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John F. Weston, DDS, FAACD — Page 3

Contemporary Adhesive Systems and Resin Composites

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EDUCATIONAL OBJECTIVES

The overall goal of this article is to provide dental professionals with information on direct composite restorative materials and adhesive systems. After completing this course, the reader will be able to:

1. Review the historical development of composite resins and adhesive systems

2. Review the adhesive system options and considerations when selecting a speci� c method

3. Delineate the different types of composite materials and their relative physical and esthetic properties, as well as factors to consider when selecting an option4. List and describe the factors involved in the provision of a du-

rable, esthetic composite restoration.

SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from 3M ESPE. DESIGNATION STATE-MENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning, LLC designates this activity for 2 CE credits. Dental Learning, LLC is also designated as an Ap-proved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2012 - 1/31/2016. Provider ID: # 346890. Dental Learning, LLC is a Dental Board of California CE provider. The California Provider number is RP5062. This course meets the Dental Board of California’s requirements for 2 units of continuing education. EDUCATIONAL METHODS: This course is a self-instructional journal and web activ-ity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. PUBLICATION DATE: May, 2013. EXPIRATION DATE: April, 2016. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the � eld related to the course topic. It is a combination of many educational courses and clinical experi-ence that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Monique Tonnessen, does not have a leadership or commercial interest in any products or services discussed in this educational activity. She can be reached at [email protected]. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satis� ed with this course can request a full refund by contacting Dental Learning, LLC, in writing. Go Green, Go Online to www.dentallearning.net take your course. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected].

Current composite resin restoratives offer strength, esthetics, and the ability to offer patients minimally invasive dentistry when restorations are required. The development of technology and chemistries that enhance strength and esthetics has led to the availability of universal composites that can be used in the ante-rior esthetic zone as well as in stress-bearing posterior regions. Adhesive systems for composite resins have also been developed with reliable bonding to enamel and dentin with total etch and self-etch options, as well as universal adhesives that can be used for both approaches.

ABSTRACT


Introduction

Modern restoratives had their beginnings in the 1700s with the introduction of a metal-based direct restorative material,1 followed by various

developments in amalgam restoratives that continued to accelerate during the 20th century. It was not until the latter half of the 20th century that modern tooth-colored direct restorative materials became available. Initially, these were dif� cult to handle, offered relatively poor esthetics (although not compared to amalgam) and poor physical properties, and were not bonded to tooth structure. After the introduc-tion of the early silicate materials, a series of innovations resulted in the introduction of other tooth-colored restor-atives. The � rst composites were an improvement over pre-vious materials; however, they exhibited surface roughness and poor polishability, stained readily, and, because of their poor strength, could only be used for anterior restorations.

ABOUT THE AUTHORJohn F. Weston DDS, FAACD

Dr. John Weston, is a native Californian who

received his doctorate from Oklahoma University

in 1989 and graduated with Omicron Kappa

Upsilon Honors. As a commissioned of� cer in the

US Navy, he received multiple advanced medical

certi� cations while completing a General Practice

Residency at the Naval Hospital, San Diego. He

also served independent duty in support of opera-

tion Desert Storm. Dr Weston has earned the credential of “Accredited

Member” and “Accredited Fellow” from the American Academy of

Cosmetic Dentistry (AACD), an honor shared by fewer than 50 clinicians

worldwide. Dr. Weston has been the past Scienti� c Chair of the AACD

Professional Education Committee twice, and has served two consecutive

terms as an elected member to the Board of Directors. He is currently an

active Accreditation and Fellowship Examiner and served a three year

term on the American Board of Cosmetic Dentistry. He lectures nation-

ally and internationally, publishes articles, evaluates new dental products

and has been practicing in La Jolla for over 20 years with an emphasis

in reconstructive and esthetic dentistry. He is owner and director of

“Scripps Center for Dental Care”, a unique multi-specialty dental center

located at Scripps Memorial Hospital, La Jolla CA. Dr. Weston is a con-

sultant for 3M ESPE, the provider of the unrestricted educational grant

for this course. Dr. Weston can be reached at [email protected].

