOE Volume 31, Number 3, March 2005 Restoration of Access Cavities 153
hydrofluoric acid (79). However, hydrofluoric acid is effective with
most of the current ceramic restorative materials (8083).
Hydrofluoric acid is usually provided in a 10% concentration in a
syringe. It is very important to followthe manufacturers instructions, as
an application time that is too short will produce an inadequate etch,
while an application time that is too long may render the porcelain
brittle and thus more prone to fracture (84).
Silane
Silane acts as a coupling agent enhancing the bond between the
resin and ceramic materials. It is supplied premixed or as a two bottle
systemthat is mixed at the time of use. It is applied to the etched surface
and must be thoroughly air dried (85). A low viscosity resin adhesive is
then flowed over the surface and polymerized. Once again, it is very
important to follow the manufacturers instructions.
Silane has a limited shelf life. Storage in the refrigerator will extend
its useful life, but it should be used at room temperature (86). The two
bottle silanes have the longest shelf life (71). Silane that is past the
expiration date or that contains precipitates should be discarded (86).
Air Abrasion
Air abrasion is sometimes recommended to clean the porcelain
and provide surface roughness. Several companies sell micro-etchers
that can be used chairside. Aluminum oxide particles are sprayed onto
the surface at about 80 psi. Fifty micron particles have been shown to
produce a more retentive surface than 100 m particles (87). Two
studies reported that air abrasion has a negligible effect on bond
strength, however (76, 88). Etching and application of silane are the
two most important steps.
Cosmetics
When restoring the access cavity of a ceramic crown, it is often a
challenge to produce a good cosmetic result. Many times it is difficult to
mask the underlying metal of a metal-ceramic crown. This is particu-
larly true if the porcelain is thin. It is not uncommon to see the metal
showing through the composite. The second challenge is to match the
optical properties of the porcelain. This is true for metal-ceramic
crowns as well as all-ceramic crowns. Most composites are too low in
value (too gray and translucent) to effectively match the surrounding
porcelain (Fig. 4).
Several products are available that may be used to mask the un-
derlying metal before the restorative composite is placed. Most of these
are composite resins that contain opaquers. They may be covered with
more translucent composite materials. Several composites are available
that are quite opaque and work well when restoring access cavities in
metal-ceramic crowns. Composite stains can be used to accentuate pits
and fissures to further enhance the cosmetic result (Fig. 5).
Bonding to Metal
The metal portion of metal-ceramic crowns is not usually signifi-
cant when restoring access openings, so no extra procedures are nec-
essary to deal with it. However, for crowns in which all or part of the
occlusal surface is metal, adhesion may be desirable. Adhesion to metal
is generally obtained by mechanical means. Surface roughness may be
created with a bur or air abrasion, which provides micromechanical
retention (89). Chemical adhesion is also possible with metals that form
an oxide layer (90). Silane has no effect on bonding to metal (91).
Several studies have shown tin plating of metal enhances mechan-
ical retention (9296). Chromiumplating also works well (96). Plating
devices are available that can be used intraorally. Although effective, this
Figure 5. With knowledge of color, translucency and occlusal anatomy, beau-
tiful results are achievable when restoring access cavities with composite resins.
Figure 3. SEMof etched porcelain. (Courtesy of Dr. Bart VanMeerbeek, Leuven,
Belgium.)
Figure 4. Most restorative composites are too translucent (gray) to provide a
good match when restoring access cavities in metal-ceramic crowns.
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154 Schwartz and Fransman JOE Volume 31, Number 3, March 2005
procedure has never gained popularity. Metal primers are an alternative
that enhances the bond between metal and resin. They have been shown
to be effective and do not require any special equipment (9799).
Bonding to Dentin: Resin Materials
Bonding to dentin with resin materials is more complex than
bonding to enamel or porcelain. Dentin consists of approximately 50%
inorganic mineral (hydroxyapatite) by volume, 30% organic compo-
nents (primarily type 1 collagen) and 20% fluid (100). The wet envi-
ronment and relative lack of a mineralized surface made it a challenge
to develop materials that bond to dentin. Current strategies for dentin
adhesion were first described by Nakabayashi in 1982 (101), but his
ideas were not widely accepted for a number of years. Nakabayashi
showed that resin bonding to dentin could be obtained by applying an
acid to expose the collagen matrix and dentinal tubules, applying a
hydrophilic (water loving) resin material to the demineralized sur-
face and polymerizing the resin in situ. The collagen matrix and dentin
tubules, to a lesser extent, provide mechanical retention for the resin.
