Vision and Mission

Vision of the Faculty of Dentistry

Excellence and leadership in the field of dentistry locally, regionally and

internationally in terms of education, scientific research and community
service.

Mission of the Faculty of Dentistry

Preparing qualified graduates with theoretical knowledge, practical skills and

human behaviors that enable them to compete in the labor market and transfer
knowledge through conducting studies and scientific research and providing
distinguished community services to citizens.

‫رؤية الكلية‬

‫التميز والريادة في مجال طب األسنان محليا ً وإقليميا ً ودوليا من حيث التعليم والبحث العلمي وخدمة‬
‫المجتمع‬

‫رسالة الكلية‬

‫إعداد خريجين مؤهلين بالمعرفة النظرية والمهارات العمليه والسلوكيات اإلنسانية التي تمكنهم من‬

‫المنافسه في سوق العمل ونقل المعرفة من خلل إجراء الدراسات والبحوث العلمية وتقديم الخدمات‬

.‫المجتمعيه المتميزه للمواطنين‬

 Overall Aims of Course:
The aims of this course are to:

Provide the students with the core knowledge and basic information related to teeth
1.1
isolation.

1.2 Recognize causes and treatment of non-carious lesion

1.3 Recognize different options to patient management.

1.4 Learn students all about adhesive systems.

Intended Learning Outcomes (ILO's):

a- Knowledge and understanding:

By the end of this course, the student should be able to:

a1 Define and Outline scope of non-carious lesions.

a2 Recognize indications of different methods of teeth isolation.

a3 List the different options for treatment of non-carious lesions

a4 Recognize the difference between types of bonding systems.

a5 Describe Patient assessment and diagnosis.

a6 Identify non-carious lesions.

b- Intellectual skills:

By the end of this course, the student should be able to:

b1 Assess deep carious lesion.

b2 Differentiate between carious and non-carious lesions.
b3 Distinguish between different tooth bonding options.
b4 Classify treatment options of non-carious lesions.
b5 Plan different methods of tooth isolations.
 c- Professional and practical skills:

By the end of this course, the student should be able to:

c1 Apply different treatment options of no carious lesions

c2 Apply different bonding methods.

d- General and transferable skills:

By the end of this course, the student should be able to:

d1 Develop initiative and personal responsibility and continually improve professional and
criticizing skills
d2 Work properly in teams with proper time management and infection control measures

d3 Communicate with supervisors and colleagues with flexibility.

References

-Ritter AV, Boushell LW, Walter R, Sturdevant CM. Sturdevant’s art and science of operative dentistry. St.
Louis, Missouri: Elsevier; 2019.

-Hilton TJ, Summit JB, Broome J. Fundamentals of operative dentistry: A Contemporary Approach, 4th
edition, Quintessence Publishing, 2019.

-Rocha C, Springerlink (Online Service. Modern Operative Dentistry : Principles for Clinical Practice. Cham:
Springer International Publishing; 2020.
 Chapter 1

Patient Assessment, Examination,

Diagnosis and Treatment
Planning
Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

Introduction
For proper treatment planning we must do the followings:
I. Proper infection control.
II. Over view of the patient including: →
1. Printed questionnaire for personal and medical history.
2. Review of medical history.
3. Clinical examination of oro-facial soft tissues followed by examination of
dental caries and other teeth problems including erosion and abrasion,
then examination of previous restorations.

Patient assessment
A) General data:
1. Patient full name.
2. Address and telephone number: → To postpone the appointment if needed and to
send him a bill of fees.
3. Age: → Gives an idea about: →
a) Size of the pulp.
b) The position of the gingival attachment.
c) The depth of the cavity and the biological principles.
4. Sex: → Certain diseases are related to specific sex, e.g. gingival enlargement
during pregnancy and menstruation.
5. Occupation: → Gives an idea about certain occupational defects, e.g. notches in
anterior teeth of dressmakers and carpenters.
→ Gives an idea about the material of choice for restoring a tooth.
B) Medical review:
 Before examination and diagnosis the patient completes a standard
comprehensive medical history form.

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

 This helps in identification of any condition that may alter, complicate or

contraindicate the proposed dental procedures.
 Certain systemic diseases may need consultation with specialist before starting
treatment, e.g. cardiac patient.
 Another condition needs hospitalization, e.g. hemophilia.
 Others need certain precautions to prevent cross infection, e.g. hepatitis.
 Conditions that may alter or interfere with treatment, e.g. diabetes.
 Allergic manifestations to certain drugs, e.g. L.A.
 The following may identified
I- contagious disease: (e.g. hepatitis) that require special precautions.
II- Allergies: That may contra indicate the use of certain drugs.
III- Systemic diseases and heart problems, that demand less strenuous procedures
or prophylactic anti-biotic coverage.
 All of this information is carefully detailed in the patient permanent record.
 Following a through medical history, The patient's physical status should be
assessed by taking the pulse and blood pressure.
 It is important to do a brief update of the medical history and physical evaluation
when the patient has not been seen for some time.
C) Dental history:
The dental history is divided into two parts :
1. past dental history.
2. Present dental history.
1) Past dental history:
 Frequency of dental treatment and problems were met during past interference,
should be recorded.
 Past dental experience for the same problem (Chief complaint) should be
discussed with the patient in order to not to repeat disagreeable procedures.

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

2) Present dental history:

 The patient’s present problem (chief complaint) should be recorded in the chart.
 The onset, duration and the related factors of the chief complaint should be
recorded.
 The date and type of available radiographs should be recorded to determine the
need for additional radiograph and to minimize the patient exposure to necessary
ionizing radiation.
Examination and diagnosis

 Examination: → The process of observing both normal and abnormal conditions.

 Diagnosis: → The determination and judgment of variations from normal.

Diagnosis of dental caries

 Diagnosis of dental caries should include:
a) Determination of risk factors.
b) Clinical examination of dental caries.

a) Determination of risk factors:

 Risk factors predisposing for dental caries are either: →
1) Non-oral factors including: → Age. Sex, medical condition and general health,
fluoride and genetic role.
2) Oral factors including: → Tooth anatomy, oral flora, oral hygiene, previous
restorations and reduced salivation.
Caries risk assessment:
 It means categorization of individuals according to their liability to caries
occurrence, either of high or low risk.
 This is done by counting 2 types of bacterial species per mm3 of saliva.

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

 This is known as → Differential bacterial count.

 The two types of bacteria are → st.coccus mutans and lactobacilli.
 More than 106/mm3 the patient is classified as high risk.
 Less than 105/mm3 the patient is classified as low risk.
b) Clinical examination of caries:
1. Visual examination: → Changes in texture and color of the tooth surface.

→ Cavitation.
2. Tactile: → catching with probe or explorer.

