Adhesive Dentistry and Endodontics: Materials, ClinicalStrategies and Procedures for Restoration of AccessCavities: A ReviewRichard S. Schwartz, DDS, and Ron Fransman, DDS

AbstractThe complexity of restorative dentistry has increasedgreatly in recent years, with the myriad of productsused in “adhesive dentistry.” So too has the “simple”matter of restoring access cavities after completion ofendodontic treatment. This review discusses currentmethods of “bonding” to tooth structure, ceramic ma-terials, and metals, with emphasis on those aspectsthat are important to endodontics. Specific materials,procedures and major decision making elements arediscussed, as well as how to avoid problems in com-patibility between endodontic and restorative materi-als.

Key WordsAccess cavities, adhesive dentistry, endodontics, restor-ative dentistry

Dr. Schwartz runs a private practice limited to Endodon-tics, and is Clinical Assistant Professor, UT Health ScienceCenter at San Antonio, San Antonio, TX. Dr. Fransman runs aprivate 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 ofEndodontists

At the tomb of the unknown endodontist, there is a plaque that reads “Root canaltreatment is not complete until the tooth has been restored.” A recent article

reviewed the overall topic of restoration of endodontically treated teeth (1). This reviewwill address in detail the important issues when restoring access cavities through nat-ural tooth structure and restorative materials with emphasis on major decision makingelements, material selection and clinical procedures. It will focus on those aspects ofadhesive dentistry that are important and unique to endodontics.

Contamination of the Root Canal SystemOne 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 bethe 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 toprevent recontamination of the root canal system. Gross contamination can occurduring 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. Thesame things can occur with a “permanent” restoration, but “permanent” materials tendto leak less than temporary materials (6). Exposure of gutta-percha to saliva in the pulpchamber results in migration of bacteria to the apex in a matter of days (2, 7–9).Endotoxin reaches the apex even faster (10).

The importance of the coronal restoration in successful endodontic outcomes iswidely accepted and has been supported by studies by Ray and Trope (11), Hommez etal. (12), Tronstad et al. (13), Iqbal et al. (14), and Siqueira et al. (2). However, studiesby Riccuci et al. (15), Ricucci and Bergenholz (16), Heling et al. (17), and Malone etal. (18) indicate that contamination may not as important a factor in failure as iscommonly believed. Therefore, it must be concluded that the significance of bacterialcontamination as a cause of endodontic failure is not fully understood. Because there isclearly no benefit to introducing bacterial contamination into the root canal system, andsince it may be a contributing factor in endodontic failure, a basic premise of this reviewwill be that every effort should be made to prevent contamination.

TemporizationTo minimize the likelihood of contamination, immediate restoration is recom-

mended upon completion of root canal treatment (19 –21).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 providea second layer of protection against contamination in addition to the temporary materialat 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 dentinsurface that is free of films and debris.

3. Place a temporary or “permanent” restorative material in the orifices and overthe floor of the chamber.

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A bonded material such as composite resin or glass ionomer ce-ment is preferred (23–27). Temporary materials may also be used(28). Mineral trioxide aggregate (MTA) may also be used (29). Thereis probably some benefit to using a material that is clear so that therestorative dentist can see the underlying obturating material if re-entryis needed into the canal system (1) (Fig. 1).

Results varied in studies that evaluated temporary materials for theaccess cavities (21, 30 –36). The most common materials tested werezinc oxide eugenol (such as IRM, Dentsply Int.), zinc oxide/calciumsulfate (Cavit, Premier Corp.) or resin based materials including com-posite resin and resin modified glass ionomer materials. Generally, allof the temporary materials were adequate if placed in a thickness of 3mm or greater (21, 33–36).

All temporary materials leak to some extent (20, 21, 37– 40). Thezinc oxide/calcium sulfate materials are more resistant to microleakagethan the zinc oxide eugenol materials (21, 34), probably because ofsetting 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 leakagewith the use of two materials in combination (42).