Although not as durable and reliable as enamel bonding, steady im-
provements have been made in dentin bonding and in simplifying den-
tin-bonding procedures.
Most in vitro studies of dentin bonding report on bond strengths,
microleakage, or both. Like enamel, bond strengths are usually re-
ported in Mpa. Depending on the test method used, initial bond
strengths can be obtained that are equal or greater to those of etched
enamel. However, dentin bonding is not as durable as enamel bonding
or as stable. It is well documented that bond strengths decrease with
time and function. This has been shown in vitro (66, 102109) and in
vivo (110, 111). Microleakage is probably a more important issue to
endodontics than bond strength. None of the current adhesive systems
are capable of preventing microleakage over the long term (65, 112
117). There is not a direct relationship between bond strength and
microleakage (116).
Dentin adhesive systems utilize an acid as the first step of the
bonding process to remove or penetrate through the smear layer and
demineralize the dentin surface. The smear layer covers the surface of
ground dentin and consists of ground up collagen, hydroxyapatite, bac-
teria, and salivary components (59). Most dentin adhesive systems can
be categorized as etch and rinse or self etching, based on the acid
etching process (59).
Etch and Rinse Adhesives
Most of the etch and rinse adhesive systems utilize a strong acid
such as 30 to 40%phosphoric acid. When phosphoric acid is applied to
dentin, the surface is demineralized to a depth of about 5 m. The acid
is rinsed off after about 15 s, removing the smear layer and exposing the
collagen matrix and network of dentinal tubules for resin bonding. A
hydrophilic primer is then applied to the surface to infiltrate the colla-
gen matrix and tubules. The primer contains a resinous material in a
volatile carrier/solvent, such as alcohol or acetone, which carries the
resinous material into the collagen matrix and dentinal tubules. The
surface must be wet (moist) for the primer to penetrate effectively. After
the primer is in place a streamof air is used to evaporate the carrier and
leave the resin behind. A hydrophobic (water hating) resin monomer
(adhesive) is then applied and polymerized, which adheres to the infil-
trated resin from the primer. A hybrid layer or interdiffusion zone
is formed that consists of resin, collagen and hydroxyapatite crystals
(59) (Fig. 6). It bonds the hydrophobic restorative materials to the
underlying hydrophilic dentin. Poor bond strengths and increased mi-
croleakage result from excessive etching (118). The same is true if
residual carrier/solvent is left behind (119), which makes the bond
more subject to hydrolytic breakdown (119).
Self Etching Adhesives
Most of the self etching products combine an acid with the
primer. Rather than removing the smear layer, they penetrate through it
and incorporate it into the hybrid layer. The acidic primer is applied
to the dentin surface and dried with a stream of air. There is no rinsing
step. A resin adhesive is then applied and polymerized, followed by the
restorative material.
The self etching systems can be categorizes as strong or ag-
gressive (pH 1), moderate (pH 12) or mild (pH 2) (59,
120, 121). The strong self etching systems form a hybrid layer of
approximately 5 m in thickness, similar to phosphoric acid, whereas
the mild systems form a hybrid layer of about 1 micron (120, 121).
There does not appear to be clinical significance to this difference in
thickness, however (121). The strong systems generally produce a
superior bond to enamel than the weak systems (59), particularly
with unground enamel (6163).
Dentin Adhesive Generations
Many of the etch and rinse adhesive systems require three steps
(etch, primer, adhesive), and are known as 4th generation adhesive
systems. The generation of a dentin adhesive generally follows the
order in which they were developed and each generation utilizes
different bonding procedures. The 5th generation adhesive systems
are etch and rinse, followed by application of a combined primer and
adhesive. These are sometimes referred to single bottle adhesive sys-
tems. Some require several applications of the primer/adhesive, how-
ever. The 6th generation adhesives utilize an acidic (self etching)
primer followed by an adhesive. The 5th and 6th generations are gen-
erally two step procedures, while the 7th generation combines every-
thing (acid, primer and adhesive) into one step.