EditorFIONA M. COLLINS, BDS

Managing EditorJULIE CULLEN

Creative DirectorMICHAEL HUBERT

Art DirectorMICHAEL MOLFETTO

Copyright 2013 by Dental Learning, LLC. No part of this publication may be reproduced or transmitted in any form without prewritten permission from the publisher.

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4 VOLUME 2 | ISSUE 3

Polymerization shrinkage was also high, which, in combina-tion with the use of the then-available adhesive systems, re-sulted in marginal gaps and leakage as well as a propensity for marginal staining. A decade later, posterior composites became available that were suitable for low-stress-bearing areas. By the early 2000s, a notable decline in the use of amalgam had occurred.2 Increasingly, tooth-colored direct restorations are favored over amalgam3 – due to the de-mand for esthetics, adhesive systems, strength that affords their use posteriorly and, in some cases, their mercury-free composition.

Minimally invasive dentistry is widely recognized as helping to preserve oral health. Where possible, this entails preventive care to prevent/reverse carious lesions before they require restorative care. However, minimally invasive den-tistry also favors the use of tooth-colored restorations when a restorative is required. No longer is it necessary to create classical preparations that require suf�cient tooth structure be removed to create preparation undercuts and mechani-cal retention. Adhesive dentistry enables the preservation of tooth structure with removal of the minimum amount of tooth structure necessary. In addition to providing for reten-tion, adhesive systems also reinforce the remaining tooth structure.

Adhesive SystemsBuonocore �rst published on the concept of adhesive

systems for restorative materials in 1955 in the Journal of Dental Research.4 The adhesion concept was in fact derived from industry, where metal surfaces were already being etched to provide for improved adherence of paints to their surfaces.5 At the time of his publication, Buonocore described the then-existing lack of ability of materials to adhere to tooth structure as a “major shortcoming” and discussed the potential with an adhesive system to prepare teeth without the need for resistance form – an early indica-tion of the contribution to dentistry that adhesive systems would later make. His early experiments were focused on the etching of enamel with phosphoric acid, demonstrating retention of acrylic resins. Shortly after this, research on

dentin bonding began, although the results were initially poor.6 Since then, along with improvements in composite resins, the improvements in adhesive system chemistries and the manner in which these are used has led to improved adhesion and retention of restorations and reductions in microleakage. Bonding is now effective for enamel and dentin.7,8 Adhesive systems rely on micromechanical locking into the relevant tooth structure for retention.9

Through the generationsOne of the methods to categorize adhesive systems is by

generation based on when they were introduced, with each generation offering something different (e.g., total etch for earlier generations and self-etch in later generations). This could convey that a later generation superseded all earlier ones, when in fact earlier and later generations are still in use. A different classi�cation utilizes the approach of usage and number of bottles/steps rather than generation.10 This classi�-cation is based on total etch and self-etch modes of use.

Total etch (etch-and-rinse) adhesive systemsTotal etch adhesive systems were the �rst adhesive

systems, initially for enamel-only etching and adhesion and subsequently for both enamel and dentin. A reliable bond to dentin was achieved when hydrophilic monomers were added that enable penetration of the dentin by the adhesive resin. Total etch adhesive systems are available in either a 3-bottle or a 2-bottle system – in the case of the 3-bottle system, a primer is applied before use of the bond-ing agent, while with the 2-bottle system the bonding agent and primer are combined.10 Note that although commonly referred to as a 3-bottle or 2-bottle system, etchants are now typically delivered in a syringe as a gel rather than in a bottle. The etchant consists of phosphoric acid (vary-ing from 10-40%). Etching is generally recommended for 15 to 30 seconds – the manufacturer’s recommendations should be followed for speci�c adhesive systems. Care should be taken not to exceed the etching time and overex-pose dentin to the etchant.11

The primer is hydrophilic, containing a hydrophilic


5MAY 2013

monomer that aids dentin penetration (see above) by wet-ting the collagen.12,13

Etch-and-rinse adhesives produce higher resin-dentin bonds that are more durable than most 1- and 2-step self-etch adhesives. They have been proven to offer effective bonding to enamel and dentin.14 A recent review of 3-step etch-and-rinse adhesive systems found that at 13 years post-placement, composites were still clinically acceptable with bond degradation that was minor, with small clinically ac-ceptable marginal defects.15 Total etch options can be found in Table 1.

