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CLINIC MEETS RESEARCH VOL.1 ADHESION

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Modern dentistry means to glue. Nowadays we use adhesion procedures in all our clinical works. So
lets understand which procedure we have to use and in which case we have to chose one or another.
A blog by Giuseppe Marchetti and Giovanna Orsini
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2)The two steps etch-and-rinse-technique despite the one-bottle concept is extremely user friendly,
acetone-based adhesives may lose their efficacy with constant utilization6.

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3)The self-etch technique can include either two or one-step systems, if the etching/primer agent is
separated from the adhesive or combined with it to have a single application. With the multi-bottle
system we dont have to rinse and we can apply it fast. It is important to respect the application time
of the acidic primer and the bonding before polymerization; it may not work on sclerotic dentin and
it may request the etching procedures of the enamel to avoid enamel microleakage 5. In contrast to
the control three-step etch & rinse adhesive, the bond strength to dentin of both one-step and twostep self-etch adhesives decreased after six-month water storage. These failures just under the
hybrid layer may be attributed to insufficient encapsulation of surface smear. (Filler Debonding &
Subhybridlayer Failures in Self-etch Adhesives - K.L. Van Landuyt*, J. De Munck, A. Mine, M.V. Cardoso,
M. Peumans, and B. Van Meerbeek - J Dent Res 89(10):1045-1050, 2010)

Walter Devoto
Dr. Walter Devoto Born in
Chiavari on 29/03/1965
graduated in Dentistry in 1991
at Genova University.

Angelo Putignano
M.D. degree and D.D.S. post
graduate certificate from
University of Ancona-Italy.

FOUNDERS ENDO

Pio Bertani
Pio Bertani is a full member of
the prestigious association...

4)The all-in-one application may be a very quick alternative, but it has a very low bond strength
value, needs multiple coatings to bond effectively to dentin and has not proven their efficacy over
time 5. One-step adhesives have been especially documented with problems, such as insufficient
polymerization, water-uptake and subsequent plasticization, water- and enzyme-induced
nanoleakage, and/or the presence of voids due to phase-separation or osmosis. It was hypothesized
that these shortcomings may weaken the adhesive layer and, as such, may jeopardize long-term
bonding(Filler Debonding & Subhybridlayer Failures in Self-etch Adhesives - K.L. Van Landuyt*, J. De
Munck, A. Mine, M.V. Cardoso, M. Peumans, and B. Van Meerbeek - J Dent Res 89(10):1045-1050, 2010)
So causes of failure for the etch-and-rinse techniques may be: over-etching, no proper sequence,
multi-layering. In the self-etch technique (especially in all-in-one application) failures can be due to:
stability over time, phase separation, low degree of conversion, continuous etching.
TARGETS AND CLINICAL CONSIDERATIONS:

Fabio Gorni
Fabio Gorni is an active
member of the Italian Society
of Endodontics and the Italian
Academy...

MEMBERS
Monaldo Saracinelli
Ive been a student of prof.
Fabio Toffenetti and
Riccardo Garberoglio.

Jordi Manauta
Was born in Mexico City,
where he graduated cum
laude. in dentistry from
UNITEC.

Gaetano Paolone
My passion is aesthetic
direct and indirect
adhesive dentistry in
anterior and posterior
teeth.

Daniele Rondoni
Born in Savona in 1961
where he lives and has

The target of a bonded restoration is to reach a close adaptation of the restorative material with the
dental substrate (enamel, dentin) and the different restorative materials(composite resins and
ceramics.) While adhesion to enamel is stable over time, adhesion to dentin is more unstable, because
of its heterogenous characteristics 10. The wetness of dentin surfaces, the presence of pulpal
pressure, and the thickness of dentin are extremely important variables during bonding procedures,
especially when testing bond strength of adhesive materials in vitro with the intention of simulating
in vivo conditions. While enamel is predominantly mineral, dentin contains a significant amount of
water and organic material, mainly type I collagen 11, 12. Several other substrate-related variables
may affect the clinical outcome of bonded restorations.

worked in his own

laboratory since...