3. Radiographic: → radiolucent area appears in bite wing or periapical view.

4. Transillumination: → Dark area appeared when the tooth is subjected to fiber-

optic light.
5. Digitizers: → a) Scanning usual radiographs.

b) Direct using R.V.G.

c) Indirect using Digora.
a) Scanning usual radiographs: → Analyzing the degree of radiolucency of the
carious lesion to estimate its extent by subtracting old from new radiographs.
b) Direct using R.V.G.: → There is no film but a special intra-oral sensor is used
instead of the conventional X-ray film, which transmits the image to a
computer monitor.
c) Indirect using Digora: → The radiograph is analyzed using a computer
system, which could differentiate between different gray tones of the
radiograph.
6. Laser tomography: → CO2 gas laser with spectroscopy.

→ Mechanism → Enamel has decreased water and carbon

contents and increased content of minerals, so it shows decreased effect of CO 2
gas laser.
Caries has increased water and carbon contents and decreased minerals, so it is
very sensitive to CO2 gas laser.
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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

When caries is exposed to CO2 gas laser, its water contents will be evaporated
leaving black carbonized residue.
7- The caries detector discloses caries in dentin and increases the likelihood of
conservative cavity preparation.

Recent diagnostic aids of carious lesion

1- Electronic caries detector
 It is based on the fact that sound enamel is a good insulator, while the carious
enamel is porous and filled with fluids and ions from saliva, so it becomes a good
conductor.

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

 Can measure quantitatively any change in enamel electrical conductivity. This

means that slight drop in the enamel resistance values indicates the presence of
early demnineralization

2- Quantitative laser (light) fluorescence technique. (Diagnodent)

 It aid to detect initial mineral loss from smooth-surface enamel lesions.
 The laser fluorescence system, kavo-diagnodent are efficient for diagnosis of
non-cavitated enamel and dentin lesions on buccal, lingual, and occlusal surfaces.

 Caries tends to occur bilaterally and adjacent proximal surfaces may be affected,
i.e. if the caries is found in the occlusal or proximal surface in one tooth on one
side, then the changes increased for the same location.
3- Computer aided radiographic method.
Computer aided radiographic method exploit the measurement potential of
computers in assessing and recording size and progression of the lesion.

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

4- Digora image plate system.

It is a modification of the digital intraoral radiography.
The radiographic information is captured on a phosphorus storage screen or image
plate which is placed in a scanning unit running by laser beam and connected to
personal computer.

5- Intraoral camera.
 It is a camera placed inside the oral cavity to allow display of intraoral images
of exceptional quality on a computer.
 Communicate and demonstrate to patients the need for treatment.
 Increase the quality of care dentists provide because (they offer):
 Improved visual access to the dental cavity.
 Improved lighting and
 Magnification

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

6- The high-resolution transilluminator.

 A high intensity light is shone through the tooth and the transilluminated image
of the tooth is captured on a charge- coupled device (CDD) intra-oral camera,
analyzed by computer software and displayed on a computer screen for
diagnosis.

• It is mouthpieces enable dentist to view decay on occlusal surfaces, around

restorations, in addition to both facial and lingual surfaces.It detects incipient
and frank caries as well as fractures.

Caries locations
1) Examination of caries in pits and fissures:
 These are the most caries susceptible areas where the developmental lobes of
calcification fail to coalesce.
 Methods: → 1. Discoloration and any changes in color by visual examination.
2. Probe catch by tactile examination.
2) Examination of caries in smooth proximal surfaces:
 Visual examination: → Chalky appearance or shadow under the marginal ridge.
→ Observable cavitation in deep cavities.
 Tactile examination: → By passing dental floss along side the proximal surface,
tearing of dental floss fibers indicating caries.
 Transillumination: → Dark cone in proximal surface in bite wing film is a true
indicator for proximal caries.
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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

3) Examination of caries in smooth cervical surfaces:

 Visual examination: → Chalky appearance of the cervical 1/3 may denote caries.
→ Disappearing-reappearing phenomenon, the chalky white
appearance of carious lesion disappears with wetting and appears with dryness.
 Tactile examination: → Sensitivity to probing.
Clinical examination of amalgam restoration
1. Amalgam blues:
 Bluish discoloration seen through enamel that may be due to: →
1. Corrosive products leaching out from amalgam.
2. Amalgam seen through undermined enamel.

2. Amalgam overhangs:
 Could be diagnosed by: →
1. Visual: → buccal, lingual or occlusal overhangs.

2. Tactile: → using explorer.

3. Radiographic: → for proximal overhangs.

4. Dental floss: → threading of the floss when passed proximally.

3. Ditching:
 Can be diagnosed visually or by probing which drops at the tooth/restoration
interface.
 When ditching is deep it can not be smoothened, amalgam should be replaced.

4. Voids:
 Represents surface discrepancies rather than ditches.
 If more than 0.2 mm the restoration should be considered as defective one and
should be replaced.

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

5. Fracture line:

 Using visual and tactile method, careful examination should be done to locate
fracture line.
 Amalgam should be replaced.
6. Improper anatomical contour:

 When inadequate embrasure or misplaced contact area should consider the

restoration is defective and should be replaced.
7. Marginal ridge discrepancy:
 The proper position and height of marginal ridge should be inspected and
compared with the neighboring tooth, other wise the restoration should be
considered defective and replaced.
8. Proximal contact defects:

 Using dental floss or passing light between the teeth may indicate the contact area
relation of amalgam restoration.
 Open contact or tight contact may lead to gingival and periodontal problems.
9. Recurrent caries:

 Could be detected visually, tactile or radiographic as primary caries.

Clinical examination of cast restoration
 The same as amalgam restoration.
Clinical examination of esthetic restoration
 The same as amalgam in addition to discoloration.
 Discoloration: →Should be observed whether marginal, surface or bulk type of
discoloration and the restoration should be considered defective.

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

Adjunctive aids for examining teeth and restorations :

1. The percussions test.
2. Palpation.
3. Thermal tests.
4. Electric pulp test.
5. Test cavity.
6. Study cast.
7) Additional aids
Adjunctive aids for examining teeth and restorations
(1) Percussion:
 Done by gentle tapping the occlusal or incisal surface of the teeth by the use of
mirror handle to determine the presence of tenderness indicating periapical
involvement.
 Pain on vertical percussion indicating periapical involvement.
 Pain on lateral percussion indicating periodontal involvement.
 Care must be taken with maxillary teeth due to close relation to maxillary sinus.
 Percussion should be done out of sequence to avoid patient concentration with the
affected tooth.
(2) Palpation:
 Done with teeth tender to percussion to determine the presence of periapical or
periodontal abscess.
 It is performed by rubbing any swelling between index finger and bone to feel
fluctuation.
 Any abscess or cyst in advanced stage may reveal tenderness to palpation.
(3) Vitality test (Thermal test):
• Either a small rod-shaped piece of ice (made by freezing water in an empty
anesthetic cartridge).

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

• Hot gutta-percha is applied directly to the tooth.