Self-etch adhesives Self-etch adhesives reduce the number of steps required

for bonding to enamel and dentin. They consist of either a 2-step system comprising use of a primer that also contains the etchant followed by use of the bonding agent (2 separate bottles), or a single-step system that combines all steps into one either using a solution in one bottle or two separate bottles that require premixing prior to application (Table 1). With both a 1-step system and a 2-step system, no rinsing is performed prior to application of the separate bonding agent – rinsing is contraindicated and will result in failure. Rewetting to achieve moist dentin is also not required, as the self-etch adhesive systems are aqueous. This further simpli�es the use of self-etch adhesives with fewer bottles/steps and no rinsing, saving time and reducing the chances for error.

Both total etch and self-etch adhesives are effective for dentin bonding, with in�ltration into the dentin and

formation of a hybrid layer, although a recent study found higher microtensile bond strengths for dentin and enamel with total etch adhesive compared to self-etch or universal adhesive.16 During formation of the dentin hybrid layer, the primer monomer permeates the dentin, leading to adhe-sion with the dentin substrate and improved bonding and marginal seal. Incomplete permeation is believed to lead to nanoleakage of water into exposed collagen �brils.17

Use of a total etch adhesive provides for a stronger bond to enamel than do self-etch adhesives, with a recent in vitro study �nding enamel shear bond strengths that were signi�cantly higher with etchant concentrations ranging from 2.5% to 40%.18 Increasing etching time does increase surface roughness but was found in another study to have no effect on bond strength. In addition, as noted above, dentin should not be overetched.19 Agitating the primer used with a self-etch adhesive on moist dentin can improve bond strength, but this has been found to have no effect on bond strength to enamel at various application times (10-30 seconds).20,21 In a comparison of composite margins following use of total etch and self-etch adhesives and after thermocycling of samples, enamel margins were superior with use of a total etch technique. For dentin margins, no signi�cant differences were found with use of either technique.22

Roughening and etching the enamel at the margins of the preparation may help reduce the likelihood of marginal staining with all adhesive systems. However, while enamel beveling has been recommended, one study found that the 18-month survival rate and level of marginal adapta-

TABLE 1. Adhesive systems

Total Etch (Etch-and-Rinse) Self-etch

3-step three bottle 2-step two bottle

2-step two bottle 1-step two bottle (mix)

1-step single bottle (no mixing)

Note that although referred to as bottles, etchant is now typically delivered in a syringe



tion or discoloration were not in� uenced by either enamel beveling or selective etching of enamel.23 As a result of the lower bond strengths to enamel with self-etch adhesives, the less retentive the preparation and the more reliant it is on enamel bonding rather than dentin for adhesion (for ex-ample, a Class IV versus a Class II restoration), the stronger the indication for use of a total etch technique. A study con-ducted on Class V restorations found total etch and self-etch

adhesive systems to be equally effective in providing bond-ing for composite restorations and without any differences in microleakage.24 Application of self-etch adhesive has been found to result in greater shear bond strength between resin-modi� ed glass ionomers and composite layers used in the sandwich technique, compared to use of a total etch adhesive.25 Self-etch options can be found in Table 1.

Selective etchFollowing the development of self-etch adhesives,

selective etching was introduced. The objective of selective etching is to pre-etch the enamel margins adjacent to prepa-rations prior to using a self-etch adhesive to increase subse-quent bond strength (Fig. 1). Selective etching does improve enamel bonding, and can increase enamel bond strength to levels experienced with total etch adhesive techniques.22,26

Pre-etching dentin must be avoided with some self-etch products, as it can reduce bond strength.27 The steps for total etch and self-etch (whether or not self-etch is preceded by selective etching) can be found in Figure 2.

