Self-etch Approach (Etch-and- Dry)

1- Classification according to their acidity or etching aggressiveness:

► Strong ► such as Adper Prompt-L Pop (3M ESPE), produce rather deep demineralization
(pH > 1),
effects in both enamel and dentin.
►The interfacial ultramorphological features promoted by these adhesives on
dental substrates resemble those of etch-and-rinse systems.
►the products originated from demineralization are not rinsed away.

►Intermediate

(pH ≥ 1.5)
► Mild (pH ☻It demineralizes dentin only partially, leaving a substantial amount of
=2). hydroxyapatite crystals around the collagen fibrils→ possible additional
chemical interaction.
☻This twofold bonding mechanism (i.e. micromechanical and chemical adhesion)
is believed to be advantageous in terms of bonding effectiveness and durability.
☻The hybrid layer formed by such adhesives is no deeper than 1 um and resin
tags are hardly observed. (neither the thickness of hybrid layer, nor the
length of resin tags seems to be important for the achievement of
bonding effectiveness and stability.)

►Ultra-mild ♫ A more recent self-etch adhesive presents a relatively low acidity and,
(pH=2.7). consequently, a considerably reduced ability to dissolve the smear layer and
demineralize the underlying dentin surface.
♫ This ultra-mild self-etch adhesive, Clearfil S3 Bond (Kuraray) can only very
superficially expose collagen on dentin, creating a characteristic nanometer-sized

hybrid layer, which has been termed a “ nano-interdiffusion zone ”.

♫ However, the key factor in this ultra-mild adhesive is related to the presence of
10-MDP in its composition and its consequent ability to chemically bond to the
mineral content of the partially demineralized dentin.

♣ self-etch adhesives interact with the smear layer rather than eliminating it→their acidic potential
may be buffered by the mineral content of a thick and dense smear layer→ poor interaction with
underlying substrate.
♣ the less acidic the adhesive → the more the smear layer → interfere with bonding. Therefore,
techniques and instruments that produce thinner and less compact smear layers should be preferred
during cavity preparation.
♣ Finishing the cavity walls with an extra-fine diamond instrument →in thinner smear layers →
promote a better interaction between mild and ultra-mild self-etch adhesives and the dental substrate.
♣ some self-etch adhesives bond reasonably well to ground enamel, but there are general concerns
nowadays about the adhesion of such adhesives to unground aprismatic enamel where
micromechanical retention is hardly achieved → preparing beveled cavosurface margins is helpful for
 improving the bonding effectiveness of self-etch adhesives in cavities whose margins are placed in
enamel
2- Classification According to Steps of Application
1.Two-Step Self- ♫Some self-etch systems are most accurately described as non-rinsing conditioners or
Etch Systems self-priming etchants.
♫Acidic primers include a phosphonated resin molecule that performs two functions
simultaneously- etching and priming of dentin and enamel.
♫The bonding mechanism of self-etch primer (SEP) is based on the simultaneous
etching and priming of enamel and dentin, forming a continuum in the substrate and
incorporating smear plugs into the resin tags In addition to simplifying the bonding
technique, the elimination of rinsing and drying steps reduces the possibility of over-
wetting or over drying, either of which can affect adhesion adversely.
♫One disadvantage of SEPS that are currently available is that they do not etch enamel
as well as phosphoric acid, particularly if the enamel has not been instrumented. The
seal of enamel margins in vivo might he compromised
♫SEPS are less technique sensitive than are etch-and-rinse adhesives. SEPS do not
remove the smear layer from dentin completely (, which is the main reason that they
might result in less postoperative sensitivity compared with etch-and-rinse adhesives.

2. One-Step Continuing the trend toward simplification, no-rinse, self- etching

Self-Etch materials that incorporate the fundamental steps of etching, priming, and
Adhesives bonding into one solution have become increasingly popular. These one-
step self-etch or "all-in-one" adhesives contain uncured ionic monomers
that contact the composite restorative material directly.
One-step adhesives tend to behave as semi-permeable membranes,
resulting in a hydrolytic degradation of the resin-dentin interface. Because
these adhesives must be acidic enough to be able to demineralize enamel
and penetrate dentin smear layers, the hydrophilicity of their resin
monomers, usually organophosphates and carboxylates, also is high. Some
of these resin monomers are too hydrophilic, which makes them liable to
water degradation.
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Concerns about One-step Self-etch Adhesives
Attempting to provide faster and thus more user-friendly adhesives,
nanufacturers have introduced one-step self-etch adhesives which etch,
prime and bond the dental substrate simultaneously. For this purpose,
these adhesives have been made more acidic and more hydrophilic than
their two-step counterparts. These properties may, however, lead to a
wide variety of seemingly unrelated problems that may jeopardize the
effectiveness and stability of adhesion to a dental substrate. Actually, none
of the contemporary all-in-one adhesives can compete with the more
traditional multi-step systems in terms of bond effectiveness and
durability. One of the main disadvantages of one-step self-etch adhesives
is related to their excessive hydrophilicity that makes the adhesive layer
more prone to attract water from the intrinsically moist substrate