Many of the self etching products require fewer steps and less
time than the etch and rinse products, and are considered to be less
technique sensitive (59). There are still a number of questions about
them, however, such as the unknown effects of incorporating partially
dissolved hydroxyapatite crystals and smear layer into the hybrid layer.
There is also the question of how much of the carrier/solvent remains
behind. Because they are relatively new, there are currently no long-term
Figure 6. SEM of a demineralized specimen showing resin penetration into the
hybrid layer and dentinal tubules. (Courtesy of Dr. Bart VanMeerbeek, Leuven,
Belgium.)
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JOE Volume 31, Number 3, March 2005 Restoration of Access Cavities 155
clinical studies with the self etching adhesive systems. The three step
adhesive systems generally perform better in in vitro testing than the adhe-
sive systems that combine steps (59, 65, 66, 107, 121, 122), although the
differences lessen with time as the bonds degrade (66, 107). The self
etching adhesive systems are also less effective than the etch and rinse
systems when bonding to sclerotic dentin and caries effected dentin (123,
124). They also have compatibility problems with some composite restor-
ative materials, which will be discussed in the section on self-cure and
dual-cure composites. The single step (7th generation) adhesives are a
fairly recent addition to the market. At this point in their development, they
produce consistently lower bondstrengths invitrothanthe others (59, 107,
121, 125) and are not compatible with self-cure or dual-cure composites
(126). Most of the current research is directed toward improving the per-
formanceof thesimplifiedadhesivesystems, andthey will probably continue
to improve. Some of the common acronyms used in resin bonding are
shown in Table 1. Examples of commercial dentin bonding systems are
shown in Table 2.
Wet Bonding
Most adhesive systems utilize wet bonding. If the etched dentin
surface is dried excessively, the collagen matrix collapses and prevents
effective infiltration of the primer. The result is low bond strengths and
excessive microleakage (127129). Excessive moisture has similar
negative effects on adhesion (128, 129). An effective method to provide
the proper amount of moisture is to dry the surface thoroughly and then
rewet it with a moist sponge, so that the surface is damp, but there is no
visible pooling (127, 130).
Bonding to Dentin: Traditional Glass Ionomer Cements
Glass ionomer cements are made primarily of alumina, silica and
polyalkenoic acid and are self curing materials. Most glass ionomer
cements release fluoride for a period of time after initial placement.
They are the only restorative materials that depend primarily on a chem-
ical bond to tooth structure (131). They form an ionic bond to the
hydroxyapatite at the dentin surface (132) and also obtain mechanical
retention frommicroporosities in the hydroxyapatite (133). Glass iono-
mer materials formlower initial bond strengths to dentin than resins, on
the order of 8 Mpa. But unlike resins, they form a dynamic bond. As
the interface is stressed, bonds are broken, but new bonds form. This is
one of the factors that allow glass ionomer cements to succeed clini-
cally, despite relatively low bond strengths. Other factors are low poly-
merization shrinkage and a coefficient of thermal expansion that is
similar to tooth structure. Some glass ionomer materials also possess
antimicrobial properties (134136).
When placing glass ionomer cements, the surface is cleaned and
then treated with a weak acid such as polymaleic acid (131). The acid
removes debris from the dentin surface, removes the smear layer, and
exposes hydroxyapatite crystals. It creates microporosities in the hy-
droxyapatite for mechanical retention, but there is minimal dissolution
(131, 133). Because glass ionomer cements rely on ionic bonding to
the hydroxyapatite, strong acids should be avoided because they cause
almost total elimination of mineral from the dentin surface (137).
Traditional glass ionomer cements are not widely used for clinical
procedures because they set slowly and must be protected from mois-
ture and dehydration during the setting reaction, which in many cases is
not complete for 24 h. They are also relatively weak and generally not as
esthetic as other restorative materials.
Bonding to Dentin: Resin Modified Glass Ionomer
Materials
Resin modified glass ionomer (RMGI) materials were developed
to overcome some of the undesirable properties of the traditional glass
ionomer cements. RMGI materials contain glass ionomer cement to
which a light-cure resin is added. The purpose of the resin is to allow
immediate light polymerization after the material is placed. The resin
also protects the glass ionomer cement fromdehydration, and improves
the physical and mechanical characteristics and optical properties.