Universal adhesivesUniversal adhesives are the latest addition to the range

Figure 1. Selective etching pattern typically used prior to use of a self-etch adhesive

Apply etchant

Apply primer and gently dry

with air syringe

Apply primer/bonding agent

Apply bonding

agent

Rinse Light cureDry enamel chalky and

dentin moist

Place restorative

material

Figure 2a. Steps for total etch adhesives


7MAY 2013

of adhesive systems. These can be used with a total etch or a self-etch technique as well as for selective etching. This simpli�es the number of adhesive systems required in the of�ce, while allowing �exibility in selecting a technique. Universal adhesives allow use on dry or moist dentin, and permit suitable bond strengths. Application of universal ad-hesive to moist or dry dentin gave the same results in a 2012 study, and the universal adhesive also compared favorably with a 2-step self-etch adhesive.28 A 1-step universal adhe-sive offers the option of carrying one adhesive, and in the case of dentin reduces the complexity of treatment by being able to bond to moist and dry dentin. This also removes the possibility of inadvertently applying a total etch adhesive to dry dentin. One recent study found universal adhesive to be equally reliable regardless of the technique used in the test-ing. Options tested were total etch with moist or dry dentin, self-etch, and selective etching.29

Current Composite Resin Restorative MaterialsAs described earlier, composites for anterior and pos-

terior direct restorations now offer signi�cantly higher strength, esthetics, and ease of use than earlier variants. The basic broad categories include micro�lled, hybrid/microhybrid, and nano�lled composite resins. These are

grouped by �ller level/type, with differing properties and characteristics. Most recently, universal composites have become available that offer esthetics and strength.

Category and �llersMicro�lled composites contain a low �ller load with

particles that are between 0.004 and 1 micron in size, usu-ally consisting of pre-polymerized resin particles and silica. These offer high polishability and, with pre-polymerized particles, reduced polymerization shrinkage, but are rela-tively weak and only used in the anterior region (non-stress-bearing areas). Hybrid/microhybrid composite resins are stronger, with a higher �ller load (and higher for the hybrid than the microhybrid resins). The �ller particle load consists of a mix of particles – both silica-based �llers and glass particles. On the other hand, hybrid/microhybrid resins are less esthetic than micro�lled composites with a lower level of polishability and long-term loss of polish. The third category based on �ller characteristics is the nano�lled com-posite resins. These resins, as their name suggests, contain smaller particles (nanoparticles). The �ller load is higher in nano�lled composites, resulting in favorable strength and wear resistance,30 while the particles themselves consist of zirconium oxide (0.02 – 0.1 microns in size), which favors

Figure 2b. Steps for self-etch adhesives

Apply primer/etchant

Apply adhesive

Apply primer/etchant/adhesive

Light curePlace

restorative material



esthetics and high polishability. Nano�lled composites are available with particles that are pre-polymerized/sintered into zirconia/silica clusters to increase strength and reduce polymerization shrinkage.31

Handling characteristicsFlowable composites �ow easily and are low viscosity

with a lower �ller load. This means they offer easy han-dling for placement as well as bulk �ll (within the con�nes of the maximum depth of composite that can be cured at a time) and allow use of a syringe tip to place them. They readily �ow into and adapt to preparation margins and walls. Their disadvantage is that the lower �ller load results in reduced strength, making them suitable only for anterior restorations and non-stress-bearing areas and for the inner layer of a restoration created using a sandwich technique. In contrast, high viscosity composites have lower �owability but higher strength due to their higher �ller load, and can be “packed” with hand instruments.

Universal composite resinsUniversal composites are intended for use in anterior

and posterior regions, with chemistries designed to pro-vide the strength and esthetic requirements of a universal material. How our eyes perceive variables associated with esthetic restorations is related to how light interacts with the material – how it scatters/re�ects/refracts, how it is absorbed or transmitted. Relevant characteristics for an esthetic restorative material include opacity (with a higher opacity typically associated with greater �ller load and used where masking of staining is necessary and in deep dentin defects),32,33 translucency, opalescence, hue, chroma (degree of saturation), and value (degree of whiteness or blackness of the shade). Ideally, the composite will also exhibit a chameleon effect whereby it blends seamlessly into the surrounding tooth structure.