Multi-mode Universal Adhesives

One of the most recent novelties, in adhesive dentistry, was the
introduction of universal adhesives that have been used since 2011 in
clinical practice. These new products are known as "multi-mode" o
"multi-purpose" adhesives because they may be used as self-etch
adhesives, etch-and-rinse adhesives, or as self-etch adhesives on dentin
and etch-and-rinse adhesives on enamel (a technique commonly referred
to as "selective enamel etching").
This versatile new adhesion philosophy advocates the use of the simplest
option of each strategy, that is, one-step self-etch or two-step etch-and-
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much more challenging to dental substrates of different natures (i
sound, carious, sclerotic dentin, as well as enamel). Beforehand etchine
rinse, using the same single bottle of adhesive solution which is definitely
enamel with phosphoric acid is often recommended, in particular when
bonding to unground enamel.
Indeed, the priming and bonding components can be separated or
combined, resulting in three-steps or two-steps for etch-and-rinse systems,
and two-steps or one-step for self-etch adhesives. Contemplating these
two bonding strategies, adequate bonding to dentin can be completely
achieved with either etch-and-rinse or self-etch adhesives; however, at
enamel, the etch-and-rinse approach using phosphoric acid remains the
preferred choice. In relation to the application mode, self-etch adhesive
systems reduce the possibility of iatrogenic induced clinical mis-
manipulation during acid conditioning, rinsing and drying, which may occur
when etch-and-rinse systems are used. On the other hand, some drawbacks
may be listed for these self-etch materials. Unfortunately, one of the main
drawbacks from applying self-etch adhesives to dentin and enamel is their
inability to etch enamel to the same depth that phosphoric acid does,
which is likely responsible for the higher rates of marginal discoloration in
the enamel margins of cervical restoration due to their lower acidity.
Thereby the degradation of self-etch was attributed to its acidic content,
which increases the hydrophilicity of the adhesive layer and leads to water
uptake and plasticization. So the long-term performance of simplified one-
step adhesives is inferior in terms of bond durability, in particular when
compared to the gold-standard three-step etch-and-rinse approach. to
overcome the weakness of previous generations of single-step self-etc
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adhesives, universal adhesives have been developed that allow for
application of the adhesive with phosphoric acid pre-etching in the total-
etch or selective-etch approaches in order to achieve a durable bond to
enamel and has been accepted by showing good results in vitro and in
vivo studies.
Despite the similarities between adhesives, the composition of universal
adhesive differs from the current self-etch systems by the incorporation of
monomers that are capable of producing chemícal and micromechanical
d adhesion to the dental substrates. Its composition is an important
fartor to be taken account, since most of these adhesive contain specific
carboxylate and/or phosphate monomers that bond ionically to calcium
found in hydroxyapatite (Ca10[PO4]6[OH]2), that could be influence the
bonding effectiveness. For example, Methacryloyloxydecyl Dihydrogen
phosphate (MDP) is a functional monomer found in certain new ađhesives.
but not for older-generation bonding agents. This is a hydrophilic monomer
with mild-etching properties. MDP is one of the monomers that enable a
universal adhesive to be used with any etching techniques. Stable MDP-
calcium salts are formed during this reaction and deposited in self-
assembled nano-layers of varying degrees and quality depending on the
achesive system. It also helps promote strong adhesion to the tooth surface
via formation of non-soluble Ca? salts. Furthermore, it contains biphenyl
dimethacrylate (BPDM), dipentaerythritol pentaacrylate phosphoric acid
Ester (PEN-TA) and polyalkenoic acid copolymer may enhance adhesion to
tooth structures and have been part of the composition of different
materials for decades. This may be important in terms of durability, as
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vater sorption and hydrolytic breakdown of the adhesive interface over
ime has been implicated as one of the primary causes of bond failure.
Additionally, the matrix of universal is based on a combination of
monomers of hydrophilic (hydroxyethyl methacrylate /HEMA) hydrophobic
(decandiol dimethacrylite /D3MA) and intermediate (bis-GMA) nature. This
combination of properties allows universal adhesives to create a bridge
over the gap between the hydrophilic tooth substrate and hydrophobic
resin restorative, under a variety of surface conditions. Moreover, some
universal adhesives may contain silane in their formulation, potentially
eliminating the silanization step when bonding to glass ceramics or resin
composites,
This multi-approach capability enables the clinician to apply the adhesive