True RMGI materials utilize similar bonding procedures as glass iono-
mer cements and do not require a dentin-bonding agent.
Endodontic Issues in Dentin Bonding
Some of the materials used in endodontics may have a significant
impact on the bonding process. These issues apply not only to restora-
TABLE 1 Common abbreviations used in dental adhesive literature
Bis-GMA Bisphenol glycidyl methacrylate Unfilled resinThe original acrylic matrix material in composite resins
EDTA Ethylenediaminetetracitic acid Chelating agent sometimes used to remove the smear layer and
demineralize the dentin
HEMA Hydroxyethyl methacrylate Low viscosity hydrophilic acrylic monomer used in dentin adhesive
systems
4-Meta 4-Methacryloxyethyl trimellitate anhydride Low viscosity acrylic monomer used in dentin adhesives. Also used for
metal bonding
MMA Methyl methacrylate Basic acrylic molecule
NPG-GMA N-Phenylglycine glycidyl methacrylate Low viscosity hydrophilic acrylic monomer used in dentin adhesives
PMDM Pyromellitic acid dimdiethylmethacrylate Low viscosity hydrophilic acrylic monomer used in dentin adhesives
TEG-DMA Triethylene glycol dimethacrylate Low viscosity hydrophilic acrylic monomer used in dentin adhesives
UDMA Urethane dimethacrylate Unfilled resin. Alternative composite matrix material for composites.
Sometimes combined with Bis-GMA
TABLE 2. Selected dental adhesive systems
All-Bond 2 Three step, etch and rinse, 4
th
generation Bisco
OptiBond Total Etch Three step, etch and rinse, 4
th
generation Kerr
Scotchbond Multipurpose Three step, etch and rinse, 4
th
generation 3 M
One Step Two step, single bottle, etch and rinse, 5
th
generation Bisco
Prime&Bond Two step, single bottle, etch and rinse, 5
th
generation Dentsply
Clearfil SE Two step, self-etching, 6
th
generation Kuraray
OptiBond Solo SE Two step, self-etching, 6
th
generation Kerr
Prompt L-Pop 2 One step, self-etching, 7
th
generation 3 M/ESPE
I-Bond One step, self-etching, 7
th
generation Kulzer
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156 Schwartz and Fransman JOE Volume 31, Number 3, March 2005
tion of access cavities, but also to the obturating materials that utilize
adhesive resin technology, which will be discussed in a subsequent
article.
Eugenol
In endodontics, eugenol containing materials are widely used in
sealers and temporary filling materials. Eugenol is one of many sub-
stances that can prevent or stop the polymerization reaction of resins
(138) and can interfere with bonding (139). If resin bonding is planned
for a dentin surface that is contaminated with eugenol, additional clin-
ical steps are needed to minimize the effects of the eugenol. The surface
should be cleaned with alcohol or a detergent to remove visible signs of
sealer. Many temporary cements, whether they contain eugenol or not,
leave behind an oily layer of debris that must be removed before bond-
ing procedures (140, 141). Air abrasion is an effective method for
cleaning the dentin surface (Fig. 7). Once it is clean, the dentin should
be etched with an acid, such as phosphoric acid and then rinsed. The
acid demineralizes the dentin surface to a depth of about 5 m and
removes the eugenol rich layer. Several studies have shown that the
total etch (three step) procedure allows effective bonding to eugenol
contaminated dentin surfaces (24, 142). An etch and rinse adhesive
system should be used, because the self etching systems incorporate
the eugenol rich smear layer into the hybrid layer, rather than removing
it. Eugenol has no effect on glass ionomer cements (143).
Sodium Hypochlorite
Sodium hypochlorite is commonly used as an endodontic irrigant
because of its antimicrobial and tissue dissolving properties (144).
Sodium hypochlorite causes alterations in cellular metabolism and
phospholipid destruction. It has oxidative actions that cause deactiva-
tion of bacterial enzymes and causes lipid and fatty acid degradation
(144).