Optimizing esthetics and ease of useUsing universal composites with suf�cient strength

for posterior stress-bearing areas, and with esthetics that

meet the requirements for the anterior esthetic zone, simpli�es and streamlines procedures. The incorpora-tion of nanoparticles in universal composite provides for light scattering that results in excellent translucency and opalescence for the anterior zone, while wear resistance helps composite retain a high gloss after �nishing and polishing.34 This too helps with esthetics by re�ecting light well and reducing the risk of staining. Since the sur-face is smooth, it also helps reduce bio�lm buildup. The combination of shades that is required with a universal composite is also simpli�ed.

Although a single shade of composite may suf�ce in the posterior region, it is rarely adequate for the anterior esthetic zone. In complex esthetic cases, a multi-layering technique with four or more shades is often used to obtain the shading and degrees of opalescence, opacity, and trans-lucency required to match the natural esthetics of the tooth and adjacent teeth.

By using a universal composite, in this author’s experi-ence, it is usually possible to achieve with two main shades what was previously often only attainable with multiple layers of different composite shades and to create highly polished esthetic restorations. This simpli�es placement of the composite restoration and saves chair time without compromising esthetics.

Clinical casesThe following cases demonstrate esthetic results using

nano�lled universal composites.

Posterior restorationsThis patient presented with old, leaking amalgams in teeth #29 and 30, as well as proximal caries mesially in #30 (Fig. 3). The patient stated that she also did not like the appearance of the amalgam �llings. In this case, the restorations would have a large area of dentin for bond-ing as well as the enamel margins. As a result, retention would not rely solely on enamel bonding (which would have suggested use of a total etch approach). The amal-gams were removed and the teeth prepared to remove


9MAY 2013

caries and any amalgam staining. Care was taken to ensure that the margins in the boxes were in enamel, which would aid integrity of the restoration and was possible since the proximal caries did not extend deeply subgingivally. After preparation of the teeth, selective etching of the enamel was completed and the area then rinsed. Universal adhesive was then applied using a one-step approach and light cured (Figs. 4,5). Give that con-temporary universal composites offer suf�cient compres-sive and �exural strength, as well as fracture resistance and wear resistance, nano�lled universal composite was selected for the restoration together with an underlying

Figure 7. First increments of universal composite

Figure 5. Application of universal adhesive

Figure 6. Layer of �owable composite

Figure 4. Preparations

Figure 3. Preoperative view



layer of �owable composite. The polishability and wear resistance of universal composite are also such that long-term esthetics would also be achieved. A �owable composite was used that would readily �ow and adapt well in the base of the preparations and proximal boxes (Fig. 6). A single shade nano�lled universal composite was selected that would provide for both strength and esthetics. This was placed in three separate light-cured increments over the cured �owable composite, after which the restorations were contoured, �nished and pol-ished (Figs. 7,8). An esthetic result was achieved (Fig. 9).

Anterior restorationsThe patient presented with a fractured incisal edge in tooth

#9 (Fig. 10). On examination, the patient was found to have good oral hygiene and no carious lesions, and no root pathol-ogy or fracture was found on the periapical radiograph taken. It was decided to place a composite restoration to restore the tooth and to close the diastema at the patient’s request.

Composite resin was �rst placed over the area (without any adhesive system so that it could easily be removed) and an incisal edge guide taken of this using vinyl polysi-loxane bite registration material (Fig. 11). After the index

Figure 11. Taking the incisal edge guide

Figure 10. Clinical presentation preoperatively

Figure 9. Final restorations

Figure 8. Final increments


11MAY 2013

Figure 17. Application of enamel shade

Figure 16. Application of dentin shade

Figure 15. Finished framework

Figure 14. Creating the framework

Figure 13. Etched enamel

Figure 12. Application of etchant



and composite were removed, the tooth was prepared by creating a long bevel on the enamel surface using a coarse diamond. Since the restoration would rely on bonding to enamel for retention, a 2-step total etch approach was chosen. The etchant was applied for 15 seconds, and then rinsed off and the area dried (Figs. 12,13). Care was taken to leave the dentin slightly moist afterward. The universal bonding agent was then applied to the preparation and light cured. The incisal guide index was repositioned over the area to serve as a support and guide while the compos-ite framework for the restoration was created, and then removed (Figs. 14,15).