Resin based temporary materials must be bonded to provide aneffective seal, because they undergo polymerization shrinkage of 1 to3% (30, 43). This is offset somewhat by the fact that they swell as theyabsorb water (30). Generally, bonded resin materials provide the bestinitial seal, but lack antimicrobial properties (30). They require moresteps and more time to place than materials such as IRM or Cavit.Bonded resins are recommended for temporization that is likely to lastmore than 2 to 3 wk (42, 44). Resin modified glass ionomer materialsare 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) Thefloor and orifices are sealed with unfilled resin. (Courtesy of Dr. Fred Barnett, Philadelphia.)

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the chances of contamination of the obturating material, a barrier maybe placed over it with a self-curing material. The post space should berestored as soon as possible and it may be beneficial to flush the postspace with an antimicrobial irrigant when the temporary post is re-moved.

Restoring Access OpeningsWhen an access opening is made through an existing restoration,

several things should be considered. Removal of all existing restorationsis desirable if possible, because it allows more complete assessment forthe presence of cracks and caries (47). This is particularly recom-mended for old class 1 and class 2 restorations, because they are likelyto be removed later anyway, in the process of preparing the tooth for acrown. Magnification and caries detector are helpful in identifyingcracks and for complete removal of caries (48).

If the existing restoration is a crown or onlay that appears to beclinically satisfactory and replacement is not planned, the chamber andinternal 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 torestorations, should be examined carefully for softness or gaps (Fig. 2).Caries detector may also stain sound areas of dentin that have decreasedmineral content (49). The key to the presence of caries is determined bywhether the stained areas are hard or soft. Many times caries can beidentified internally, necessitating replacement of the crown.

Access openings made through an existing restoration results inloss of retention (50 –52) and strength (53). When the access openingis 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 restorativematerial that provides a permanent, leak proof seal. Unfortunately, nosuch material is available. All materials that we use and restorations thatwe place leak to some extent. This includes intracoronal restorationsincluding bonded resin and glass ionomer materials (38, 54) as well asthe metal or ceramic extra-coronal restorations (55, 56). To minimizeleakage, 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, aswell 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 thechoice of restorative materials. Each substrate will be addressed sepa-rately.

Bonding to EnamelEnamel 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 anacid such as 30 to 40% phosphoric acid results in selective dissolutionof the enamel prisms and creates a surface with a high surface energythat allows effective wetting by a low viscosity resin. Microporosities arecreated within and around the enamel prisms that can be infiltrated withresin and polymerized in-situ (59). These “resin tags” provide micro-mechanical retention. Bond strengths are typically in the range of 20megapascals (Mpa) (60). Megapascals are a measure of the force perunit area that is required to break the bond. Self-etching adhesive sys-tems, which will be discussed in the section on bonding to dentin, etchground enamel fairly well, but do not etch unground, aprismatic enameleffectively (61– 63). Therefore, enamel margins should be beveledwhen using self-etching adhesive systems. It is critical to prevent con-tamination of etched enamel with blood, saliva or moisture (64). Poorlyetched enamel leads to staining at the margins of the restoration (65).A good enamel bond protects the underlying dentin bond which is lessdurable (66).

Bonding to Metal-Ceramic and All-CeramicRestorations

Access cavities are often made through metal-ceramic or all-ce-ramic materials, so attaining an effective, durable bond is importantwhen restoring them. The literature is unambiguous that the bestmethod to bond to porcelain is to first roughen the surface by acidetching and then apply a silane coupling agent, followed by the resin(67–70). Bond strengths of 13 to 17 Mpa have been reported, andfailure is often cohesive within the porcelain, meaning that the interfa-cial bond strength exceeds the strength of the porcelain itself (71–73).Bonding to porcelain was initially developed as a method for repair offractured 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 theporcelain with a bur, air-abrasion or etching with hydrofluoric acid.However, acid etching is the most effective method (73, 75, 76). Thefirst to introduce acid etching of porcelain was Calamia in 1983 (77).