Several studies have shown that dentin that has been exposed to
sodium hypochlorite exhibits resin bond strengths that are significantly
lower than untreated dentin (145149). One study reported bond
strengths as low as 8.5 Mpa (147). Increased microleakage was also
reported (150). This phenomenon probably occurs because sodium
hypochlorite is an oxidizing agent, which leaves behind an oxygen rich
layer on the dentin surface. Oxygen is another substance that inhibits the
polymerization of resins (151). Morris et al. showed that application of
10% ascorbic acid or 10% sodium ascorbate, both of which are reduc-
ing agents, reversed the effects of sodium hypochlorite and restored
bond strengths to normal levels. Lai et al. and Yiu et al. reported similar
results (149, 150). Because sodiumhypochlorite is likely to remain the
primary irrigant used in endodontics for the near future, and because
adhesive resin materials are used routinely in restoring endodontically
treated teeth, this issue will have to be addressed. Future adhesive resin
products for endodontic applications may contain a reducing agent to
reverse the effects of the sodium hypochlorite. A nonoxidizing irrigant
would also solve this problem. Sodiumhypochlorite and EDTA have also
been shown to reduce the tensile strength and microhardness of dentin
(152). These are particularly timely issues for endodontics as adhesive
resin materials gain popularity as obturating materials.
Other Materials Applied to Dentin
Other materials that are applied to dentin during endodontic pro-
cedures have been tested for their effects on bonding. Not surprisingly,
hydrogen peroxide leaves behind an oxygen rich surface that inhibits
bonding (147, 148). Reduced bond strengths were shown after the use
of RC prep (Premier) (146). Electro-chemically activated water has
gained a following as an irrigating solution. It probably reduces bond
strengths of adhesive resins because it has the same active ingredient as
sodium hypochlorite, i.e. hypochlorous acid (153, 154). No loss of
bond strength is reported from chlorhexidine irrigation before resin
bonding (147, 155, 156) or placement of resin-modified glass ionomer
materials (157). Caries detector did not affect resin bond strengths
(158, 159), but chloroformand halothane resulted in significant loss of
bond strength (160).
Restorative Materials
Silver Amalgam Alloy
Not surprisingly, silver amalgam alloy is the most common choice
for restoring access cavities in metal crowns (161). The clinical tech-
nique is simple, with few steps, and provides a durable restoration.
Bonded amalgam is often recommended (57) in which a resin adhe-
sive is placed on the cavity walls before condensation of the amalgam
alloy. The adhesive provides an immediate seal. When amalgam alloy is
used without an adhesive, it leaks initially, but self seals with time as
corrosion products form at the amalgam interface with tooth structure
or other restorative materials (162). One strategy to use with amalgam
alloy, that offers theoretical advantages, is to seal only the chamber floor
and orifices with adhesive resin to provide initial protection of the root
canal system from contamination. With time the amalgam restoration
will corrode at the other interfacial areas and provide a seal that may be
more durable than resin.
There is a theoretical advantage to using ad-mixture alloys over
pure spherical alloys. Ad-mixture refers to a mixture of spherical and
lathe cut particles. Ad-mixture alloys have slight setting expansion,
which tends to reduce leakage (163), whereas spherical alloys shrink
slightly while setting (163).
Composite Resin
Not surprisingly, composite resin is the most common choice for
restoring access cavities in ceramic restorations (161). Composite can
be bonded to tooth structure and most restorative materials, and can
provide a good match of color and surface gloss. Bonded composite
materials can also strengthen existing coronal or radicular tooth struc-
ture, at least in the short term (164, 165).
The limitations of composite resin as a restorative material are
primarily related to polymerization shrinkage. Restorative resins are
reported to exhibit shrinkage in the range of 2 to 6% during polymer-
ization (43, 166). Less filler (such as found in flowable composites)
results in more shrinkage (166, 167). Polymerization shrinkage causes
stress on the adhesive bond that often results in gap formation (43).
One study reported the percentage of dentinal gaps found in vivo was 14
to 54%of the total interface (168). Marginal deterioration of composite
restorations expedites the loss of dentin adhesion (169).