Vincenzo Musella
Vincenzo Musella
graduated in dental
technician. Proud friend
and student of...

Giuseppe Marchetti
Giuseppe Marchetti was
born in Parma (Italy) in
October of 1972 and
graduated from...

Simone Grandini
Chair of Endodontics and
Restorative Dentistry,
University of Siena, Italy.

Giovanna Orsini
Giovanna Orsini is a well
known researcher in Italy
and internationally.

Paulo Monteiro
My passion for esthetic
dentistry began when I
attended the last year...

Louis Hardan
Head of Restorative and
Esthetic department in
Saint-Joseph University
in...

Patrizia Lucchi
Patrizia Lucchi Graduated
in Dentistry cum Laude in
1995 at the University of
Verona

Anna Salat
Dr Anna Salat graduated
with a degree in dentistry
from the International
University of Catalonia

Giulio Pavolucci
After graduation magna
cum laude in Dentistry, I
started focusing my daily
work on...

Marcos Vargas
Dr. Marcos Vargas
attended Cayetano
Heredia University School
of Dentistry in Lima...

Stefan Koubi
Dr. Koubi graduated from
University of Marseille
where he...

Engin Taviloglu
Dr. Taviloglu graduated
from ?stanbul University
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Dimitar Filtchev
Co-founder of the Laser
Dental Center and the
Implant...

Angie Segatto
My commitment to arts has
determined my
specialisation.

Kilian Molina
Kilian is required as a
regular lecturer in indirect
restorative...

Gregory Camaleonte
I was born in 1980 in
Marseille-France and i have
graduated in 2006 from...

Caroline Werkhoven
Caroline Werkhoven
graduated in 2002 at
ACTA, the dental faculty in
Amsterdam..

Ajay Juneja
Ajay Juneja finished his
BDS in the year 1995...

Carlos Fernndez
Villares
Member of SEPES Spanish
Soc...

Sulivan Leite
Sulivan Leite graduated
from the Ribeirao...

Maciej Zarow
Author of book edited by
Quintessence: EndoProsthodontics: guidelines
for clinical practice ...

Dan Lazar
Dan Lazar, graduated from
the Faculty of Dentistry in
2005 in Cluj-Napoca...

Murad Akhundov
Dr. Murad Akhundov
graduated from the
Faculty of Dentistry in
Baku...

Janos Grosz
Graduated summa cum
laude in 2006 from the
University of Szeged,
Faculty of Dentistry,
Hungary...

MEMBERS ENDO
Simone Grandini
Chair of Endodontics and
Restorative Dentistry,
University of Siena, Italy.

Louis Hardan
Head of Restorative and
Esthetic department in
Saint-Joseph University
in...

Filippo Cardinali
Graduate in Dentistry and
Dental Prostheses at the
University of Ancona in
1992. Active Member of...

Riccardo Tonini
He is active member of the
Italian Academy of
microscopic Dentistry and
Active member of...

Paolo Generali
Doctor Generali was
graduated from Pavia
University in the year...

Calogero Bugea
Graduate in Dentistry,
Certificate in Oral Surgery.
Active Member of the
International
Piezosurgery...

Clifford Ruddle
Internationally recognized
as a leading expert in all
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endodontics, Dr. Ruddle is
acclaimed for...

Pierre Machtou
Pierre Machtou was the
first scientific director and
general secretary of the
French Endodontic
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Marga Ree
Primary author of several
articles published in
national and international
journals and has ...

Marco Martignoni
Marco Martignoni leads a
private clinic in Rome Italy
and dedicates his practice
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pre-prosthetic...

Massimo Giovarruscio
Massimo Giovarruscio
works in Rome, Bristol and
London, specialising in
Endodontic Treatment
and...