Adhesion between the resin and porcelain may be enhanced by theuse 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 amethacrylate group that copolymerizes with resin. The use of a silane-coupling agent with porcelain was first described by Rochette in 1975(78).

Hydrofluoric AcidHydrofluoric acid provides greater surface roughness to porcelain

than air abrasion or roughening with a bur (75). It works by dissolvingthe glass particles (leucite) within the porcelain (Fig. 3). Most of theporcelains used in metal-ceramic restorations are feldspathic porce-lains that contain leucite. Some ceramic materials, such as low fusingporcelains, do not contain leucite and are not etched effectively by

Figure 2. Caries detector was applied to the inside of an access cavity. Note howthe caries detector accentuates the caries under the composite buildup. (Cour-tesy of Dr. Gary Carr, San Diego.)

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hydrofluoric acid (79). However, hydrofluoric acid is effective withmost of the current ceramic restorative materials (80 – 83).

Hydrofluoric acid is usually provided in a 10% concentration in asyringe. It is very important to follow the manufacturer’s instructions, asan application time that is too short will produce an inadequate etch,while an application time that is too long may render the porcelainbrittle and thus more prone to fracture (84).

SilaneSilane acts as a “coupling agent” enhancing the bond between the

resin and ceramic materials. It is supplied premixed or as a two bottlesystem that is mixed at the time of use. It is applied to the etched surfaceand must be thoroughly air dried (85). A low viscosity resin adhesive isthen flowed over the surface and polymerized. Once again, it is veryimportant to follow the manufacturer’s instructions.

Silane has a limited shelf life. Storage in the refrigerator will extendits useful life, but it should be used at room temperature (86). The twobottle silanes have the longest shelf life (71). Silane that is past theexpiration date or that contains precipitates should be discarded (86).

Air AbrasionAir 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 ontothe surface at about 80 psi. Fifty micron particles have been shown toproduce a more retentive surface than 100 �m particles (87). Twostudies reported that air abrasion has a negligible effect on bondstrength, however (76, 88). Etching and application of silane are thetwo most important steps.

CosmeticsWhen restoring the access cavity of a ceramic crown, it is often a

challenge to produce a good cosmetic result. Many times it is difficult tomask 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 metalshowing through the composite. The second challenge is to match theoptical properties of the porcelain. This is true for metal-ceramiccrowns as well as all-ceramic crowns. Most composites are too low invalue (too gray and translucent) to effectively match the surroundingporcelain (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 withmore translucent composite materials. Several composites are availablethat are quite opaque and work well when restoring access cavities inmetal-ceramic crowns. Composite stains can be used to accentuate pitsand fissures to further enhance the cosmetic result (Fig. 5).

Bonding to MetalThe 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 theocclusal surface is metal, adhesion may be desirable. Adhesion to metalis generally obtained by mechanical means. Surface roughness may becreated with a bur or air abrasion, which provides micromechanicalretention (89). Chemical adhesion is also possible with metals that forman oxide layer (90). Silane has no effect on bonding to metal (91).

Several studies have shown tin plating of metal enhances mechan-ical retention (92–96). Chromium plating also works well (96). Platingdevices 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. SEM of etched porcelain. (Courtesy of Dr. Bart VanMeerbeek, Leuven,Belgium.)

Figure 4. Most restorative composites are too translucent (gray) to provide agood match when restoring access cavities in metal-ceramic crowns.

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procedure has never gained popularity. Metal primers are an alternativethat enhances the bond between metal and resin. They have been shownto be effective and do not require any special equipment (97–99).