with the so-called selective enamel etching technique that combines the
advantages of the etch-and-rinse technique on enamel, with the
simplified self-etch approach on dentin with additional chemical bonding
on remnant carbonated apatite crystallites in those bonding substrates.
Therefore, the universal adhesives have much broader applications than
other systems. Additionally, manufacturers typically state that universal
adhesives can be used for the placement of both direct and indirect
restorations and are compatible with self-cure, light-cure and dual-cure
resin-based cements and bonds to metals, zirconia, porcelain and
composite. While, the manufacturers of some universal adhesives still
recommend the use of separate "activator" and dedicated primers to
optimize bond strength to substrates such as porcelain and zirconia. Thus,
it appears, at least in certain situations and with some products, that
universal adhesives actually consist of two bottles, or require the use of an
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additional activator, or have chemistries that must be mixed prior to ure
or bond most optimally to porcelain and zirconia with separately applied
and dedicated primers, or are not compatible with a total-etch protocol
Further, there is an advantage in having an adhesive that can operate on
these two procedures since it allows the dentist to choose his procedure
according to the clinical case in order to optimize the final result. For
instance, when the restoration requires strong bonding to enamel or in case
of sclerotic dentin, it may be advisable to apply prior etching. The etching
step can be modulated according to the length of time the phosphoric acid
gel is applied prior to rinsing. On the other hand, it may be preferable to
benefit completely from the self-etch path way, when dealing with cases
confronting difficult access, limited time or poor patient compliance in
very young patients.
Glass-ionomer-based Adhesives
Glass-ionomers are still considered the only materials that self-adhere to
tooth tissue. A short polyalkenoic acid pre-treatment cleans the tooth
surface; it removes the smear layer and exposes collagen fibrils up to about
0.5-1 um deep; therein, glass-ionomer components inter-diffuse and
establish a micro-mechanical bond following the principle of hybridization.
In addition, chemical bonding is obtained by ionic interaction of the
carboxyl groups of the polyalkenoic acid with calcium ions of
hydroxyapatite that remained attached to the collagen fibrils. This
additional chemical adhesion may be beneficial in terms of resistance to
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hydrolytic degradation. Consequently, a two-fold bonding mechanism is
established, similar to that mentioned above for mild self-etch adhesives.
basic difference with the resin based self-etch approach is that glass
ionomers are self-etching through the use of a relatívely high-molecular-
weight (from 8000 to 15,000) polycarboxyl-base polymer. This limits their
infiltration capacity, so that only shallow hybrid layers are formed. In
addition, because of this high molecular weight, they cannot infiltrate
shosphoric-acid-decalcified dentin. Consequently, such aggressive
conditioners should not be used in conjunction with glass ionomers.
Microleakage and Nanoleakage
" Microleakage" is defined as the passage of bacteria and their toxins
between restoration margins and tooth preparation walls. Clinically,
microleakage becomes important when one considers that pulpal irritation
is more likely caused by bacteria than by chemical toxicity of restorative
materials. An adhesive restoration might not bond sufficiently to etched
dentin to prevent gap formation at margins. The smear layer itself can
serve as a pathway for leakage through the nano-channels within its core.
The term "nanoleakage" has been used to describe small porosities in the
hybrid layer or at the transition between the hybrid layer and the
mineralized dentin that allow the penetration of minuscule particles of a
silver nitrate dye.
The term "water trees" is associated with porosities in the polymerized
adhesive layer. Water trees might be one of the factors responsible for
degradation of the bonding interface with time.
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EXPANDED CLINICAL INDICATIONS FOR DENTIN ADHESIVES
►Treatment of Dentin Hypersensitivity
Dentin hypersensitivity is a common clinical condition that is difficult to
treat because the treatment outcome is not consistently successful. Dentin
hyper sensitivity will be discussed in details in chapter 9.
►Bonded Amalgam Restorations
Postoperative sensitivity, marginal discoloration and recurrent carious
lesions are potential consequences of the penetration of oral fluids and
bacteria through gaps at the dentin resin interface toward the pulp. With
amalgam restorations, delayed interfacial marginal leakage occurs at the
amalgam-tooth interface. Corrosion products from amalgam seal the
interface after a few months; however, this process may take more than 6