Bonding to caries-affected dentin is stopped by its lower hardness, presence of mineral deposits in
the tubules and disorganized collagen 13. Hybrid layers in caries-affected dentin are usually thicker
but more porous than those in sound dentin 14. Non-carious cervical areas contain hypermineralized
dentin and denatured collagen, which is not the ideal combination for a bonding substrate. An
increase in number of tubules with depth and, consequently, increase in dentin wetness, make
bonding to deeper dentin more difficult than to superficial dentin. Dentin permeability increases with
cavity depth and it can be also increased by acids that remove the smear layer. Etch-and-rinse
adhesives result in higher micro-permeability compared to self-etch ones 16. The application of acidic
agents open the pathway for the diffusion of monomers into the collagen network, it also facilitates
the outward seepage of tubular fluid from the pulp to the dentin surface, deteriorating the bonding
for some of the current adhesives. Further factors that might influence with the bonding efficacy are:
the orientation of the dentinal tubules and other regional variables; the instruments used to create
the smear layer. For instance, dentin surfaces ground with diamond burs tended to present compact
smear layers of which denseness may compromise bonding action, especially of self-etch systems 17.
Special attention should be directed to water-based agents, mainly the all-in-one agents. A multiple
layer application under a continuous brushing technique has also been claimed to increase the bond
strength of these materials 14,23
Adhesive systems and restorative substrates:
We know that adhesion to composite resins is stable over time but adhesion on other restorative
materials is more unstable, for their different characteristics. Bonding to traditional silica-based
ceramics, generally employing both mechanical and adhesive retentions, has been well researched,
and bond strengths are predictable. A strong resin bond relies on chemical adhesion between the
cement and ceramic (by way of silane chemistry), and on micromechanical interlocking created by
surface roughening. Current roughening techniques are: (1) grinding, (2) abrasion with diamond (or
other) rotary instruments, (3) air abrasion with alumina (or other) particles, (4) acid etching (5%
hydrofluoric), and (5) a combination of any of these techniques. Unfortunately, the composition and
physical properties of certain materials like Zirconia differ from conventional silica-based materials
like porcelain and requires very aggressive mechanical abrasion methods to increase surface
roughness, possibly creating strength reducing surface flaws20. Therefore, in order to achieve
acceptable cementation in a wide range of clinical applications, alternate attachment methods, ideally
utilizing chemical adhesion in addition to mechanical retention, are required.

Different restorative procedures may need different types of bonding systems. Literature reports
generally differentiated adhesive approaches for direct versus indirect restorations Luting indirect
restorations: if margins are in enamel, the etch-and rinse adhesives and the etch-and-dry systems
with pre-etching treatment performed well. When margin are in dentin, the total-etch technique with
a 3-steps etch and-rinse is still considered the gold standard 22. The final film thickness of a resin
adhesive and a resin cement could be affected by previous polymerization of the adhesive systems
on dentin surfaces. Instructions regarding polymerization of the adhesive layer must be followed
when adhesive systems are used in combination with dual polymerized resin based cements 23.
Clinical interpretations and applications:
In case of inlays, onlays and overlays, the following uses can be suggested: (1) a 2-step self etch
adhesive, to make the build-up and to treat the dentin, on the day of inlay preparation; (2) a totaletch adhesive, on the day of the indirect restorations cementation.

In case of luting ceramic veneers with margins on enamel it can be suggested the total-etch
technique. Translucency and opacity of the veneers have to be also taken into account. For instance,
when the veneer is opaque, it is advisable to treat the prepared tooth by applying and light-curing a