Bonding to Dentin: Resin MaterialsBonding 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 challengeto develop materials that bond to dentin. Current strategies for dentinadhesion were first described by Nakabayashi in 1982 (101), but hisideas were not widely accepted for a number of years. Nakabayashishowed that resin bonding to dentin could be obtained by applying anacid to expose the collagen matrix and dentinal tubules, applying ahydrophilic (“water loving”) resin material to the demineralized sur-face and polymerizing the resin in situ. The collagen matrix and dentintubules, 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 bondstrengths can be obtained that are equal or greater to those of etchedenamel. However, dentin bonding is not as durable as enamel bondingor as stable. It is well documented that bond strengths decrease withtime and function. This has been shown in vitro (66, 102–109) and invivo (110, 111). Microleakage is probably a more important issue toendodontics than bond strength. None of the current adhesive systemsare capable of preventing microleakage over the long term (65, 112–117). There is not a direct relationship between bond strength andmicroleakage (116).

Dentin adhesive systems utilize an acid as the first step of thebonding process to remove or penetrate through the smear layer anddemineralize the dentin surface. The smear layer covers the surface ofground dentin and consists of ground up collagen, hydroxyapatite, bac-teria, and salivary components (59). Most dentin adhesive systems canbe categorized as “etch and rinse” or “self etching,” based on the acidetching process (59).

“Etch and Rinse” AdhesivesMost of the “etch and rinse” adhesive systems utilize a strong acid

such as 30 to 40% phosphoric acid. When phosphoric acid is applied todentin, the surface is demineralized to a depth of about 5 �m. The acidis rinsed off after about 15 s, removing the smear layer and exposing thecollagen matrix and network of dentinal tubules for resin bonding. Ahydrophilic primer is then applied to the surface to infiltrate the colla-gen matrix and tubules. The primer contains a resinous material in avolatile carrier/solvent, such as alcohol or acetone, which carries theresinous material into the collagen matrix and dentinal tubules. Thesurface must be wet (moist) for the primer to penetrate effectively. Afterthe primer is in place a stream of air is used to evaporate the carrier andleave 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 theunderlying 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 bondmore subject to hydrolytic breakdown (119).

“Self Etching” AdhesivesMost of the “self etching” products combine an acid with the

primer. Rather than removing the smear layer, they penetrate through itand incorporate it into the “hybrid layer.” The acidic primer is appliedto the dentin surface and dried with a stream of air. There is no rinsingstep. A resin adhesive is then applied and polymerized, followed by therestorative material.

The “self etching” systems can be categorizes as “strong” or “ag-gressive” (pH �1), “moderate” (pH 1–2) or “mild” (pH �2) (59,120, 121). The strong “self etching” systems form a hybrid layer ofapproximately 5 �m in thickness, similar to phosphoric acid, whereasthe mild systems form a hybrid layer of about 1 �micron (120, 121).There does not appear to be clinical significance to this difference inthickness, however (121). The “strong” systems generally produce asuperior bond to enamel than the “weak” systems (59), particularlywith unground enamel (61– 63).

Dentin Adhesive “Generations”Many of the “etch and rinse” adhesive systems require three steps

(etch, primer, adhesive), and are known as “4th generation” adhesivesystems. The “generation” of a dentin adhesive generally follows theorder in which they were developed and each “generation” utilizesdifferent bonding procedures. The “5th generation” adhesive systemsare “etch and rinse,” followed by application of a combined primer andadhesive. 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 lesstime than the “etch and rinse” products, and are considered to be less“technique sensitive” (59). There are still a number of questions aboutthem, however, such as the unknown effects of incorporating partiallydissolved hydroxyapatite crystals and smear layer into the hybrid layer.There is also the question of how much of the carrier/solvent remainsbehind. Because they are relatively new, there are currently no long-term

Figure 6. SEM of a demineralized specimen showing resin penetration into thehybrid layer and dentinal tubules. (Courtesy of Dr. Bart VanMeerbeek, Leuven,Belgium.)

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clinical studies with the “self etching” adhesive systems. The three stepadhesive systems generally perform better in in vitro testing than the adhe-sive systems that combine steps (59, 65, 66, 107, 121, 122), although thedifferences lessen with time as the bonds degrade (66, 107). The “selfetching” 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 anddual-cure composites. The single step (7th generation) adhesives are afairly recent addition to the market. At this point in their development, theyproduce consistently lower bond strengths in vitro than the 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 the simplifiedadhesive systems, and theywill probably continueto improve. Some of the common acronyms used in resin bonding areshown in Table 1. Examples of commercial dentin bonding systems areshown in Table 2.