months for copper-rich amalgam alloys, such as the spherical and blended
ER
amalgam alloys currently used in dentistry. High-copper amalgam alloys
undergo a much slower corrosion process than conventional amalgam alloys
because of the elimination of the y2 phase.
To help overcome the inevitable marginal microleakage, the use of dentin
adhesive systems has been proposed for amalgam restorations, and some
laboratory and clinical studies have shown that resin-based adhesives can
be used to bond amalgam restorations.
The attachment mechanism between the adhesive and the amalgam is not
fully understood, but it may be micromechanical entanglement of the
uncured adhesive material with the setting amalgam mix during
condensation of the amalgam. The bonding mechanism might depend on
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the type of amalgam used (e.g. spherical amalgam alloys typically have
higher bond strengths than dispersed phase or admixed amalgam alloys).
The earliest shear bond strengths between amalgam and dentin were
reported to range from 3 to 5 MPa. Other studies have shown, however,
that some current adhesive systems provide initial bond strengths ranging
10 to 14 MPa. Nevertheless, primary mechanical retention features
wol
ve still recommended when an adhesive system is used with amalgam
because it is unclear whether the initial bonds would he maintained at an
adequate level over years of clinical service,.
The use of adhesive systems beneath amalgam restorations might reduce
marginal leakage and improve marginal integrity of the restoration
compared with the use of a copal varnish. Despite anecdotal evidence to
the contrary, however, post-operative sensitivity may be one clinical
parameter that dentin adhesives do not improve over the rise of copal
varnishes. Another potential advantage from the use of dentin adhesives
under amalgam restorations is that the residual tooth structure becomes
more resistant to fracture than when teeth are restored with a copal
varnish and amalgam. Any reinforcing effect may not be as evident for wide
tooth preparations as for narrow tooth preparations.
►Indirect Adhesive Restorations
Some current dentin adhesive systems are considered as uniyersal
adhesives because they bond to various substrates besides dentin
Developments in adhesion technology have led to new indications for
bonding to tooth structure, such as indirect ceramic and resin- based
restorations (crowns, inlays, onlays, and veneers). The use of a universal
adhesive system in conjunction with resin cement provides durable bonding
of indirect restorations to tooth structure.
Ceramic restorations (with the exception of aluminous-core porcelains,
such as In-Ceram High Strength Ceramic [Vita Zahnfahrik, Bad Sdckingen,
Germany] and zirconia-core porcelain such as Lava [3M FSPF., St. Paul,
Minn]) must be etched internally with 6% to 10% hydrofluoric acid for 1 to
2 minutes to create retentive microporosities analogous to those that occur
in enamel on etching with phosphoric acid. Hydrofluoric acid must be
rinsed off carefully with running water for at least 2 minutes.
08T
After rinsing off the hydrofluoric acid and drying with an air syringe, a
silane coupling agent is applied on the etched porcelain surface and air
dried. The coupling agent acts as a primer because it modifies the surface
characteristics of etched porcelain. Because etched porcelain is an
inorganic substrate, the coupling agent makes this surface more receptive
to organic materials, the adhesive system and composite resin cement.
Indirect composite restorations also can he bonded to etched dental
substrates using a universal adhesive system and a resin luting cement. One
of the great advantages of indirect composite restorations is the
polymerization shrinkage occurs outside the mouth. Additionally, the
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degree of monomer conversion is higher for indirect resin-based
restorations.
This increased level of double bond conversion results however, in only a
tew monomer double bonds on internal surface of the indirect composite
restoration decreasing the potential for bonding with the adhesive system
and with the composite luting cement. To overcome this unsuitable
bonding surface, the composite may be treated with surface activators to
re-establish the surface energy (e.g., Composite Activator; Bisco Inc,
Schaumburg, Il, USA)
Another alternative is sandblasting the bonding surface of the indirect
restoration to expose an internal area where more double bonds may be
present. Hydrofluoric acid is contraindicated for heating indirect
composites because it softens some composite materials.
Cast metal restorations traditionally have been cemented with zinc
phosphate, polycarboxylate, or glass-ionomer cements. With the advent
of new adhesive techniques, the treatment of the internal surface of the
metal restoration with acids, sandblasting, or tin- plating (for gold) has
resulted in high bond strengths between metal and tooth structure using
resin cements.
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