Composite restorative materials come in several forms: light-cure,
self- (chemical) cure or dual-cure. Light-cure materials consist of a
Figure 7. Example of the cleaning effect of sandblasting. Cleaning with alcohol
and chloroformleft a filmon the dentin surface, shown in the first picture. Note
how much cleaner the dentin appears in the second picture, after microabra-
sion (Courtesy of Dr. Fred Tsusui, Los Angeles).
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JOE Volume 31, Number 3, March 2005 Restoration of Access Cavities 157
single paste and polymerization is initiated with a curing light. Self-cure
materials consist of two pastes that are mixed together to initiate poly-
merization. Dual-cure materials also consist of two pastes that are
mixed together to initiate polymerization, but may also be light activated.
Dual-cure materials have the advantage of rapid polymerization in the areas
irradiated by the curing light, but chemical polymerization occurs in areas the
light can not reach.
Light-cure materials polymerize in a matter of seconds and
generally have the best physical properties. However, they have sev-
eral disadvantages. Because of the rapid polymerization, they tend to
stress the adhesive bond to tooth structure more than the slower
self-cure composites (167). The stress is sometimes so great that
the restorative material debonds at the weakest interface (43, 170).
For example, in class 5 composite restorations, they tend to debond
at the interface with cementum, which forms a weaker bond than
enamel (54). Because most curing lights can only effectively poly-
merize a thickness of 2 to 3 mm of composite material, cavities must
be filled incrementally, a time consuming and tedious task. An ac-
cess cavity may require 3 to 5 increments. Because curing lights lose
intensity with distance, the light intensity may be greatly reduced at
the floor of the chamber when curing through an access opening in
a crown. In addition, it may not be possible to irradiate all areas
inside an access cavity because of undercuts or difficulty in obtain-
ing the proper angle with the light.
Self-cure materials may be bulk filled because they do not require
penetration with a curing light. They polymerize more slowly than light-
cure materials, allowing the material to flow during polymerization
contraction, and placing less stress on the adhesive bond (43, 167). The
Figure 8. (A) The access cavity is clean and ready to restore. (B) There was 10% hydrofluoric acid applied to the porcelain for 1 min and then rinsed thoroughly.
(C) There was 37%phosphoric acid applied to the dentin and porcelain for 15 to 20 s. It demineralizes the dentin surface and cleans the porcelain. (D) The porcelain
is thoroughly air dried and silane is applied and dried.
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158 Schwartz and Fransman JOE Volume 31, Number 3, March 2005
same is true for dual-cure materials in the areas that are not irradiated
by the curing light.
The problem with polymerization shrinkage is amplified in
access cavities because of a concept known as C-factor or configu-
ration factor (43, 167). C-factor refers to the ratio of bonded sur-
faces to free or unbonded surfaces. The higher the C-factor, the
greater the stress from polymerization shrinkage (43). Restorations
with C-factor higher than 3:1 are considered to be at risk for
debonding and microleakage (170). In a class 5 restoration, the
ratio might be 1:1. In an access cavity, the C-factor might be 6:1 or
even 10:1. In a root canal system obturated with a bonded resin
material, it might be 100:1 (43).
An incremental filling technique with light-cure composite resins
partially overcomes the problem of C-factor. Incremental filling is pos-
sible because atmospheric oxygen prevents complete polymerization on
the external surface of the resin. This oily surface is referred to as the
Figure 8 (continued). (E) A dentin primer is applied to all internal surfaces and air dried, and a dentin adhesive is applied to all internal surfaces and light
polymerized. (F) A flowable composite is injected into the orifices and on the chamber floor and polymerized. This method minimizes voids between the restorative
material and dentin. Because it is somewhat translucent, it makes location the canals easier if re-entry is necessary at a later time. (G) Incremental build-up, light
composite over dark. Increments should be only 2 to 3 mm in thickness to allow adequate polymerization. (H) Application of opaque composite. This is often
necessary when restoring metal-ceramic crowns that tend to be quite opaque.
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JOE Volume 31, Number 3, March 2005 Restoration of Access Cavities 159
oxygen inhibited layer (151). Because of the unpolymerized surface
layer, additional increments may be added and polymerized and a
strong chemical bond is formed between increments (151). Incremen-
tal filling allows complete polymerization of each increment, and less-
ens the stress from polymerization shrinkage (171, 172) because the
C-factor is more favorable for each increment than if the cavity was bulk
filled. Another strategy to lessen the effects of C-factor is to use slow
setting self-cured materials that flowduring polymerization, thus reduc-
ing stress (31, 167).