Wet BondingMost adhesive systems utilize “wet bonding.” If the etched dentin

surface is dried excessively, the collagen matrix collapses and preventseffective infiltration of the primer. The result is low bond strengths andexcessive microleakage (127–129). Excessive moisture has similarnegative effects on adhesion (128, 129). An effective method to providethe proper amount of moisture is to dry the surface thoroughly and thenrewet it with a moist sponge, so that the surface is damp, but there is novisible pooling (127, 130).

Bonding to Dentin: Traditional Glass Ionomer CementsGlass ionomer cements are made primarily of alumina, silica and

polyalkenoic acid and are self curing materials. Most glass ionomercements 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 thehydroxyapatite at the dentin surface (132) and also obtain mechanicalretention from microporosities in the hydroxyapatite (133). Glass iono-mer materials form lower initial bond strengths to dentin than resins, on

the order of 8 Mpa. But unlike resins, they form a “dynamic” bond. Asthe interface is stressed, bonds are broken, but new bonds form. This isone 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 issimilar to tooth structure. Some glass ionomer materials also possessantimicrobial properties (134 –136).

When placing glass ionomer cements, the surface is cleaned andthen treated with a weak acid such as polymaleic acid (131). The acidremoves debris from the dentin surface, removes the smear layer, andexposes 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 tothe hydroxyapatite, strong acids should be avoided because they causealmost total elimination of mineral from the dentin surface (137).

Traditional glass ionomer cements are not widely used for clinicalprocedures because they set slowly and must be protected from mois-ture and dehydration during the setting reaction, which in many cases isnot complete for 24 h. They are also relatively weak and generally not asesthetic as other restorative materials.

Bonding to Dentin: Resin Modified Glass IonomerMaterials

Resin modified glass ionomer (RMGI) materials were developedto overcome some of the undesirable properties of the traditional glassionomer cements. RMGI materials contain glass ionomer cement towhich a light-cure resin is added. The purpose of the resin is to allowimmediate light polymerization after the material is placed. The resinalso protects the glass ionomer cement from dehydration, and improvesthe 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 BondingSome 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 resin—The original acrylic matrix material in composite resinsEDTA Ethylenediaminetetracitic acid Chelating agent sometimes used to remove the smear layer and

demineralize the dentinHEMA Hydroxyethyl methacrylate Low viscosity hydrophilic acrylic monomer used in dentin adhesive

systems4-Meta 4-Methacryloxyethyl trimellitate anhydride Low viscosity acrylic monomer used in dentin adhesives. Also used for

metal bondingMMA Methyl methacrylate Basic acrylic moleculeNPG-GMA N-Phenylglycine glycidyl methacrylate Low viscosity hydrophilic acrylic monomer used in dentin adhesivesPMDM Pyromellitic acid dimdiethylmethacrylate Low viscosity hydrophilic acrylic monomer used in dentin adhesivesTEG-DMA Triethylene glycol dimethacrylate Low viscosity hydrophilic acrylic monomer used in dentin adhesivesUDMA 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, ”4th

generation“ BiscoOptiBond Total Etch Three step, etch and rinse, ”4th generation“ KerrScotchbond Multipurpose Three step, etch and rinse, ”4th generation“ 3 MOne Step Two step, ”single bottle,“ etch and rinse, ”5th generation“ BiscoPrime&Bond Two step, ”single bottle,“ etch and rinse, ”5th generation“ DentsplyClearfil SE Two step, self-etching, ”6th generation“ KurarayOptiBond Solo SE Two step, self-etching, ”6th generation“ KerrPrompt L-Pop 2 One step, self-etching, ”7th generation“ 3 M/ESPEI-Bond One step, self-etching, ”7th generation“ Kulzer

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tion of access cavities, but also to the obturating materials that utilizeadhesive resin technology, which will be discussed in a subsequentarticle.