simplified adhesive. On the other hand, when the veneer is translucent the adhesive can be also left
uncured and a 3-step system can be used. Low-viscosity and extremely thin bonding agents are
indicated for young dentin, V and IV class direct restorations, and porcelain veneers and inlays
(because they do not compromise the fit). High-viscosity (high filler content) bonding systems can be
effective for replacing old restorations with sclerotic dentin or in case of slow caries-affected regions.
Conclusions:
In this aesthetic era, managing different adhesive systems could be difficult, but it is the way to allow
good results which can be stable in time. So for a correct appliance of these systems, the tips are: 1)
Extended polymerization time: Cadenaro et al. 2005-2008 2) Improved impregnation i.e. prolonged
impregnation time multilayering: Pashley et al. 2004. 3) Use of an hydrofobic coating to reduce
water sorption and stabilizes hybrid layer: De Munck et al.2005, Van Landuyt et al. 2007 4) Improve
solvent evaporation by air-blowing: De Munck et al. 2005; Van Landuyt et al. 2007 5) Use of inhibitors
of metallo-proteinases (MMPs), which are the enzymes responsible of the bonding degradation:
Breschi et al. 2008 Hebling et al. 2005 Carrilho et al. 2007 6)Ethanol wet-bonding with hydrophobic
resins to completely replace water from the extrafibrillar and intrafi- brillar collagen compartments
and immobilize the collagenolytic enzymes: Sauro et al. 2010
TIPS SYSTEM BY SYSTEM:
1) Etch and rinse three steps technique. Respect etching time( 15 seconds for dentine and 30 seconds
for enamel). Rinse it for the same time. Do not overdry dentine. Apply primer for 10 seconds and dry
it. Apply adhesive for 20 seconds and gently dry it. 2) Etch and rinse two steps technique. Respect
etching time( 15 seconds for dentine and 30 seconds for enamel). Rinse it for the same time. Do not
overdry dentine. Apply primer&bonding multilayering. Dry to evaporate solvents. 3) Etch and dry two
step technique. Respect the application time of the acidic primer and the bonding before
polymerization. Requires the etching procedures of the enamel to avoid enamel microleakage 5.

4) Etch and dry one step technique. Has a very low bond strength value, needs multiple coatings to
bond effectively to dentin and has not proven their efficacy over time
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References
1. Zimmer S, Robke FJ, Roulet JF. Caries prevention with fluoride varnish in a socially deprived
community. Community Dent Oral Epidemiol. 1999;27:103-108
2. Hashimoto M, Fujita S, Endo K, Ohno H. Effect of dentinal water on bonding of self-etching
adhesives. Dent Mater J. 2009;28:634-641
3. Van Meerbeek B, De Munck J, Yoshida Y, Inoue S, Vargas M, Vijay P, Van Landuyt K, Lambrechts P,
Vanherle G. Buonocore memorial lecture. Adhesion to enamel and dentin: Current status and future
challenges. Oper Dent. 2003;28:215-235
4. De Munck J, Van Landuyt K, Peumans M, Poitevin A, Lambrechts P, Braem M, Van Meerbeek B. A
critical review of the durability of adhesion to tooth tissue: Methods and results. J Dent Res.
2005;84:118-132
5. Breschi L, Mazzoni A, Ruggeri A, Cadenaro M, Di Lenarda R, De Stefano Dorigo E. Dental adhesion
review: Aging and stability of the bonded interface. Dent Mater. 2008;24:90-101