If contamination occurs with blood or saliva during incremental
filling, the bond between increments may be ruined. However, if the
surface is rinsed, dried and a dentin adhesive is applied, there is no loss
of bond strength (173).
Glass Ionomer Cement and Resin Modified Glass Ionomer Materials
Both types of glass ionomer materials may be bulk filled. Most of the
RMGI materials are dual-cure. Traditional glass ionomer cements are self-
cure andhave very little polymerizationshrinkage. Because resinis addedto
RMGI materials, they exhibit some polymerization shrinkage, although less
than composite resins. Both types of glass ionomer materials are useful for
bulk filling access cavities. Even though they bond to tooth structure, the
bondstrengths are toolowtoprovide significant strengthening effect (174).
Material Incompatibilities
The self etching adhesive systems have generally been shown to
result in low bond strengths when used with self-cure composites and
Figure 8 (continued). (I) Ocre colored modifiers are placed in the grooves. (J) Cusp inclines and triangular ridges are built up. (K) Brown modifiers are added to
the grooves and occlusion is checked. (L) Final result.
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160 Schwartz and Fransman JOE Volume 31, Number 3, March 2005
dual-cure composites that have not been light activated (126, 175
178). This is in part because of residual acid on the dentin surface.
Self-cure composites contain tertiary amines in the catalyst that initiate
the polymerization reaction and have a high pH. Loss of bond strength
results because residual acid from the acidic primer inhibits the basic
amines, resulting in incomplete polymerization at the interface between
the adhesive and the restorative material (175, 176, 179, 180). Dual-
cure composites exhibit bond strengths comparable to light-cure com-
posites in the areas that are effectively light-cured (177), because they
are not dependent on the basic amines. One study reported lower bond
strengths with the self-cure composites than light-cure composites with
etch and rinse, single bottle (5th generation) adhesives as well (181).
The second problem with many of the self etching adhesive
systems is that they act as permeable membranes. This is a problem
when they are used with restorative materials that polymerize slowly. A
permeable adhesive layer allows penetration of moisture from the den-
tin to the interface with the restorative material, which is hydrophobic
(122, 179). Moisture penetration can result in a phenomenon known in
polymer chemistry as emulsion polymerization, in which there is
poor adaptation between the adhesive and restorative material (122).
Moisture at the interface probably also contributes to the degradation of
the bond over time (122).
Clinical Strategies
Most strategies for restoring access cavities require several steps
and at least two layers of restorative material. Many approaches utilize
an adhesive system and two restorative materials. The exception is un-
bonded amalgam alloy.
Restoring Access Cavities with Tooth Colored Materials
Light-cure composite can be used to fill the entire access cavity if
it is filled incrementally. This method will provide the strongest bond to
tooth structure (181) and is the preferred method when it is necessary
to maximize the tooth strengthening effects of the restoration. When
executed with skill and knowledge of the materials, excellent esthetic
results are possible (Fig. 8). However, this is a slow, time consuming
method. High initial bond strengths are also obtained with dual-cure
composites that are placed incrementally and light polymerized (177).
This method may be preferred to incremental fill with purely light-cured
materials if there are concerns about light penetration to all areas of the
cavity.
As discussed earlier, the 4th generation adhesive systems are pref-
erable for endodontic restorative applications with composite materi-
als. They tend to form the best bond to dentin, and have few compati-
bility problems with restorative resins. They are also effective despite the
use of eugenol containing sealers or temporary materials.
A method to restore access cavities in teeth with ceramic restora-
tions: Light-cure composite
1. Clean the internal surfaces with a brush or cotton pellet con-
taining a solvent such as alcohol.
2. Sandblast the cavity, metal and ceramic, or lightly refresh them
with a bur.
3. Etch the ceramic with hydrofluoric acid or other appropriate
etchant.
4. Rinse and dry.
5. Apply phosphoric acid to the inside of the access cavity if restor-
ing with composite. Etching with phosphoric acid adds no re-
tention to porcelain, but it cleans the porcelain and enhances
the silane adaptation (182).