Figure 22. Applying universal composite

Figure 21. Applying universal adhesive

Figure 20. Etched enamel

Figure 19. Etching the enamel

Figure 18. Application of incisal shade


13MAY 2013

For this case, three shades were selected that were sequentially placed and light cured. An opaque shade of nano�lled universal composite was used, followed by a more translucent “enamel shade,” and then an incisal edge shade (Figs. 16-18). After light curing of the incisal shade, the restoration was contoured, �nished and pol-ished. The diastema on the adjacent tooth was then treat-ed. A Te�on strip was �rst placed over the new Class IV restoration to protect it. As before, a total etch approach was used since the restoration would rely on enamel bonding. After applying the etchant for 15 seconds, the area was rinsed off and the enamel dried. Universal

adhesive was then applied and light-cured (Figs. 19-21). A single shade (Shade A2) of universal composite was then placed and light-cured, closing the diastema (Figs. 22,23). The single shade restoration was then �nished and polished. The result was highly esthetic with a lifelike appearance and gloss �nish for both restorations and an excellent esthetic match with each other (Fig. 24).

ConclusionsModern science-based and tested materials have en-

abled the provision of esthetic, minimally invasive restora-tions. In addition, esthetics and strength have been opti-mized and combined in universal restorative materials that allow a streamlined and predictable approach to anterior and posterior restorations.

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Figure 23. Manipulating universal composite

Figure 24. Completed restorations



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21. Velasquez LM, Sergent RS, Burgess JO, Mercante DE. Effect of placement agitation and placement time on the shear bond strength of 3 self-etching adhesives. Oper Dent. 2006;31(4):426-30.

22. Frankenberger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching reconsidered: better than etch-and-rinse and self-etch? J Adhes Dent. 2008;10(5):339-44.

23. Perdigão J, Carmo AR, Anauate-Netto C, Amore R, Lewgoy HR et al. Clinical performance of a self-etching adhesive at 18 months. Am J Dent. 2005;18(2):135-40.

24. Santini A, Ivanovic V, Ibbetson R, Milia E. Influence of cav-

ity configuration on microleakage around Class V restorations bonded with seven self-etching adhesives. J Esthet Restor Dent. 2004;16:128-36.

25. Chandak MG, Pattanaik N, Das A. Comparative study to evaluate shear bond strength of RMGIC to composite resin using different adhesive systems. Contemp Clin Dent. 2012;3(3):252-5.

26. Erickson RL, Barkmeier WW, Kimmes NS. Bond strength of self-etch adhesives to pre-etched enamel. Dent Mater. 2009;25(10):1187-94.

27. van Landuyt KL, Peumans M, De Munck J, Lambrechts P, van Meerbeek B. Extension of a one-step self-etch adhesive into a multi-step adhesive. Dent Mater. 2006;22(6):533-44.

28. Perdigão J, Sezinando A, Monteiro PC. Laboratory bond-ing ability of a multi-purpose dentin adhesive. Am J Dent. 2012;25(3):153-8.

29. Mena-Serrano A, Kose C, De Paula EA, Tay LY, Reis A, et al. A new universal simplified adhesive: 6-month clinical evaluation. J Esthet Restor Dent. 2013;25(1):55-69.

30. Beun S, Glorieux T, Devaux J, Vreven J, Leloup G. Charac-terization of nanofilled compared to universal and microfilled composites. Dent Mater. 2007;23(1):51-9.

31. Mitra SB, Wu D, Holmes BN. An application of nano-technology in advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.

32. Lee YK. Influence of filler on the difference between the trans-mitted and reflected colors of experimental resin composites. Dent Mater. 2008;24(9):1243-7.

33. Dias WR, Pereira PN, Swift EJ Jr. Maximizing esthetic results in posterior restorations using composite opaquers. J Esthet Restor Dent. 2001;13(4):219-27.

34. Mitra SB, Wu D, Holmes BN. An application of nano-technology in advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.

