Bonding in 2019

Adhesive dental technology has evolved to the point where we now have the ability to
completely predictably restore and adhere to most teeth. It’s been a revolution.

The word revolution here is very important as the type of dentistry we are referring to is
almost the antithesis of conventional prosthetic dentistry.

We call this collective science within the field of advanced adhesive dentistry as
‘biomimetic dentistry’.

Biomimetics means mimicking life, mimicking biology. It is relevant to how light behaves
when it interacts with your aesthetic work — it looks like natural biology, but perhaps
superseding that, in terms of relevance, is how your dental work adheres to the remaining
tooth structure and how it will survive in the mouth.

The interface between resin based composite materials and dental tissues is well
understood and, if protocols are followed, very predictable. The interface between intagilo
(fit) surfaces is also deeply understood but should always remain under scrutiny with high-
quality evidence. Outcome evidence is probably what matters most to those of us making
a living from doing dentistry.

As modern dentists we need to understand that there has been a fundamental paradigm
shift, and if we can increase our understanding of the natural tooth in its entirety along with
the nature of the technology currently available to us, we can now perform dentistry in
ways that our forebears could not imagine. We are duty-bound to have a full and complete
understanding of this and to be skilled enough to provide this within our practices.
The advantages of biomimetic dentistry are many:

• Firstly, it is far more conservative and protects much more intact natural tooth.

• The adhesively restored tooth is much better able to handle and manage functional
stresses.

• The biomimetically restored tooth has no internal gaps or fit issues into which pathogens
can colonise and breed. As such, deformation and stress concentrations are never
exacerbated into areas where the intaglio surface and tooth structure become
decoupled.

• Together this reduces or potentially completely eliminates post-operative pain and

sensitivity and protects the pulp.

• Lastly, in preserving natural dentine and pulp vitality, the dentine itself remains well
hydrated, which improves its natural flexibility and fracture resistance.

The disadvantages are all behavioural and environmental rather than biological:

• Procedures take longer. Introducing superior techniques which require more time can be
met with artificial manmade barriers such as ‘faster work = more profit’ factories. These
are usually enforced by a practice owner who has flown the nest of actually providing
clinical care and enjoys his worker bees making him honey. The quicker they fly, the
more honey. Plenty more bees available if you drop dead.

• Equipment investment. Still? Seriously? See Raheel’s blog on self-investment. He is

nicer than me and puts it in kinder terms. FFS.

• You. What you are doing now works, sort of, so why try something new? That’s up to
you. I’m not going to beg. I know this works and the outcomes are truly excellent. I want
you to have what I have, truly I do. I'm trying to give it to you.

This technology began to evolve in the 80s and 90s and, as its evolution has been
somewhat slow, it has passed through to current practice almost silently. There has now
been a dynamic profile shift with a rapidly evolving technological platform over 2 decades,
with ‘new’ concepts (albeit many years in coming to fruition): from the simple use of
creating a peripheral seal zone, made out of pure biological tooth tissue (not colonised by
plaque, bacteria, saliva, blood or caries) through to immediate dentine sealing and
management of polymerisation shrinkage to the point where we now have a set protocol to
optimise our biological interface. We will call this our biobond. This is that interface
between tooth and dentistry. Biobond.
Goals

The goals of creating a biomimetic biobond are 4:

1. Maximum bond strength

Reducing the stresses of polymerisation shrinkage during the development of a

hybrid layer results in anything between a 300-400% increase in bond strength.
This exposes the reality that a developing hybrid layer takes a little bit of time. If it is
allowed to develop under controlled conditions and with adequate time, we can get
dentine bond strengths ranging from 30-60 MPa, which is comparable with the
cohesive strength of dentine to itself and the enamel dentine junction. The
advantages of this are obvious.