• Hot and cold testing should elicit from the health pulp a response that will
subside within a few seconds of removal of the stimulus.
• Pain of less than approximately 10 seconds duration elicited by heat and cold
suggests hyperemia.
• Intense pain of longer duration from ice usually suggests irreversible pulpits.
• Pain that results from heat but is quickly relieved by ice also suggests
irreversible pulpits.
 Thermal: → Either hot or cold.
→Sensitivity to hot or cold with exaggerated response indicates deep caries or
acute pulpitis.
 Electric: → Using electric pulp tester (EPT).
→ It causes tingling effect when pulp is vital.
→ No response to EPT indicates pulp death.
→ It is important to obtain readings on adjacent and contra-lateral teeth
to evaluate the affected tooth response.
 Lack of response to thermal tests may indicate that the pulp is not vital.
(4) Cavity test:
 Done when there is no other means to diagnose the pulp vitality.
 Using round bur without anesthesia, a cavity is made through the restoration into
dentin.
 Lack of sensitivity indicating non-vital pulp.
(5) Mounted Study casts:
 They are helpful in providing an understanding of the occlusion and planning of
treatment.
 They are also useful for explaining the treatment for the patient.

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

For example, study casts provide for further evaluation of :

1. Plane of occlusion
2. Tilted cross-bites
3. Extruded cross-bits
4. Plunger cusps
5. Wear facets
6. Defective restorations
7. Coronal contours
8. Proximal contacts and Embrasure spaces
(6) Electric pulp tester:
 The electric pulp tester is placed on the tooth structure and not on a restoration.
 It delivers a small electric current to the tooth
 This often causes a tingling sensation when the pulp is vital and usually causes
no response if the pulp is non-vital
 It is important to obtain readings on adjacent and contralateral teeth so the
tooth in question can be evaluated relative to the responses of the other teeth
 Results of an electric pulp test do not necessarily indicate whether a pulp is
health or non-vital. Instead pulp test results provide additional information that,
when combined with other findings, may lead to a diagnosis
 Electric pulp testing is sometimes not possible in teeth with large or full-
coverage restorations.
(7) Additional aids:
 Transillumination.
 Mobility test, for periodontal examination.
 Anesthesia test, for diagnosis of referred pain.
 Occlusal analysis, for any defects in occlusion.

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Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

Radiographic examination of teeth and restorations

Idications:
1. Teeth Identification of caries
2. Detective restorations as Improper contour Overhangs
3. Other abnormalities as Advanced periodontal disease
4. Pulpal abnormalities such as :
Pulp stones Internal resorption may be identifi
• To minimize the patient's exposure to this potentially harmful process,
radiographs should be taken only when clearly indicated
Types of Radiographs
Panoramic:
• Show overall the teeth
• Produces broad view of the maxillary and mandibular arches and their
associated structures.
• Panoramic radiograph is produced by using tomography and technique is
referred to as pantomography.

Periapical:
• Specified for each tooth
• Periapical radiographs are helpful in :
• Diagnosing periapical abscesses
• Dental granulomas
• Cysts
• Impacted third molars
• Supernumerary teeth may also be discovered

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Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

Bite-wing:
1. Show occlusal surfaces for more than one tooth in the same film
2. Specified for inter-proximal caries

Limitation of Radiograph
• The limitations imposed by looking at a picture that is a two-dimensional
representation of three dimensions. For example:
• Misdiagnoses can occur when "cervical burnout" ( the radiographic picture of
the normal structure and contour of the cervical third of the crown) mimics
caries
• Class V lesion or a radiolucent tooth-colored restoration may be
radiographically superimposed on the proximal area, mimicking proximal
caries
• Caries is worse or deeper

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

Treatment planning
Types:
1) Ideal treatment plan:
 It is the plan where the best forms of treatment are done irrespective to the patient
and dentist limitations.
2) Optional treatment plan:
 It is the plan where the maximum form of treatment is done in relation to the
patient general and oral conditions as well as the dentist knowledge and
experience.
Sequence of treatment planning:

1) Control phase:

 This phase removes etiological factors and stabilizes the patient health including:
1. Elimination of pain.

2. Elimination of active disease such as caries and inflammation.

3. Removal of conditions preventing maintenance e.g. overhanged restoration.

4. Elimination of the potential disease causes e.g. impacted third molar.

5. Starting preventive dentistry instructions.

2) Holding phase:

 The holding phase is a time between the control and definitive phase that allows
for resolution of the inflammation and time for healing:
1. Home care habits are reinforced.

2. Motivation for further treatment is assessed.

3. Initial treatment is reassessed before starting definitive care.

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 Chapter 1 Patient Assessment, Examination, Diagnosis and Treatment Planning

3) Definitive phase:

 After reassessment of the initial treatment the need for further care should be
determined.
 This includes some forms of endodontics, periodontics, orthodontics, oral surgery,
and operative procedures prior to fixed or removable prosthetic treatment.
4) Maintenance phase:

 Regular recalls examinations that may reveal the need for further adjustment.
 Reinforcement of home cares.

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Chapter 2
Chapter 2 Control of fluids

Restorative procedures in the mouth cannot be done efficiently unless the

moisture is controlled.

Source of fluids in the operating field

(1) Saliva

-Normal physiologic fluid.

-Consists of water, mucin, bacteria and remaining food debris.

- From salivary glands.

(parotid, submandibular, sublingual)

(2) Blood

- Inflamed gingival tissues.

- Iatrogenic damage.

(3) Gingival crevicular fluid (GCF)

-Inflamed gingival tissues.

(3) Cooling fluid

- Coolant of hand piece

- Water spray from air water syringe

(4) Materials used during treatment

- (etchants, irrigation solutions and disinfectants for cavity toilet)

(5) Respiratory moisture.

-Precipitates on the reflecting surfaces such as the dental mirror

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 Chapter 2 Control of fluids

Reasons for fluid control

I. Patient related factors.

II. Operator related factors.

III. Restorative material and technique related factors.

I. Patient related factors

-More Comfort.

-Protects patients swallowing or aspirating foreign bodies.

-Protects patient soft tissues – tongue, cheeks by retracting them from

operating field.

N.B

-A small round bur detached from the slow speed handpiece and lodged
in patients‟ left bronchus.

-A disturbing number of endodontic instruments find themselves in

patients' gastro-intestinal tracts.

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Chapter 2 Control of fluids

II. Operator related factors

1) Asepsis

- Infection control to minimise infection.

- Prevents contamination of cavity preparation/ root canal.

2) Convenience and efficiency

-Increased accessibility to operative site, allowing greater convenience

and efficiency of operative

-Procedures (e.g. patient‟s “need to swallow”) causes fewer problems.

- Wasting time

3)Visibility

-Improves the working field and diagnosis.

-Less fogging of the dental mirror.

-Haemorrhage from gingiva decrease vision of cavities during

preparation.

III. Restorative material and technique related factors.

Dental materials are moisture sensitive; success of adhesion and physical

properties relies on a dry field.
-Insertion of filling

-Cementation of inlays and crowns.

-Moisture interfere with the setting reaction of the materials.

-Prevent a good marginal adaptation (bonding).

-Impression distortion in watery field.

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Chapter 2 Control of fluids

Troubles caused by improper control of the field

A) Diagnosis:

-Fogging on the mirror in indirect vision

-Affect determine the lesion and its dimensions properly.

B) Cavity preparation:

-patient discomfort, gagging sensation and also irritation to the oral

tissues

C) Restoration:

Amalgam

-Amalgam is sensitive to any fluid contamination.