EugenolIn 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 plannedfor a dentin surface that is contaminated with eugenol, additional clin-ical steps are needed to minimize the effects of the eugenol. The surfaceshould be cleaned with alcohol or a detergent to remove visible signs ofsealer. 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 forcleaning the dentin surface (Fig. 7). Once it is clean, the dentin shouldbe etched with an acid, such as phosphoric acid and then rinsed. Theacid demineralizes the dentin surface to a depth of about 5 �m andremoves the eugenol rich layer. Several studies have shown that the“total etch” (three step) procedure allows effective bonding to eugenolcontaminated dentin surfaces (24, 142). An “etch and rinse” adhesivesystem should be used, because the “self etching” systems incorporatethe eugenol rich smear layer into the hybrid layer, rather than removingit. Eugenol has no effect on glass ionomer cements (143).

Sodium HypochloriteSodium hypochlorite is commonly used as an endodontic irrigant

because of its antimicrobial and tissue dissolving properties (144).Sodium hypochlorite causes alterations in cellular metabolism andphospholipid 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 tosodium hypochlorite exhibits resin bond strengths that are significantlylower than untreated dentin (145–149). One study reported bondstrengths as low as 8.5 Mpa (147). Increased microleakage was alsoreported (150). This phenomenon probably occurs because sodiumhypochlorite is an oxidizing agent, which leaves behind an oxygen richlayer on the dentin surface. Oxygen is another substance that inhibits thepolymerization of resins (151). Morris et al. showed that application of10% ascorbic acid or 10% sodium ascorbate, both of which are reduc-ing agents, reversed the effects of sodium hypochlorite and restoredbond strengths to normal levels. Lai et al. and Yiu et al. reported similarresults (149, 150). Because sodium hypochlorite is likely to remain theprimary irrigant used in endodontics for the near future, and becauseadhesive resin materials are used routinely in restoring endodonticallytreated teeth, this issue will have to be addressed. Future adhesive resinproducts for endodontic applications may contain a reducing agent to

reverse the effects of the sodium hypochlorite. A nonoxidizing irrigantwould also solve this problem. Sodium hypochlorite and EDTA have alsobeen shown to reduce the tensile strength and microhardness of dentin(152). These are particularly timely issues for endodontics as adhesiveresin materials gain popularity as obturating materials.

Other Materials Applied to DentinOther 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 inhibitsbonding (147, 148). Reduced bond strengths were shown after the useof RC prep (Premier) (146). Electro-chemically activated water hasgained a following as an irrigating solution. It probably reduces bondstrengths of adhesive resins because it has the same active ingredient assodium hypochlorite, i.e. hypochlorous acid (153, 154). No loss ofbond strength is reported from chlorhexidine irrigation before resinbonding (147, 155, 156) or placement of resin-modified glass ionomermaterials (157). Caries detector did not affect resin bond strengths(158, 159), but chloroform and halothane resulted in significant loss ofbond strength (160).

Restorative MaterialsSilver Amalgam Alloy

Not surprisingly, silver amalgam alloy is the most common choicefor 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 amalgamalloy. The adhesive provides an immediate seal. When amalgam alloy isused without an adhesive, it leaks initially, but “self seals” with time ascorrosion products form at the amalgam interface with tooth structureor other restorative materials (162). One strategy to use with amalgamalloy, that offers theoretical advantages, is to seal only the chamber floorand orifices with adhesive resin to provide initial protection of the rootcanal system from contamination. With time the amalgam restorationwill corrode at the other interfacial areas and provide a seal that may bemore durable than resin.

There is a theoretical advantage to using ad-mixture alloys overpure spherical alloys. Ad-mixture refers to a mixture of spherical andlathe cut particles. Ad-mixture alloys have slight setting expansion,which tends to reduce leakage (163), whereas spherical alloys shrinkslightly while setting (163).