2. A long-term marginal seal

The oral environment is extremely good at dissolving almost anything. Hydrolysis of

a biobond begins almost immediately after a restoration is placed unless it is
metallic. The strongest and most secure bond that we achieve needs to be
established at the peripheral margin of our restorations and this needs to be able to
withstand functional stresses during loading. The hydrolysis proceeds more quickly
in defects, leaks and contaminated surfaces.

3. Maintaining vitality

The main causes of devitalisation of a pulp are excessive generation of heat and
bacterial invasion. By maintaining a highly bonded seal, sugar substrates essential
to the propagation of carious species are cut off. Fractures are far less likely if we
keep the pulp alive. Vital teeth are 3 times more resistant to fracture in like-for-like
comparisons.

4. Decreased residual stresses

Residual stress, whilst hard to visualise, leads to cuspal deformation, debonding,

gaps, cracks, pain and sensitivity, which may result in recurrent decay or loss of the
tooth. Biomimetics reduces residual stresses, avoiding all of the above.

We need to think about our protocols for achieving these goals with 2 approaches:

• The first is to reduce stress

• The second is to maximise our bond
Stress Reducing Protocol

Stress-reducing protocols have 10 points. Stay with me people, it's an easy 10.

1. Indirect Restorations

When bonding to a tooth, if there is an extensive area to be replaced, using indirect

or perhaps even semi-indirect restorations produces a far lower level of stress at
the interface. There is a greatly reduced volume of shrinking of restorative material
and a more favourable outcome. An Emax onlay is great (better than a massive
MOD composite) if there is very little cusp volume/thickness left!

2. Take your time

To reduce polymerisation shrinkage stress, particularly that which can develop later
on in the dentine bond at the hybrid, allow a minimum of 3 to 5 minutes before
loading your prepared surface with composite. This means once you have etched,
created a hybrid layer with dentine bonding agent and then placed a layer of pure
adhesive resin on top, and then cured it, this should not be loaded with composite
for 3-5 minutes. If this is prohibitively long for you, then very small increments
should be placed at any time.

Placing minimal thickness layers prevents the connection from breaking down and
decoupling from deep dentine or enamel before the hybrid layer is matured and
close to its full strength. If you are doing an MO, cure the bond on the mesial base
of the box, then work distally placing composite for a short time and come back to
the base of the box to place the composite.

This procedure neutralises the ‘hierarchy of bondability’, which states that the
shrinkage of composite moves towards the walls of the preparation that are most
mineralised and dry and flows away from the walls of the preparation that are most
moist and organic. Essentially, most decoupling occurs at the base of a box but we
can overcome this by either waiting for a full-strength bond to develop or placing
very small incremental layers.

3. Incremental Build up

Dentine layers should be 1mm or less. This ensures that the risk of decoupling,
over time, is reduced and a secure bond is achieved. It means that the flow of
composite is not moving away from the deep dentine during the early stages of
horizontal layer development. This essentially overcomes our configuration factor
stresses, which many of you will be familiar with from your time on the course.
Small volume increments are always associated with small ratios of bonded to
unbonded surface areas, thus high C-factor stresses can be reduced into micro C-
factor stresses. This is the basic protocol of the stress-reduced direct composite
technique. It is also why we are not in favour of bulk composites until they achieve
zero shrinkage. Good luck with that BTW.
4. Fibre-Reinforced Composite

For large restorations, always place fibre inserts or fibre-reinforced composites on

the pulpal floor and axial walls. This is a relatively new inclusion in our protocol, but
it has been shown to minimise stress on the developing bond strength of the hybrid
layer. These fibre nets allow the composite on either side of the net to move in
different directions. This means when the Polymer network is curing, shrinkage is
not applied to the hybrid later. The best and simplest material to use is GC everX
Posterior.

5. Light cure

Ensure you have a high-quality light-curing system. This is a somewhat grey area
as we want to deliver a lot of energy to our composites to get them completely
cured but, equally, if you have not waited long enough for your hybrid layer
formation, then there is some benefit in having slow start or pulse-activated
polymerisation techniques. All of these techniques are available with the Valo light.