-Moisture contamination  delayed expansion  pressure on dentin
and odontopalstic processes  delayed pain
-The restoration grows out  surface blisters and over hanging of the
restoration  premature contact in the form of shiny facet

Anterior esthetic restorations

- Moisture contamination  voids in the final restoration  these

voids will be occupied by other fluids such as tea and coffee 
failure in esthetic.

Cast gold

-Affect the strength qualities of the cement used.

Gold foil

-Retention of gold foil depends on the attraction of its cohesive property

as we clean the surface of increments from oxides.
-Contamination by fluids in the oral cavity will lead to formation of
surface oxides  less cohesion  Friable and weak restoration

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Chapter 2 Control of fluids

Methods of moisture control

I.Direct methods
1. cotton rolls.
2. Absorbents.
3. Evacuation system.
A) Saliva ejectors.
B) High volume vacuum.
4. Svedopter.
5. Isolite System.
6. Air Water Syringe.
7. Gingival retraction.
8. Rubber dam.
II. Indirect methods
1)Mechanical.
A) Laser.
B) Electrosurgery.
2)Chemical methods of fluid control.
A) Local anesthesia.
B) Drugs.
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Chapter 2 Control of fluids

1) Direct methods

1.cotton rolls

Uses

-Controls small amounts of moisture.

-Retract cheek and tongue.
-Can be used with other methods of moisture control ( saliva ejector)

Advantage

-Keeps its shape and does not fall apart when full of saliva
-Provides acceptable dryness
-cheap
-Easy to use

Disadvantages

-Only provides short term moisture control

-Ineffective if high volumes of fluid
-Active tongues and shallow sulci may make placement and retention
difficult

Application
-Cotton rolls placed in lingual or buccal vestibules

-When removing cotton rolls make sure they are moist to prevent
inadvertent removal of the epithelium

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Chapter 2 Control of fluids

Cotton roll holder

Advantages
• Cheek and tongue are slightly retracted.

• Enhances visibility.

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Chapter 2 Control of fluids

Types of cotton rolls

1. Manually rolled

2. Pre-fabricated
A) Smooth

B) Woven

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Chapter 2 Control of fluids

Cotton roll with spring action

Designed with a thin plastic core, make it fit to the contours of the
oral cavity making it ideal for cosmetic dentistry.

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Chapter 2 Control of fluids

2. Absorbent

Absorbent pads and wafers

-Made of cellulose, & hence also called cellulose wafers

-Available in different shapes

-Most commonly used inside the cheeks to cover the parotid ducts

-More absorbent than cotton rolls

A) Dry Angles

-It is a triangular absorbent pad.

-The pad is placed on the buccal mucosa over parotid duct opening
(opposite the maxillary second molar)

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Chapter 2 Control of fluids

B) Reflective shields

 Mirror-like film on one side improves visibility and absorbent material

(non-woven Cotton) on the other maintains a dry field.

Advantages
-Special heart shape accommodates buccal curvatures and keeps shield in
cheek with the parotid gland.

-Improve visibility of the oral cavity.

-Cotton nonwoven material provides moisture retention and patient

comfort without sticking to the cheek

C) Silver Absorbent Wafers

-Have silver laminated coating on one side that provides an additional
source of light and keeps work areas extra dry.

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Chapter 2 Control of fluids

D. Lingual Absorbents

 Absorbent pad designed for collection of all saliva produced by the

sublingual glands as well as the submandibular glands.

3. Evacuation system

A) Saliva ejector (low volume evacuating equipment)

Uses
-used to remove small amounts of saliva or water from the patient‟s
mouth.

Advantages
-Prevent pooling of saliva and water in the floor of the mouth.

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Chapter 2 Control of fluids

Disadvantages
-Have little capacity for picking up solids.
-Remove water slowly

Placement

-Position under the tongue.

-Opposite the side of working.
-Should be placed with their tips on the floor of the mouth directed
backwards and not directly in contact with the tissue.

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Chapter 2 Control of fluids

Types of Saliva Ejector Tips

 Saliva Ejector Mirrors

 Sweflex saliva ejectors

- Flexible.

- Curved Efficient.

-Comfortable.

Fast Dam
-Anatomically-shaped maintains dry quadrant field.

-Used to isolate lower premolars and molars.

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Chapter 2 Control of fluids

Disadvantages

-Suction holes tend to sucking the tissue which blocks the holes.

B) High volume evacuating equipment (HEV)

-Are preferred for suctioning water and debris from the mouth.

Uses
• Maintain the mouth free from saliva, blood, water, and debris.

• Retract the tongue or cheek away from the procedure site.

HVE tips are made of

A) Stainless steel

B) Disposable plastic

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Chapter 2 Control of fluids

Position of HEV
-Places the tip of the evacuator just distal and opposite to the tooth to be

prepared.

Advantages
1. Cuttings of tooth and restorative material and other debris are
removed from the operating site.

2. A clean operating field improves access and visibility.

Caution

-soft tissue may be sucked and into the tip, Keeping the tip at an angle

of the soft tissue helps prevent injury to soft tissues.

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Chapter 2 Control of fluids

4) Svedopter

Uses

-Function both as saliva ejector and tongue retractor

-Used effectively in mandibular teeth

Consists of

-Metal saliva ejector with attached tongue deflector

34
Chapter 2 Control of fluids

Disadvantages
- Access to the lingual surface of mandibular teeth is limited.

5- Isolite System

35
Chapter 2 Control of fluids

Composition

 Single-Use Mouthpieces.

 Control head.

 Single-Use Mouthpieces

36
Chapter 2 Control of fluids

Advantages

1.Combine functions of light, suction and retraction in a single device

2.Gently holds the patient's mouth open, keeps the tongue out of the
working field

3. Isolates maxillary and mandibular quadrants simultaneously

4. Retracts and protects tongue and cheek

5. Continuously aspirates fluids and oral debris

6. Protection from unsafe aspiration of materials

7. Very soft flexible and easy to attach

8. Easy to place and remove

Disadvantages

1. Patient position cannot be “too upright”

2. Cannot be used with a patient that has an extreme gag reflex

Placement
Step 1: Prepare for Placement
Place isthmus at corner of mouth
Step 2: Position Isthmus
Step 3: Insert Mouthpiece
Instruct patient to open wide
Step 4: Isthmus Behind Tuberosity
Place the isthmus behind the maxillary tuberosity, resting on the
retromolar pad.
Put cheek shield into buccal vestibule.

37
Chapter 2 Control of fluids

Put tongue retractor into lingual vestibule.

38
 Chapter 2 Control of fluids

6) Air-Water-Syringe
• useful to dry tooth or soft tissues during examination or used
during operative procedures

Disadvantages
 can dehydrate dentine and cause pain and discomfort to patient
 Not effective if large volumes of moisture are present slide

7) Gingival retraction

Objective of gingival retraction

1. Improve access and visibility by:

a) Controlling gingival bleeding

b) Retract the gingival tissues


 1)Prevent trauma to gingival tissues during cavity preparation.
 2)Restricts excess restorative material from gingival cervices.
 3)Provides isolation and retraction of the gingival tissues when
doing restorations in cervical area.
2.