6. Rinse and dry.
7. Apply silane agent to the porcelain and dry.
8. Apply a dentin primer and adhesive to the internal walls and light
cure.
9. Fill the cavity incrementally with no increments greater than 3
mm.
10. Light cure each increment for 40 s (time depends on type of light
used).
11. The restoration should be slightly overfilled so it can be finished
back to the margins.
12. Contour and adjust the occlusion.
13. Finish and polish the restoration.
In many cases, it is desirable to bulk fill most of the cavity with a
glass ionomer material or self-cure or dual-cure composite, then ve-
neer it with a light-cure composite material that is esthetic and will
withstand occlusal function. This method is more efficient than using a
purely light-cure composite, but the esthetic result may not be as good.
A simple method to restore access cavities in teeth with ceramic
restorations: Glass ionomer and composite
1. Treat the dentin with a polyalkenoic acid for 30 s.
2. Bulk fill with a dual-cure glass ionomer material to within 2 to 3
mm of the cavo-surface margin and light cure.
3. Etch the ceramic material with 10% hydrofluoric acid, or other
suitable etching gel for 1 min, depending on the product.
4. Rinse and dry.
5. Apply silane to the etched ceramic surface and air dry.
6. Apply the dentin primer and adhesive to the glass ionomer ma-
terial and etched ceramic and light cure.
7. Place the first increment of light-cure composite. The first in-
crement should include the longest vertical wall and taper to the
base of the opposing vertical wall.
8. Light cure for 40 s (time depends on type of light used).
9. Fill the remaining space with the second increment and light
cure. The restoration should be slightly overfilled so it can be
finished back to the margins.
10. Contour and adjust the occlusion.
11. Finish and polish the restoration.
A Simple Procedure for Composite Resin
The procedures are similar to those described with glass ionomer
material, but a 4th generation dentin adhesive system is used on the
dentin and a dual-cure composite is substituted for the glass ionomer
material.
1. Treat the dentin and enamel, if present, with 30 to 40% phos-
phoric acid for 15 s.
2. Thoroughly rinse and dry the dentin then rewet with a moist
sponge.
3. Apply primer and adhesive, following the manufacturers in-
structions.
4. Bulk fill with a dual-cure or self-cure composite to within 2 to 3
mm of the cavo-surface margin and light cure.
5. Etch the ceramic material with 10% hydrofluoric acid, or other
suitable etching gel for 1 min.
6. Rinse and dry.
7. Apply silane to the etched ceramic surface and air dry.
8. Apply the dentin primer and adhesive to the etched ceramic and
light cure for 15 s.
9. Place the first increment of light-cure composite. The first in-
crement should include the longest vertical wall and taper to the
base of the opposing vertical wall.
10. Light cure for 40 s.
11. Fill the remaining space with the second increment and light
cure.
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JOE Volume 31, Number 3, March 2005 Restoration of Access Cavities 161
12. Contour and adjust the occlusion.
13. Finish and polish the restoration.
Dual-cure composites that are bulk filled develop relatively low
bond strengths to dentin, comparable to glass ionomer materials. Resin
adhesives lose bond strength with time and function, whereas glass
ionomer bond strengths are relatively stable. So there is little if any
benefit to the use of dual-cure composites over glass ionomer materials
for bulk filling the cavity.
Conclusions
1. Prevent contamination of the root canal system.
2. Restore access cavities immediately whenever possible.
3. Use bonded materials
4. The 4th generation (three step) resin adhesive systems are pre-
ferred because they provide a better bond than the adhesives that
require fewer steps.
5. The etch and rinse adhesives are preferred to self etching
adhesive systems if a eugenol containing sealer or temporary
material was used.
6. Self etching adhesives should not be used with self-cure or
dual-cure restorative composites.
7. When restoring access cavities, the best esthetics and highest
initial strength is obtained with an incremental fill technique with
composite resin.
8. A more efficient technique which provides acceptable esthetics is
to bulk fill with a glass ionomer material to within 2 to 3 mmof the
cavo-surface margin, followed by two increments of light-cure
composite.
9. If retention of a crown or bridge abutment is a concern after root
canal treatment, post placement increases retention to greater
than the original.
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