6. High-Quality Composite

Use a high-quality composite with a shrinkage rate of less than 3% and a modulus
of elasticity between 12-20 GPa.

7. Dual cured composite in root filled teeth

If you are going to use a composite core in root-filled teeth, then it is best to use a
dual-cured system as it is almost impossible to measure whether adequate
numbers of appropriate wavelength photons have reached the base of the
composite inside your access cavity. Chemically-cured composites have a slow
chemical-initiation-of-polymerisation time of around 4-5 minutes, so stress reduction
is ensured. Again, this comes back to avoiding decoupling, as this slow
polymerisation allows sufficient time for dentine bonding systems to mature to a
strong hybrid layer.

If you don’t have access to dual-cured composite, then use very thin layers of light-
cured composite and try to use a high-quality, powerful light-curing source. As you
know, we love the Valo light. The Valo also comes with a fibre optic tip attachment
which can be placed within the access cavity.

8. Cracks

Be fastidious in your removal of cracks that extend into dentine. We will discuss
creating a secure peripheral seal zone shortly. In a peripheral seal zone, which
essentially extends from 5mm from the occlusal surface and 2-3mm from the axial
walls, cracks into dentine should be removed and not left under the restoration. It
has been shown that if they are left, micromovements under function will allow the
cracks to get longer and propagate. The bigger the crack, the more likely it is to
propagate.
 9. Onlay

If you are left with an axial wall that is thinner than 2mm, this requires an onlay. The
onlay may be either direct composite restoration or indirect, but certainly a cusp
which is thinner than 2mm will have a resin-to-tooth interface that is predominantly
suffering from tensile forces. If this cusp is reduced, then the forces on it are largely
compressive, which enhances this protection from bond fatigue.

10. Occlusal Forces

Lastly, we need to try and verticalise occlusal forces to reduce tensile stresses at
the resin interface. This is done by looking elsewhere in the mouth and trying to re-
establish anterior guidance by bonding composites on other teeth and perhaps re-
establishing canine guidance.

Maximising Bonding Protocols.

This list has 8 key points, which are all evidence-based points to give you the maximum
possible bond strength, particularly when carried out with the details included above.

1. Caries-Free Peripheral Zone

Establish a caries-free peripheral zone. This essentially means you can excavate
caries inside the tooth as necessary — but very deep caries can be left and caries
excavation should be limited to a depth of 5mm from the peripheral surface of a
tooth. The caries-free zone is a 2-3mm circumferential area around the cavity which
does not expose the pulp. Measuring from the proximal tooth, the depth of
excavation is ideally 3mm, where you will fastidiously remove all caries and all
plaque. This may well require you using plaque-disclosing tablets or paste to ensure
that you are bonding to pure tooth surface.

2. Air abrasion

Air-abrade your surfaces. Air abrasion has been shown to increase the bond
strength to both normal and carious dentine. It also changes the failure mode to
eliminate failures in the hybrid layer. Air abrasion should also be used if you are
bonding composite to pre-existing composite. Use 27-30 micron alumina trioxide.

3. Bevelling Enamel

Always bevel your enamel. Bevelled enamel (obliquely across its enamel rods)
offers increased bond strength. This is a simple anatomical advantage whereby you
cut obliquely across the tangent of the enamel rods so that your etch opens up into
a prismatic space and you can flow resin into these sites.

4. Deactivate matrix metalloproteinases

As soon as a composite restoration is placed in the mouth it starts to hydrolyse and

break down. This is largely carried out by matrix metalloproteinases (MMP).