39
 Chapter 2 Control of fluids

3.

Techniques

A) Cordless technique
 -Mechanical
 -Chemical
 -Chemo mechanical
B) Retraction cord technique
 -Mechanical
 -Chemo mechanical

40
 Chapter 2 Control of fluids

A) Cordless technique
1) Mechanical

 Material designed for easy & fast retraction of sulcus without potentially
traumatic packing or pressure.
 Based on flowable vinyl polysiloxane which expanding the sulcus
 material is syringed around the margin and a cap is placed and maintain
pressure. then cap and foam are removed
 Like: GingiTrac and Magic Foam Cord

Classification

1) Class I (vasoconstrictors, adrenergic) as epinephrine

-Do not coagulate, but act by constricting blood vessels and

decreasing their size.

Disadvantages
-Elevation of blood pressure and increase in heart rate no benefits
have been recognized over other non-impregnated cords.

•
2) Class II (hemostatic agents, astringents) as zinc chloride

41
Chapter 2 Control of fluids

-Act by precipitating proteins on the superficial layer of mucosa and

make it mechanically stronger.

-Cause superficial and local coagulation.

•
2) Chemicals

Disadvantage
A relatively high level of acidity lead to: -
-Raises inflammatory responses in gingival tissues

-Interferes with some bonding processes by removing the smear layer,

thus interfering with self-etch adhesive systems which depends on the
smear layer.

-exposed root surfaces cause post-operative sensitivity

3) Chemo mechanical
Acting both as a chemical hemostatic agent and chemical retraction
material

Like: Expasyl

• It is consisting of:

1. Kaolin to ensure the consistency of the paste and its mechanical

action

2. Aluminum chloride enhances the hemostatic action

• paste is injected into sulcus, Exerting stable, non-damaging pressure

of 0.1 N/mm.

• Left in place for 1 min.

• Obtain sulcus opening of 0.5 mm for 2 minutes.

42
Chapter 2 Control of fluids

B) Retraction cord technique

43
Chapter 2 Control of fluids

Advantages:
 Effective in control gingival haemorrhage or gingival crevicular
fluid and at same time retracting gingival tissues

Disadvantages:
 Difficult to insert
 Risk of damage to the epithelial attachment
 Risk of irreversible gingival retraction and excessive bleeding
 the level of the gingival margin is difficult to predict following
periodontal healing and therefore may present aesthetic problems

Sizes of cord

Size: 000

 Within the front tooth area

 lower cord with the double-cord technique
 With very sensitive and thin gingiva

Size: 00

 Lower cord with the double-cord technique

 Preparation and fixing of veneers

Size: 0

 Lower cord with the double-cord technique

 Restoration of the classes III, IV and V

44
Chapter 2 Control of fluids

Size: 1

 Front tooth area and premolar area

Size: 2

 Upper cord with the double-cord technique

 Premolar and molar areas

Size: 3

 Upper cord with the double-cord technique

 Molars with pronounced, thick gingiva

45
Chapter 2 Control of fluids

Types of retraction cord technique

1. Mechanical
Plain Retraction cord (Non-impregnated)

2. Chemo mechanical
cord with hemostatic agent (Impregnated)

Requirements of Instrument used for placing cord

 Blade should be small enough in all dimensions to avoid

gingival injury during cord placement

 End of blade should be flat

 No sharp corners should be present

46
Chapter 2 Control of fluids

Placement of cord

 The cord is twisted to make it tight and small as possible

 The cord should be inserted starting from the mesial surface of

the tooth till the distal surface.
 By pushing it into the sulcus in the mesial surface
 It should be tacked into the distal cervice to hold the cord in
place

 The instrument should be held facing mesially to prevent

dislodgement of the cord from the previously tacked areas

47
Chapter 2 Control of fluids

 It may be necessary to hold the cord with one instrument while

packing with the second

 The instrument should be angled slightly toward the root to facilitate

the subgingival placement of the cord

48
Chapter 2 Control of fluids

 The instrument should not parallel to the tooth surface to prevent

rebounce

 Excess cord is cut off near interproximal area of the mesial surface

 After cutting off the excess at the mesial end, the distal end of the cord
is a tucked in until it overlaps the tucked mesial end.

49
Chapter 2 Control of fluids

 The retraction cord must be slightly moist before removal.

 Removing dry cord from the crevice can injure the delicate epithelial
lining of the gingiva

50
Chapter 2 Control of fluids

8
.
T
h
e

R
u
b
Rubber Dam

Advantages
1. The rubber dam is the most effective method of isolating

2. creates a dry, clean operating field

3. Improves access and visibility

4. Improves properties of dental materials as ideally all the materials

require a dry field for best results.

5. provides protection to the patient from accidently fallen

instruments and materials.

6. Increases operating efficiency and output of the work

7. The dam is important barrier for prevention of microbial

transmission from patients to dentist

51
Chapter 2 Control of fluids

Disadvantages
1. Time consumption
2. patient‟s objection, as it looks uncomfortable to the patient.

3. Patients suffering from asthma, psychological problems not tolerate

the rubber dam.

Contraindication
1. Incompletely erupted third molar

2. Malposed teeth
Materials and Instruments

 Rubber dam material

 Rubber dam Frame
 Rubber dam clamps
 Rubber dam punch
 Rubber dam forceps
 Rubber dam napkin
 Lubricants
 Dental floss

52
Chapter 2 Control of fluids

Rubber dam material

Thickness

The thicknesses available are thin, medium, heavy and extra heavy

 Thicker dam is more effective in retracting tissue and more

resistant to tearing recommended for isolating Class V.

 Thinner dam passing through the contacts easier helpful when

contacts are tight.


Colors

• Light and dark are available

Darker colors are generally preferred for contrast.

 The rubber dam material has a shiny side and a dull side.

 The dull side is placed facing the occlusal side of the isolated
teeth Because it is less light reflective.

53
Chapter 2 Control of fluids

Frame

 maintains the borders of the rubber dam in position.

 U-shaped metal, with small metal projections for securing the
borders of the rubber dam.

54
Chapter 2 Control of fluids

Clamps (retainers)

Consists of

 Four prongs which that rest on the mesial & distal line angle of
the tooth
 Two jaws connected by a bow
 Two holes

Function

 To anchor the dam to tooth to be isolated.

 To retract gingival tissue.

55
Chapter 2 Control of fluids

Sizes of clamps

 Various sizes depending on the tooth

 small clamps are designed to be used on small single-rooted
teeth
 larger clamps are for use with molar teeth.

Spe
cifi
call
y,
for
gin
giv
al
retr
acti

on

Cer
vica
l
retr
acti
ng
cla
mp

 t

56
Chapter 2 Control of fluids

he jaws with their blades are movable even after attaching the
clamp to the tooth.
 By moving the blade apically, the gingiva can be retracted
apically

Disadvantages

• As the jaws of these clamps are fine, they are not particularly
stable and may require support as compound stick
• They have limited life.