WebliographyFedorowicz Z, Nasser M, Wilson N. Adhesively bonded versus non-bonded amalgam restorations for dental caries. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD007517. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/19821423.

Perdigão J, Dutra-Corrêa M, Saraceni CH, Ciaramicoli MT, Kiyan VH, Queiroz CS. Randomized clinical trial of four ad-hesion strategies: 18-month results. Oper Dent. 2012 Jan-Feb;37(1):3-11. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed?linkname=pubmed_pubmed_reviews&from_uid=2194223


15MAY 2013

1. Modern tooth-colored direct restorative materials became available in the ______________.a. �rst half of the 20th centuryb. last two decadesc. last decade d. latter half of the 20th century

2. By the early 2000s, a notable decline in the use of ____________ had occurred.a. amalgamb. sealantsc. compositesd. none of the above

3. Minimally invasive dentistry favors the use of _____________ when a restorative is required.a. tooth-colored direct restorationsb. veneersc. indirect restorationsd. dentures

4. Adhesive dentistry _____________.a. enables removal of the minimum amount of tooth structure

necessary b. reinforces the remaining tooth structurec. is in its early daysd. a and b

5. The adhesion concept was derived from industry, where ____________ were already being etched.a. plastic surfacesb. metal surfacesc. graphites d. all of the above

6. Buonocore described the then-existing lack of ability of materials to adhere to tooth structure as _______________.a. an inconvenienceb. unfortunatec. a “major shortcoming”d. none of the above

7. Adhesive systems rely on ______________ into the relevant tooth structure for retention.a. chemical adhesionb. micromechanical lockingc. macromechanical lockingd. all of the above

8. Total etch adhesive systems were the �rst adhesive systems, initially for ___________ bonding.a. enamel-only b. dentin-onlyc. enamel and dentind. amalgam

9. A reliable bond to dentin was achieved when _____________ were added that enable penetration of the dentin by the adhesive resin.a. hydrophobic monomersb. hydrophilic polymers c. hydrophilic monomers d. all of the above.

10. Total etch adhesive systems are available in _______________.a. a 3-bottle or 2-bottle systemb. a 2-bottle or 1-bottle systemc. a 3-bottle, 2-bottle or 1-bottle systemd. only a 1-bottle system

11. Etch-and-rinse adhesives produce higher resin-dentin bonds that are _____________ than most 1- and 2-step self-etch adhesives.a. more durableb. less durablec. more visibled. none of the above

12. A recent review of 3-step etch-and-rinse adhesive systems found that the composite restorations were clinically acceptable ______________ years post-placement.a. tenb. elevenc. twelved. thirteen

13. Compared to total etch, self-etch adhesives _______________ required for bonding to enamel and dentin.a. reduce the number of steps b. increase the number of steps c. change the con�guration of the crystalsd. b and c

14. A self-etch adhesive consists of a _____________.a. 2-step system with two bottlesb. 1-step system with two bottlesc. 1-step system with one bottled. any of the above

CEQuizTo complete this quiz online and immediately download your CE veri�ca-tion document, visit www.dentallearning.net/CAS, then log into your ac-count (or register to create an account). Upon completion and passing of the exam, you can immediately download your CE veri�cation document. We accept Visa, MasterCard, and American Express.



15. If a 2-step self-etch adhesive system is used, _____________ is performed prior to application of the separate bonding agent.a. rinsingb. no rinsingc. decontaminationd. none of the above

16. Incomplete permeation of dentin by primer is believed to lead to nanoleakage of water into exposed _____________.a. enamel prismsb. collagen �brilsc. composited. all of the above

17. Roughening and etching the enamel at the margins of the preparation may help reduce the likelihood of _____________ with all adhesive systems.a. marginal stainingb. poor permeation of primerc. sensitivityd. all of the above

18. Application of self-etch adhesive has been found to result in greater shear bond strength between _____________ used in the sandwich technique.a. �owable and packable composite layersb. resin-modi�ed glass ionomers and composite layers c. amalgams and the tooth surfaced. none of the above