Composite ResinNot surprisingly, composite resin is the most common choice for

restoring access cavities in ceramic restorations (161). Composite canbe bonded to tooth structure and most restorative materials, and canprovide a good match of color and surface gloss. Bonded compositematerials 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 areprimarily related to polymerization shrinkage. Restorative resins arereported 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 causesstress on the adhesive bond that often results in gap formation (43).One study reported the percentage of dentinal gaps found in vivo was 14to 54% of the total interface (168). Marginal deterioration of compositerestorations 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 alcoholand chloroform left a film on the dentin surface, shown in the first picture. Notehow much cleaner the dentin appears in the second picture, after microabra-sion (Courtesy of Dr. Fred Tsusui, Los Angeles).

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single paste and polymerization is initiated with a curing light. Self-curematerials consist of two pastes that are mixed together to initiate poly-merization. Dual-cure materials also consist of two pastes that aremixed together to initiate polymerization, but may also be light activated.Dual-cure materials have the advantage of rapid polymerization in the areasirradiated by the curing light, but chemical polymerization occurs in areas thelight can not reach.

Light-cure materials polymerize in a matter of seconds andgenerally have the best physical properties. However, they have sev-eral disadvantages. Because of the rapid polymerization, they tend tostress the adhesive bond to tooth structure more than the slowerself-cure composites (167). The stress is sometimes so great thatthe 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 thanenamel (54). Because most curing lights can only effectively poly-merize a thickness of 2 to 3 mm of composite material, cavities mustbe filled incrementally, a time consuming and tedious task. An ac-cess cavity may require 3 to 5 increments. Because curing lights loseintensity with distance, the light intensity may be greatly reduced atthe floor of the chamber when curing through an access opening ina crown. In addition, it may not be possible to irradiate all areasinside 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 requirepenetration with a curing light. They polymerize more slowly than light-cure materials, allowing the material to flow during polymerizationcontraction, 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 porcelainis thoroughly air dried and silane is applied and dried.

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same is true for dual-cure materials in the areas that are not irradiatedby the curing light.

The problem with polymerization shrinkage is amplified inaccess 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, thegreater the stress from polymerization shrinkage (43). Restorationswith C-factor higher than 3:1 are considered to be at risk for

debonding and microleakage (170). In a class 5 restoration, theratio might be 1:1. In an access cavity, the C-factor might be 6:1 oreven 10:1. In a root canal system obturated with a bonded resinmaterial, it might be 100:1 (43).

An incremental filling technique with light-cure composite resinspartially overcomes the problem of C-factor. Incremental filling is pos-sible because atmospheric oxygen prevents complete polymerization onthe 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 lightpolymerized. (F) A flowable composite is injected into the orifices and on the chamber floor and polymerized. This method minimizes voids between the restorativematerial 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, lightcomposite over dark. Increments should be only 2 to 3 mm in thickness to allow adequate polymerization. (H) Application of opaque composite. This is oftennecessary when restoring metal-ceramic crowns that tend to be quite opaque.

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“oxygen inhibited layer (151).” Because of the unpolymerized surfacelayer, additional increments may be added and polymerized and astrong 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 theC-factor is more favorable for each increment than if the cavity was bulkfilled. Another strategy to lessen the effects of C-factor is to use slowsetting self-cured materials that flow during polymerization, thus reduc-ing stress (31, 167).

If contamination occurs with blood or saliva during incrementalfilling, the bond between increments may be ruined. However, if thesurface is rinsed, dried and a dentin adhesive is applied, there is no lossof bond strength (173).

Glass Ionomer Cement and Resin Modified Glass Ionomer MaterialsBoth types of glass ionomer materials may be bulk filled. Most of the

RMGI materials are dual-cure. Traditional glass ionomer cements are self-cure and have very little polymerization shrinkage. Because resin is added toRMGI materials, they exhibit some polymerization shrinkage, although lessthan composite resins. Both types of glass ionomer materials are useful forbulk filling access cavities. Even though they bond to tooth structure, thebond strengths are too low to provide significant strengthening effect (174).