6. Van Meerbeek B, Kanumilli P, De Munck J, Van Landuyt K, Lambrechts P, Peumans M. A randomized

controlled study evaluating the effectiveness of a two-step self-etch adhesive with and without
selective phosphoric-acid etching of enamel. Dent Mater. 2005;21:375-383
7. Taschner M, Nato F, Mazzoni A, Frankenberger R, Kramer N, Di Lenarda R, Petschelt A, Breschi L. Role
of preliminary etching for one-step self-etch adhesives. Eur J Oral Sci. 2010;11
8:517-524 8. Sano H, Yoshikawa T, Pereira PN, Kanemura N, Morigami M, Tagami J, Pashley DH. Longterm durability of dentin bonds made with a self-etching primer, in vivo. J Dent Res. 1999;78:906-911
9. Cadenaro M, Breschi L, Antoniolli F, Navarra CO, Mazzoni A, Tay FR, Di Lenarda R, Pashley DH.
Degree of conversion of resin blends in relation to ethanol content and hydrophilicity. Dent Mater.
2008;24:1194-1200
10. Lehmann N, Debret R, Romeas A, Magloire H, Degrange M, Bleicher F, Sommer P, Seux D. Selfetching increases matrix metalloproteinase expression in the dentin-pulp complex. J Dent Res.
2009;88:77-82
11. Perdigao J. Dentin bonding-variables related to the clinical situation and the substrate treatment.
Dent Mater. 2010;26:e24-37
12. Can-Karabulut DC, Oz FT, Karabulut B, Batmaz I, Ilk O. Adhesion to primary and permanent dentin
and a simple model approach. Eur J Dent. 2009;3:32-41
13. Marshall GW, Habelitz S, Gallagher R, Balooch M, Balooch G, Marshall SJ. Nanomechanical
properties of hydrated carious human dentin. J Dent Res. 2001;80:1768-1771
14. Yoshiyama M, Tay FR, Doi J, Nishitani Y, Yamada T, Itou K, Carvalho RM, Nakajima M, Pashley DH.
Bonding of self-etch and total-etch adhesives to carious dentin. J Dent Res. 2002;81:556-560
15. Kinney JH, Nalla RK, Pople JA, Breunig TM, Ritchie RO. Age-related transparent root dentin: Mineral
concentration, crystallite size, and mechanical properties. Biomaterials. 2005;26:3363-3376
16. Rosales-Leal JI, de la Torre-Moreno FJ, Bravo M. Effect of pulp pressure on the micropermeability
and sealing ability of etch & rinse and self-etching adhesives. Oper Dent. 2007;32:242-250
17. Sattabanasuk V, Vachiramon V, Qian F, Armstrong SR. Resin-dentin bond strength as related to
different surface preparation methods. J Dent. 2007;35:467-475
18. Pashley DH, Tay FR, Yiu C, Hashimoto M, Breschi L, Carvalho RM, Ito S. Collagen degradation by
host-derived enzymes during aging. J Dent Res. 2004;83:216-221
19. Carrilho MR, Geraldeli S, Tay F, de Goes MF, Carvalho RM, Tjaderhane L, Reis AF, Hebling J, Mazzoni
A, Breschi L, Pashley D. In vivo preservation of the hybrid layer by chlorhexidine. J Dent Res.
2007;86:529-533
20. Thompson JY, Stoner BR, Piascik JR, Smith R. Adhesion/cementation to zirconia and other nonsilicate ceramics: Where are we now? Dent Mater. 2011;27:71-82
21. Heintze SD, Roulet JF. Glass ionomer derivates have better retention rates in cervical restorations
compared to self-etching adhesive systems. J Evid Based Dent Pract. 2010;10:18-20
22. Van Meerbeek B, Peumans M, Poitevin A, Mine A, Van Ende A, Neves A, De Munck J. Relationship
between bond-strength tests and clinical outcomes. Dent Mater. 2010;26:e100-121
23. Zahra VN, Abate PF, Macchi RL. Film thickness of resin cements used with adhesive systems. Acta
Odontol Latinoam. 2008;21:29-33
24. Tay FR, Pashley DH. Guided tissue remineralisation of partially demineralised human dentine.
Biomaterials. 2008;29:1127-1137
25. Hashimoto M. A reviewmicromorphological evidence of degradation in resin-dentin bonds and
potential preventional solutions. J Biomed Mater Res B Appl Biomater. 2010;92:268-280
All of the research works and references are by Prof. Angelo Putignano and Prof. Giovanna Orsini. All
of the clinical work( from pictures 1 to 26) is by Dr. Giuseppe Marchetti. The creation of this article is
by Dr. Giuseppe Marchetti, Dr. Giovanna Orsini and Style Italiano. This a copyright of Style Italiano
www.styleitaliano.org

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