MMPs can create degradation in your bond strength of between 25-30% relatively
quickly. We can deactivate these enzymes by using a 30 second treatment of 2%
 chlorhexidine. There are other ways of reducing it, including the use of
Benzalkonium chloride (MicroPrime B made by Bisco), and pragmatically scrubbing
the base of your box with 2% Hibiscrub is also very effective. Dentine-bonding
systems that include the MDPB monomer, such as Navier or SE Protect, both made
by Kuraray, will also help deactivate the enzymes. Please note that Corsodyl mouth
rinse is 0.2%, Hibiscrub is 2%.

5. Dentine Bonding Agent

Always employ gold standard bonding systems. Using a gold standard dentine
bonding system that can achieve a micro tensile bond strength of 25-35 MPa on
enamel, and 40-60% of this on flat dentine surfaces, is best achieved with 3-step
total etch bonding systems such as OptiBond FL.

6. Immediate Dentine Sealing (IDS)

Use immediate dentine sealing. This has been widely covered in the course but
essentially it means to use dentine-bonding systems and adhesive resin at the time
of preparation and before your impression is taken. It is applied to freshly-cut live
dentine. There are numerous advantages and we know that this ultimately
increases the micro tensile bond strength by 400% when compared to traditional
methods of bonding at your cement appointment. Immediate dentine sealing is
fundamental to modern adhesive dentistry.

IDS is possible with one-bottle bonding systems (where the dentine bonding agent
and adhesive are combined) but may be more fragile if the filler component of the
adhesive component is inadequate. It is worth finding out the details of what system
you are using. If you cannot confirm these details, then ask Richard or Raheel. This
is important, as if your adhesive is a bit thin and has low filler content you may need
to add a small amount of flowable composite over the IDS to stabilise it.

Two-bottle systems like OptiBond FL and All-Bond 3 have excellent filler make up in
their adhesive, so it’s all done already.

This high-quality filler is so important as it stabilises the bond enormously. If you

use OptiBond FL for your immediate dentine sealing then we know that this is a
bonding system that has a thicker and highly filled adhesive component with filler
particles of around 80 microns, and this is adequate to achieve this protective resin
coating. Just buy some flipping FL!

7. Marginal Elevation

Consider achieving deep marginal elevation. If your box extends sub-gingivally and
it’s wet down there, then adhesive dentistry simply will not work. The base of the
box is too wet. This means adhesive dentistry must be repositioned supra-gingivally
to obtain biomimetic micro-tensile bond strengths of anything around 30 MPa.

Deep marginal elevation, in conjunction with immediate dentine sealing, resin

coating and a composite dentine replacement, is referred to creating your ideal
biobase.
 Marginal elevation can be achieved by using a tight conventional matrix band such
as a Tofflemire, Siqvalend or Omni-Matrix. The tight metal grip at the base of this
box enables effective drying, although the anatomical form created by this matrix
band is not adequate for replacing the entire composite. You need to ensure you
can, however, get the base of the box dry in this circumstance and inject a resin-
modified glass ionomer cement and allow it to fully cure or use composite to elevate
the base. The occlusal aspect of this resin-modified GIC/composite should be
supra-gingival, which means the rest of your resin bonding can be carried out
supra-gingivally with the margin on the deeper restoration.

Conclusion and Key Points

The concepts above require you to grasp the following concepts:

• Biomimetic paradigms
• Stress-reducing protocols
• Bond-maximizing protocols
• Minimally-invasive dentistry
• Structural analysis of existing tooth structure
• Polymerisation dynamics of composites

The purpose of using biomimetic restorative concepts and protocols is to increase the
longevity of restorative dental treatments and to reduce or eliminate future cycles of
retreatment. 70% of all dentistry is re-doing other dentists’ work. Not so with you!

In addition, conservation of tooth structure prevents periodontal complications and pulp

death. Dentists and patients who choose biomimetic dentistry enjoy these benefits every
day.

Finally, you cannot do this without being able to see. Loupes at x3.5 and below or at any
magnification without illumination are inadequate. Magnification x4 and above with a big,
powerful light enables you to clearly see you have achieved the goals each step requires.
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