Material IncompatibilitiesThe “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 tothe grooves and occlusion is checked. (L) Final result.

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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 initiatethe polymerization reaction and have a high pH. Loss of bond strengthresults because residual acid from the acidic primer inhibits the basicamines, resulting in incomplete polymerization at the interface betweenthe 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 theyare not dependent on the basic amines. One study reported lower bondstrengths 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” adhesivesystems is that they act as permeable membranes. This is a problemwhen they are used with restorative materials that polymerize slowly. Apermeable 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 inpolymer chemistry as “emulsion polymerization,” in which there ispoor adaptation between the adhesive and restorative material (122).Moisture at the interface probably also contributes to the degradation ofthe bond over time (122).

Clinical StrategiesMost strategies for restoring access cavities require several steps

and at least two layers of restorative material. Many approaches utilizean adhesive system and two restorative materials. The exception is un-bonded amalgam alloy.

Restoring Access Cavities with Tooth Colored MaterialsLight-cure composite can be used to fill the entire access cavity if

it is filled incrementally. This method will provide the strongest bond totooth structure (181) and is the preferred method when it is necessaryto maximize the tooth strengthening effects of the restoration. Whenexecuted with skill and knowledge of the materials, excellent estheticresults are possible (Fig. 8). However, this is a slow, time consumingmethod. High initial bond strengths are also obtained with dual-curecomposites that are placed incrementally and light polymerized (177).This method may be preferred to incremental fill with purely light-curedmaterials if there are concerns about light penetration to all areas of thecavity.

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 theuse 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 themwith a bur.

3. Etch the ceramic with hydrofluoric acid or other appropriateetchant.

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 enhancesthe 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 lightcure.

9. Fill the cavity incrementally with no increments greater than 3mm.

10. Light cure each increment for 40 s (time depends on type of lightused).

11. The restoration should be slightly overfilled so it can be finishedback 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 aglass ionomer material or self-cure or dual-cure composite, then ve-neer it with a light-cure composite material that is esthetic and willwithstand occlusal function. This method is more efficient than using apurely light-cure composite, but the esthetic result may not be as good.

A simple method to restore access cavities in teeth with ceramicrestorations: 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 thebase 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 befinished 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 ionomermaterial, but a 4th generation dentin adhesive system is used on thedentin and a dual-cure composite is substituted for the glass ionomermaterial.

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 moistsponge.

3. Apply primer and adhesive, following the manufacturer’s in-structions.

4. Bulk fill with a dual-cure or self-cure composite to within 2 to 3mm of the cavo-surface margin and light cure.

5. Etch the ceramic material with 10% hydrofluoric acid, or othersuitable 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 andlight 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 thebase 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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12. Contour and adjust the occlusion.13. Finish and polish the restoration.

Dual-cure composites that are bulk filled develop relatively lowbond strengths to dentin, comparable to glass ionomer materials. Resinadhesives lose bond strength with time and function, whereas glassionomer bond strengths are relatively stable. So there is little if anybenefit to the use of dual-cure composites over glass ionomer materialsfor bulk filling the cavity.

Conclusions1. Prevent contamination of the root canal system.2. Restore access cavities immediately whenever possible.3. Use bonded materials4. The 4th generation (three step) resin adhesive systems are pre-

ferred because they provide a better bond than the adhesives thatrequire fewer steps.

5. The “etch and rinse” adhesives are preferred to “self etching”adhesive systems if a eugenol containing sealer or temporarymaterial was used.

6. “Self etching” adhesives should not be used with self-cure ordual-cure restorative composites.

7. When restoring access cavities, the best esthetics and highestinitial strength is obtained with an incremental fill technique withcomposite resin.

8. A more efficient technique which provides acceptable esthetics isto bulk fill with a glass ionomer material to within 2 to 3 mm of thecavo-surface margin, followed by two increments of light-curecomposite.

9. If retention of a crown or bridge abutment is a concern after rootcanal treatment, post placement increases retention to greaterthan the original.

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