what’s new & what’s not in adhesive restorative materials · 10/18/2017 · what’s new...

What’s New & What’s Not in Adhesive Restorative

MaterialsEdmond R. Hewlett, D.D.S.

October 18, 2017

Disclaimer No financial interest in any products discussed.

No contractual or non-contractual agreements with any manufacturers or corporations.

Resin-Enamel Bonding

Image: Peumans, et al. J Dent 2000



Hybridized Zone


Phosphoric acid (H3PO4), 32%-35%: IDEAL

↑↑ surface area

CLEANS• Debris, contaminants

Resin-Enamel Bonding >60 years of clinical experience with

phosphoric acid etching

Predictable and Durable!

As good as it gets


Selective Etching…

..for Self-Etching systems• minimal etch of enamel – adequate?• PRE-ETCH enamel w/phosph. acid for best seal

Dr Mario de Goes

Resin-Dentin Bonding

Resin-Dentin Bonding Product choices

• 3-step etch/rinse • 2-step etch/rinse• Self-etching• solvent type?• monomer type?• filler?• mixing?

Technique choices• etch time?• wet, moist, or dry? • disinfectant?• desensitizer?• application time?• apply once? twice?...• drying technique?• curing technique• flowable liner?

Resin-Dentin BondingProduct choices

3-step etch/rinse 2-step etch/rinseSelf-etchingsolvent type?monomer type?filler?mixing?

Technique choicesetch time?wet, moist, or dry? application time?apply once? twice?...drying technique?curing techniqueflowable liner?

Substrate variables deep or shallow? caries affected? sclerotic? tubule density? fluid/pulpal pressure? pulpal proximity etch depth? un-hybridized collagen? smear layer components? contamination?

Resin-Dentin BondingProduct choices

3-step etch/rinse 2-step etch/rinseSelf-etchingsolvent type?monomer type?filler?mixing?


Substrate variablesdeep or shallow?caries affected? sclerotic?tubule density?fluid/pulpal pressure?pulpal proximityetch depth?un-hybridized collagen?smear layer components?contamination?

Resin-Dentin Bonding –a pathway to predictability?

Product choices3-step etch/rinse 2-step etch/rinseSelf-etchingsolvent type?monomer type?filler?mixing?


Substrate variablesdeep or shallow?caries affected? sclerotic?tubule density?fluid/pulpal pressure?pulpal proximityetch depth?un-hybridized collagen?smear layer components?contamination?

Dentin as a Bonding Substrate

No such thing as “NORMAL dentin” Substrate variability = Bonding

variability Don’t be complacent!

- Summary:

What Do The Experts Say?

Product Classification

(Adapted from Tay, et al., J Appl Oral Sci 2004)

No Mix

(3-Step Etch & Rinse)


(2-Step Self-Etch)

(1-Step Self-Etch, Mix)

(1-Step Self-Etch, No Mix)

3-Step Etch & Rinse Systems

1. Etch 2. Primer 3. Adhesive Resin

Product Classification

(Adapted from Tay, et al., J Appl Oral Sci 2004)

No Mix



(2-Step Self-Etch)

(1-Step Self-Etch, Mix)

(1-Step Self-Etch, No Mix)

Two-Step Self-Etching Systems

1. Etch/Primer 2. Adhesive Resin

Durability of the resin-dentin bond

“The most compelling problem associated with resin-dentin bonds is their limited durability…”

- Tay & Pashley, J Dent Res 2009

Durability of the resin-dentin bond•Dentin bonds made w/ hydrophilic contemporary adhesives

deteriorate over time:

•Hydrolysis of hydrophilic resin components via water sorption

•Hydrolysis of unpolymerized resin by host enzymes from saliva

•Degradation of exposed demineralized collagen fibrils by host enzymes from dentin and saliva

Nanoleakage

(Perdigao, J.)

(cut dentin surface)


After etching:

EXPOSED demineralizedcollagen fibers

Over-etchedUnder-primed

Susceptible to enzymes(MMPs)

Sequential Etching…

… for Etch & Rinse products Enamel: etch for ∼ 30-45 sec. Dentin: etch for ∼ 10 sec.

Dr Mario de Goes

Preventing Dentin Bond Degradation

Degradation of demineralized collagen matrix over time by enzymes (MMPs) Pashley, Tay, et al.-JDentRes 2004

Chlorhexidine may inhibit MMPs after etching 2% for 30 sec. Blot dry

“Phosphoric-acid etching of dentin

could nowadays be considered too

aggressive for dentin, given all the

consequences related to exposure of

the vulnerable collagen.”- Van Meerbeek, et al., 2011

“Universal” Adhesive Systems –The End of “Generations”?