Types of clamps

There are three basic types of clamps

(a) Winged rubber dam clamp

57
Chapter 2 Control of fluids

(b) Wingless rubber dam clamp

(c) Butterfly rubber dam clamp

Other rubber dam clamps

1.Clamp with long guard extension

• These clamps retract and protect the cheek and tongue along with
isolation.
• They can be used with gauze or cotton rolls.
• The larger wing of the clamp is used for the retraction of the tongue

2. Tiger clamp
These are the clamps with serrated jaws

These serrations will increase the stabilization of the clamp on the

partially erupted or broken-down teeth.

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Chapter 2 Control of fluids

3.S-G (Silker-Glickman) clamp

-This is a clamp with anterior extension which allows for retraction of the
dam around a severely broken-down tooth

4.Super Clamp

 wings extension to retract the cheeks and the tongue

 Have pre-cut rubber dam material designed to fit the clamp.
 isolate of single tooth without covering the patient „s whole mouth
and nose
 Protects the tongue and cheeks while treatment with the rotary
instrument
 It is very simple to use, quick and easy to place.

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Chapter 2 Control of fluids

Rubber dam punch

Types

1) Ivory-design rubber dam punch

2) Hygienic rubber dam punc

60
Chapter 2 Control of fluids

The rubber dam punch has: -

1) Tapered, sharp-pointed plunger
2) Rotating metal disk with holes of varying sizes

•
Hole-Positioning Guides

Teeth as a guide: The teeth themselves, or a stone cast of the teeth

Advantage: is exact positioning of the marks even when teeth are

malaligned.
Disadvantages: the time-consuming nature of the procedure and the
inability to punch a dam before the patient is seated.

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Chapter 2 Control of fluids

2) Template:

3) Rubber dam stamp:

62
Chapter 2 Control of fluids

Dams should be pre_stamped by an assistant

Rubber dam clamp forceps

• Used for placement and removal of clamps from the tooth.

Types

1) Ivory-type clamp forceps

• Have stabilizers that prevent the clamp from rotating on the beaks
• I
t

l
i
m
i
t
s

63
Chapter 2 Control of fluids

he use of these forceps to teeth that are within a range of normal

angulation

2) Stokes-type clamp forceps:

• Have notches near the tips of their beaks

• Allow a range of rotation for the clamp so that it may be positioned on

teeth that are mesially or distally angled

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Chapter 2 Control of fluids

Rubber dam
napkin

placed between the rubber dam and the patient‟s skin has the
following benefits:

 It improves patient comfort by reducing direct contact of the

rubber material with the skin.
 It absorbs any saliva seeping at the corners of the mouth.
 It acts as a cushion.

Lubricant

• A water-soluble lubricant applied to both sides of the dam in the

area of the punched holes aids in passing the dam through the
contacts
65
 Chapter 2 Control of fluids

• A rubber dam lubricant is commercially available, but other

lubricants such as shaving cream also are satisfactory.
Recent Advances in Rubber Dam

Pre-Framed Dental Dams

• Built-in flexible frame which eliminates the use of separate frame.

• Pre-punched hole helps eliminate tearing.
• Radiographs may be taken by bending the frame without removing
the dam.
• Single-use and hence eliminates the need for sterilization

1) Opti Dam

• 3-dimensional shape and nipple design

• Opti Dam is available in two versions: anterior and posterior.

Advantage
• easier rubber dam application and low risk of clamp displacement
• less working time than for conventional rubber dams.
• (no marking of the tooth position)
• It offers maximum patient comfort and allows them to breath with no
pressure around the nasal area.

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Chapter 2 Control of fluids

2) Optra dam

• combining the benefits of a lip and cheek retractor, with the total
isolation of a rubber dam
• Place without the need for clamps.
• there is no need for a separate rubber dam frame
• more comfort to patient
• easily to place
• create large isolated field and complete isolation of both arches can
be achieved at the same time

67
Chapter 2 Control of fluids

How to use

68
Chapter 2 Control of fluids

Stretch the material Hold outer and inner ring together

Put the rubber dam wings The inner ring rest in vestibule of
upper
in the buccal corners and lower lips

Indirect methods

1) Mechanical methods
a) Laser
b) Electrosurgery
2) Chemical methods of fluid control
a) Local anesthesia
b) Drugs
Laser
Soft tissue lasers (Diode lasers)

69
Chapter 2 Control of fluids

• characterized by a high absorption in chromophores found in

soft tissue, e.g. hemoglobin
• using lasers on soft tissue prevent bleeding due to
1. Sealing of small vessels through tissue protein denaturation
2. Stimulation of Factor VII production in clotting.

Electrosurgery

• It uses high frequency electric current

• Electrode is similar to a probe, and is designed to produce intense
heat during surgical procedures. This heat helps to vaporise the
target tissue

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Chapter 2 Control of fluids

o Uses

• To access sub gingival caries

• Control small amount of bleeding

Indications
• In areas of inflamed gingival tissue, where it is impossible to use
retraction cord

Advantages
• Can be done in cases with gingival inflammation.
• Produces little to no bleeding.

• Quick procedure.

Disadvantages

-Very technique sensitive.

-may produce severe tissue damage through:
Application of excessive pressure
Difficult to control lateral dissipation of heat

Contraindications
• Patient with cardiac pacemakers

Chemical methods of fluid control

1) Local anesthesia

71
Chapter 2 Control of fluids

• control moisture by reducing salivary flow.

• Incorporating a vasoconstrictor also reduce blood flow, which

helps control hemorrhage at the operating site.

2) Drugs

Rarely indicated
-Antianxiety drugs
-Muscle relaxants
-Medication for controlling gingival bleeding
-Pain control medication
\
Anti-sialagogues
•
• -These are group of drugs that can be effectively used to control
salivary flow.
• -They inhibit the action of myoepithelial cells in the salivary
glands, producing dry mouth.
• -Most common used Atropine-5mg, 30min before the procedures-
reduce salivation

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 Chapter 2 Control of fluids

Contraindications

• -Hypersensitive patients.
• -patients with glaucoma.
• -patients with asthma.
• -Obstructive conditions of congestive heart failure.

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 Chapter 3

Management of Non-Carious Lesion

A. Identification:
 Chronic destructive processes other than caries (no bacteria).
 Affecting teeth faces leading to loss of tooth structures
 Responsible for 25 % loss of hard tooth structures
Chapter 3 Management of Non-Carious Lesion

 While dental caries which is the main tooth pathologic disease of

hard tooth structure  75% loss.
 Tooth wear can be defined as the surface loss of dental hard tissues
other than by caries or trauma, and is natural consequence of
ageing. It is commonly divided into three components (erosion,
attrition, and abrasion) but these conditions often coexist.

B. Acceptable and

pathological levels of tooth wear:

It is normal for teeth to wear but the process is regarded as pathological if
they become so worn that they function ineffectively or seriously bad
appearance.
The distinction between acceptable and pathological tooth wear at a given
age is based on a prediction as to whether the tooth will survive that rate
of wear in a functional and reasonably aesthetic state until the end of the
patient's normal lifespan.