19. Universal adhesives _____________.a. allow use on dry or moist dentin b. reduce the complexity of treatment c. can be used with a total etch or a self-etch technique d. all of the above

20. Micro�lled composites _____________.a. contain a low �ller load b. offer high polishabilityc. can only be used in non-stress-bearing areasd. all of the above

21. Hybrid/microhybrid composites _____________ composites.a. are stronger than micro�lled b. are less esthetic than micro�lled c. have a higher �lled load than micro�lledd. all of the above

22. When a composite blends seamlessly into the surrounding tooth structure it is said to be exhibiting a _____________.a. translating effectb. camou�age effectc. chameleon effectd. none of the above

23. A nano�lled composite _____________ than micro�lled and microhybrid/hybrid composites.a. contains smaller particles b. has a higher �ller load c. has a more favorable strength and wear resistanced. all of the above

24. Selective etching is used to pre-etch the enamel margins adjacent to preparations prior to using a self-etch adhesive to increase subsequent _____________.a. bond strengthb. primer permeationc. dentin bondingd. all of the above

25. Universal composites _____________.a. are intended for use in anterior and posterior regionsb. are less esthetic than micro�lled compositesc. have been around for 30 yearsd. all of the above

26. An opaque composite shade is used when _____________.a. a grey incisal edge is requiredb. deep dentin defects are presentc. the enamel is chalkyd. all of the above

27. Wear resistance helps composites _______________.a. retain a high gloss after �nishing and polishingb. increase bond strengthc. increase fracture resistanced. all of the above

28. The incorporation of nanoparticles in universal composites provides for _____________.a. light transmissionb. light scatteringc. light absorptiond. chameleon activity

29. When a restoration would rely largely or wholly on bonding to enamel for retention, a _____________ approach is preferred. a. 3-step total etch b. 2-step total etchc. self-etchd. a or b

30. Universal restorative materials allow a _____________ approach to anterior and posterior restorations.a. streamlined b. predictablec. deliberatived. a and b

CE QUIZ

17MAY 2013

Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. COURSE EVALUATION and PARTICIPANT FEEDBACK: We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. INSTRUCTIONS: All questions should have only one answer. Participants will receive con�rmation of passing by receipt of a veri�cation form. Veri�cation forms will be mailed within two weeks after taking an examina-tion. EDUCATIONAL DISCLAIMER: The content in this course is derived from current information and evidence. Any opinions of ef�cacy or perceived value of any products mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily re�ect those of Dental Learning. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the �eld related to the course topic. It is a combination of many educa-tional courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST: All participants scoring at least 70% on the examination will receive a veri�cation form verifying 2 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact Dental Learning, LLC for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. Dental Learning, LLC is a California Provider. The California Provider number is RP5062. The cost for courses ranges from $29.00 to $110.00. Many Dental Learning, LLC self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB). To �nd out if this course or any other Dental Learning, LLC course has been approved by DANB, please RECORD KEEPING: Dental Learning, LLC maintains records of your successful completion of any exam. Please contact our of�ces for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within �ve business days of receipt. CANCELLATION/REFUND POLICY: Any participant who is not 100% satis�ed with this course can request a full refund by contacting Dental Learning, LLC in writing or by calling 1-888-724-5230. © 2012

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

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Fill in the circle of the appropriate answer that corresponds to the question on previous pages.

EDUCATIONAL OBJECTIVES• Review the historical development of composite resins and adhesive systems

• Review the adhesive system options and considerations when selecting a speci�c method

• Delineate the different types of composite materials and their relative physical and esthetic properties, as well as

factors to consider when selecting an option

• List and describe the factors involved in the provision of a durable, esthetic composite restoration.

If you have any questions, please call Dental Learning, LLC at 1-888-724-5230.

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1. Read the entire course.

2. Complete this entire answer sheet in either pen or pencil.

3. Mark only one answer for each question.

4. A score of 70% will earn your credits.

OR

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1. Read the entire course

2. Go to www.dentallearning.net/CAS

3. Choose this course from the course listing

4. Log in to your account or register to create an account

5. Complete course and submit for grading to receive your CE veri�cation document

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