Updated chemistry Resin monomers Less water, more alcohol

Dentin: Moist or Dry? Indirect w/ Self- or Dual-Cure

ScotchbondUniversal (3M ESPE)

Either is OKMix w/DCA, Apply, Dry, & Cure

All-Bond Universal (Bisco)

Moist, Do Not Dessicate for TE AND SE

Apply, Dry, & Cure

Prime & Bond Elect (Caulk)

TE: Moist, Do Not DessicateSE: Dry

Mix w/SCAApply, Dry, & Cure

G-Premio Bond (GC) “rinse…and gently dry” Apply, Dry, & Cure

OptiBond Universal (Kerr)

Air dry, Do not Dessicate Apply Twice, Dry, & Cure

Clearfil Universal Bond/Universal Bond Quick (Kuraray)

“dry with air or with cotton pellets”

Mix w/DCA, Apply, Dry, & Cure

Vital Pulp Therapy

Cao, et al. J Calif Dent Assn 2016

Vital Pulp Therapy

aka:

Direct pulp capping

Pulpotomy


Vital Pulp Therapy

Primary goal:

Preserve healthy pulp tissue to encourage pulpal repair by hard tissue bridge formation


- Ricucci D, et al. J Dent 2014

Vital Pulp Therapy

Critical Factors:

Hemorrhage control Sodium hypochlorite 5.25% ↓ bleeding AND disinfects

Seal out bacteria Bonded/sealed definitive restoration


Vital Pulp Therapy

ZOE? Resin bonding? Gl ionomer?

Calcium hydroxide? MTA? CSCs?

Formation of a hard tissue bridge - What material?

Vital Pulp Therapy

ZOE? High leakage, but eugenol kills bacteria (-/+) Eugenol is cytotoxic (-) Eugenol release drops quickly with time (-)

Resin bonding? Cytotoxic (-) Poor outcomes in human studies (-) Seal? (+/-)

Vital Pulp Therapy

Calcium hydroxide? Excellent antibacterial (+) Long track record (+) Bioactive molecule release (+)

Vital Pulp Therapy

Calcium hydroxide? Inconsistent outcomes Success rate ↓ as time ↑ “Tunnel defects” in dentin bridge Allowes bacteria ingress

“CH…can no longer be considered the material of choice for VPT.”

- Cao, et al. J Calif Dent Assn 2016

Vital Pulp Therapy with Calcium Silicate Cements (CSCs)

Mineral Trioxide Aggregate (MTA) First developed as a sx. root repair

mat

Vital Pulp Therapy with CSCs

MTA (Mineral Trioxide Aggregate) Excellent biocompatibility and sealing ability (+) Prolonged alkaline pH Radiopaque (+) High solubility (-)

Poor handling properties (-) Prolonged setting time (-)


MTA (Mineral Trioxide Aggregate)

Success rate > calcium hydroxide Mineral infiltration zone at dentin interface Long-lasting seal Better dentin bridge density


Biodentine™ Chemically similar to MTA Sets in 10-12 min. (vs. 3-4 hrs.) “Mineral infiltration zone” at interface Interim restoration – lasts up to 6 months


TheraCal LC™ Light-cured, resin-modified calcium silicate liner

Calcium release stimulates hydroxyapatite and secondary dentin bridge formation

Alkaline pH promotes healing


TheraCal LC™ Light-cured, resin-modified calcium silicate liner

Per msds: Portland Cement Type III <60% Polyethlene glycol dimethacrylate <50% Barium zirconate <10%

Neo MTA (NuSmile) MTA Flow (Ultradent)

ACTIVA BioACTIVE (Pulpdent)

Bioactive glass filler Ion-releasing Allows diffusion of Ca2+, PO4-, & F-

Rubberized resin Elastic modulus similar to dentin Less interfacial stress

Better SEAL

ACTIVA BioACTIVE (Pulpdent)

“3. Etch prepared tooth surfaces for 10 seconds…with…phosphoric acid etching gel…”

“D3120 pulp cap – indirect (excluding final restoration)”

“Procedure in which the nearly exposed pulp is

covered with a protective dressing to protect the

pulp from additional injury and to promote

healing and repair via formation of secondary

dentin. This code is not to be used for bases

and liners when all caries has been removed.”

Restoration Longevity

Restoration Longevity 70 y.o. female

Restoration age?

How?

Why?

Restoration Longevity 65 y.o. female

∼ 50 y.o. amalgam!

How?

Why?

30 Years

Restoration Longevity Factors Healthy diet Meticulous OH Good quality/quantity

of saliva Petite Light biting force Anterior guidanceFRIENDLY, LOW RISK

ENVIRONMENT

Restoration Longevity Factors Healthy diet Meticulous OH Good quality/quantity of

saliva Petite Light biting force Anterior guidance FRIENDLY

ENVIRONMENT

THANKS!Edmond R. Hewlett, D.D.S.

October 18, 2017

what’s new & what’s not in adhesive restorative materials · 10/18/2017 · what’s new...

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