C. Consequences of pathological tooth wear:

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Chapter 3 Management of Non-Carious Lesion

There are several important clinical features that can result from
pathological tooth wear. These include the following:
 Exposure of dentine on buccal or lingual surfaces normally covered
by enamel.
 Notched cervical surface.
 Exposure of dentine on incisal or occlusal surfaces - further erosion
often results in preferential loss of dentine to produce a Cupped surface.
 Restorations (which do not erode) are left projecting above the tooth
Surface.
 Exposure of reparative dentine or pulp.
 wear producing sensitivity
 Pulpits and loss of vitality attributable to tooth wear.
 Wear in one arch more than in the other.
 Inability to make contact between worn incisal or occlusal surfaces
in any excursion of the mandible.
 Reduction in length of the incisor teeth so that length is out of
proportion to width.
Some of these features require operative intervention to protect the pull,
reduce sensitivity, and improve appearance or function however;
restorations will not prevent further wear.
Just as with dental caries, restoration can temporarily replace the lost
tooth surface but wear will continue on any tooth surface exposed around
the restoration if the cause is not identified and prevented

D. Diagnosing and monitoring tooth wear:

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Chapter 3 Management of Non-Carious Lesion

It is relatively easy to diagnose that teeth are worn, provided that they are
viewed clean and dry.
Differentiating between acceptable and pathological levels of wear can be
more difficult because the decision depends on the age of the patient.
Also, a single examination will not show whether the wear is static or
progressing, nor the speed of any progression.
Where a pathological rate of tooth wear is suspected, study models taken
at six months or yearly intervals will determine the rate of progress and
the effectiveness of preventive measures. If these measures are not
entirely successful, the series of' models will help to decide if and when
to intervene operatively.

Classification of non-carious tooth defects

I. Attrition.
II. Abrasions.
III. Demastication.
IV. Erosion.
V. Abfraction.
VI. Trauma & fracture.
VII. Acquired developmental conditions.
i. Enamel hypoplasia.
ii. Enamel hypomineralization.
VIII. Hereditary condition.
i. Hypodontia microdontia.
ii. Amelogenesis imperfecta
iii. Dentinogenesis imperfecta.

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Chapter 3 Management of Non-Carious Lesion

Types of non carious tooth defect

I. Attrition:
1) Definition:
 It is a physico-mechanical loss of the tooth structures (enamel and
dentin).
 The surface tooth structures loss resulting from normal direct
functional forces between contacting teeth.
 Considered as a continuous age-dependent process.
 Beginning from the time the tooth being erupted and come in
contact with the opposing and the adjacent tooth or teeth during
eating, swallowing and speaking.

2) Clinical signs and symptoms:

 Differ from one person to other, from one tooth to other and from
one area in the same tooth to other.
Site
 Occur at the occluding surfaces (incisal or occlusal surface).
 It also includes the proximal surface wear at the contact area
because of the physiologic tooth movement.
 May occur at labial or lingual surfaces as in cross bite.

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Chapter 3 Management of Non-Carious Lesion

Appearance
 Attrition is seen as loss, flattening, faceting (facets), saucering at
the occluding surfaces or, at reverse cusping of the occluding
surfaces or elements (palatal cusps of upper premolars and molars
and facial cusps of lower posterior teeth).
 Shiny facets on amalgam contacts
 Facets: flat surface with a circumscribed and well-defined border.
 Reverse cusp: in severe cases and it is in the place of the cusp tip
and the inclined planes, leading to loss of the vertical dimension of
the teeth. palatal cusps of upper premolars and molars and facial
cusps of lower posterior teeth.
 Sometimes there may be presence of peripheral, ragged, sharp
enamel edges.
 The degree of wear in both arches is normally equal.
 The presence of hypertrophic masseter is indication of impact of
Para functional habits such as bruxism and clenching which
accelerate the attrition.
Attrition can predispose to the following: -
A) Proximal surface attrition (proximal surface facets)
 Results from surface tooth structure loss and flattening, resulting in
widening of the proximal contact areas.
 Surface area proximally increases in dimension, which is
susceptible to decay.
 Mesiodistal dimension of the teeth is decreased, leading to drifting,
with the possibility of overall reduction in the dental arch.
B) Occluding surface attrition (OCCLUSAL WEAR)
 It is the loss, flattening of the occluding elements.
 It leads to loss of vertical dimension of the tooth.

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Chapter 3 Management of Non-Carious Lesion

3) Complications associated with attrition process:

 Tooth sensitivity will occur due to dentin exposure to the oral
environments.
 Pulpal & periapical affection due to the presence of abnormal
physiological forces and stresses.
 Tearing of the periodontal ligaments.
 Micro-cracks (crazing) and liability for stagnation of irritating
substrates on the created flat or concave areas of exposed dentin
with discomfort and pain
If the loss is severe & accomplished in a relatively short time: -
 There would be no chance for the alveolar bone to erupt occlusally
to compensate for the occlusal tooth loss & therefore the vertical
loss might be imparted to the face.
 Leading to overclosure during mandibular functional movements &
strain areas on stomato-gnathic system.
 In sever attrition conditions, tempro-mandibular disorders and
musculature problems.
If the loss occurs over a long period: -
 The alveolar bone can grow occlusally, bringing the teeth to their
original occlusal termination i.e. vertical dimension loss will be
confined to teeth but not imparted to face.
 Deficient masticatory capabilities.
 Cheek biting: vertical overlap between the working inclined planes
will be lost, which will cause surrounding cheek, lip, tongue to be
fed between the teeth.
 Decay: because the underlying dentin will be exposed & there by
becomes more susceptible to decay.

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Chapter 3 Management of Non-Carious Lesion

 Severe occluding surface attrition → predominantly horizontal

masticatory movement of the mandible→ extreme strain on the
muscles of stomatognathic system.
 TMJ problems by the over closure situation (will overstretch the
joint ligaments).
 When surface attrition is slower & compensated by, intrapulpal
deposition of secondary & tertiary dentin, then there will be no
pulpal exposure.
 At other times, the attrition is faster than the intrapulpal dentine
deposition, leading to direct pulpal exposure.

4) Treatment modalities:
Line of treatment according to the complications may be: -
 Treatment of hypersensitivity
 Direct occlusal correction through a mounted diagnostic casts and
correction can be made with selective grinding.
 Soft vinyl night mouth guards.

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Chapter 3 Management of Non-Carious Lesion

5) Bruxism and attrition:

 Bruxism can be defined as non functional approach and Para
function activity of mandibular movements and grinding of upper
and lower jaws.
 Lead to sever wearing and loss of enamel and dentin structures
hyper mobility of teeth and TMJ disorders.
 Bruxism is associated with muscle spasm, split teeth and fractured
fillings.
 It is the screeching, grating sound in the night
 Attrition process is usually accelerated by Bruxism.
 Its considered pathological attrition.
II. Abrasion:
1. Definition:
 The pathological wearing away of dental hard tissue through
abnormal mechanical processes involving foreign objects or
substances repeatedly introduced in the mouth contacting the teeth.
 The pattern of wear can be diffuse or localized.
 Clinically there is frequent coincidence of smooth surface cervical
lesion with excessive tooth brushing.
2. Etiological factors:
 Patient factors include: brushing technique, frequency of brushing,
time spent on brushing and force applied
 Material factors refer to: type of material stiffness and end
rounding of tooth brush bristles, tuft design of the brush, flexibility
and length of tooth brush grip, abrasiveness, pH and amount of
dentifrice used.
 Abrasion on proximal tooth surfaces by extensive use of interdental
devices such as tooth picks or interdental brushes and floss

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Chapter 3 Management of Non-Carious Lesion

 Occupational abrasion, tooth wear due to any professional causes

such as abrasive dust at work place, holding nails, biting thread.
 Iatrogenic causes such as dentures with porcelain teeth opposing
natural teeth or using cast alloys with higher abrasive resistance
than enamel.
 Depression abrasion (pipe smoker): (Habits like pipe smoking)

3. Clinical signs and symptoms:

Site
 It occurs most frequently on the cervical neck of the teeth.
 The labial or buccal surfaces and lingual surfaces (in case of poorly
fitted clasps and artificial dentures).
 Proximal surface as in tooth pick or interdental brushes and floss.
Appearance
 May be linear in outline.
 The peripheries of the lesion are angularly demarcated from the
adjacent tooth surface.
 Surface of the lesion is extremely smooth and polished.
 Walls of the abrasive lesion tend to make a v-shape meeting at an
acute angle axially.
 Probing or stimulating (hot, cold, sweet) can elicit pain.

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Chapter 3 Management of Non-Carious Lesion

4. Microscopic appearance:
 The abraded surface shows-oriented scratch marks and numerous
pits.
 The length, and depth of these scratches are depending on the
abrasive material and the pressure applied during mastication.

5. Treatment modalities:
 Diagnose the cause of the present abrasion.
 Try to prevent the patient from practicing the causative habits
(removal of the cause).
 It is preferable to desensitize the exposed dentin before restorative
treatment (Desensitization can be accomplished by topical
application of 10% stannous fluoride for 4 to 8 min and the patient
is recommended not to rinse his mouth or eat for 15 min after
application. Ionophoresis using an electrolyte containing fluoride
ions can also be used)
 Restorative treatment:
a) If the lesions are multiple, shallow (less than 0.5 mm in dentin)
wide and involve enamel or cementum only there is no need to
restore only the edges are eradicated to a smooth surface for
esthetic and plaque control. Surface should be treated with
fluoride solution to improve caries resistance.
b) If the lesion is at an occluding surface, no need for cavity
preparation, restoration can be done with bonded direct tooth
colored materials.
c) If the abrasive lesions are deep and at an occluding tooth surface,
metallic restoration should be used.

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 Chapter 3 Management of Non-Carious Lesion

III. Demastication:

 Wearing a way of tooth substance during the mastication of certain

type of food.
 wear is influenced by the abrasiveness of the-individual food
 A physiological process affecting primarily the occlusal and incisal
surfaces.
 May be termed pathological when occurring due to abnormal food
consumption such as betel nut Demastication.
 Can also be looked at as a combination of abrasion and attrition.

IV. Erosion:
Definition:
 Irreversible pathological, chronic, localized, painless loss of dental
hard tissue by a chemical process that does not involve bacteria
 Acids responsible for erosion are not products of the intraoral flora.
 Such tissue loss is not apparent until the patient reports symptoms
of sensitivity.
 Unlike-dental caries, erosion occurs on plaque free sites.

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Chapter 3 Management of Non-Carious Lesion

1. Etiological factors:
A. Acidic material:
 Acids play great role in the production of the erosion lesions.
 Citric acid was found to be the most damaging agent.
1. Dietary foods:
 Habitual drinking of acid beverages (citrate ions).
 Excessive consumption of citrus fruits (lemon juice &
grape fruit).
 Habitual lemon sucker patients.
 Prolonged contact between the candy and lozenges of low
PH values.

2. The acids of salivary secretions:

 Salivary secretion has citrate ions, responsible for the
acidic medium of the saliva and its low PH which increase
the severity of the erosion of tooth structure.

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3. Acids secreted by the gingival glands:

 In cases of traumatic occlusion more acids are secreted
around the eroded tooth
4. Low PH medications and oral hygiene products:
 Oral hygiene products containing EDTA
 Saliva substitute with low PH
 Increase use of vitamin C
 Chewable aspirin.
 Iron tonic products for athletics
5. The industrial atmospheric pollution in work places:
 Battery factors
 Galvanizing factory
 Researches in laboratories
 Etching with sulfuric acid in some
industries

6. The individuals with habitual regurgitation:

Reflux, Regurgitation and Vomiting of gastric contents
 Anorexia
 Bulimia
 Pregnancy/Hormones
 Obesity
 Eating and Drinking too much
 Alcoholism
 Chronic vomiting.
 Persistent esophageal reflux
 Peptic ulcer.
 Chronic gastritis.

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B. Alkaline material:
 Alkaline PH materials act as an effective chelating agent with
decalcification of the tooth surfaces producing an erosive area.
 Alkaline material is responsible for decalcification of the tooth
surface.
 Calcium removed from the tooth surface in alkaline media,
decalcification accelerating the erosion.

2. Types of erosive lesions:

a. Dish or saucer shaped:
 Shallow concavities most commonly occurring on incisors
 Deepest part is the center of concavity and the walls radiate
upwards to sound tooth structure
 It appears glossy when the tooth is dried
b. Wedge, notch or V-shaped:
 Occur on the buccal surface of premolar and molar
 Start at the level of the gingival borders as thin, straight and
sharp depression
 May cause pulp exposure and has a marked sensitivity
c. Irregularly shaped:
 Occur in the proximal and lingual surfaces of teeth
 Due to systemic or environmental disorders
 Chemical fumes and chronic regurgitation can cause this type

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Classification of erosion
A) Extrinsic
Environmental factors
 Exposure to acid fumes
 Battery factory workers (sulfuric acid)
 Galvanizing factory workers (hydrofluoric acid)
 Acidic water in swimming pools
Dietary factors
 Citrus fruits juice
 Acidic carbonate beverage and Acidic fruit flavored candies
 wines
Medication
 Low Ph medications taken frequently and in contact to the
dentition.
 Increased use of Vitamin C (ascorbic acid)
 Chewable tablets of aspirin
 Iron tonic products of low pH of 1.5
 Mouth washes containing EDTA
B) Intrinsic
 As a result of endogenous acids.
 Gastric acids reach the oral cavity and the teeth during recurrent
vomiting
 disorder of alimentary tract (peptic ulcer)
 Specific metabolic and endocrine disorder (hyperthyroidism,
adrenal insufficiency, and pregnancy)
 As a side effect of drugs Estrogens, chemotherapeutic agents, and
tetracycline
 Certain psychosomatic disorders, stresses inducing vomiting.

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4. Treatment modalities:

a) Conservative approach:

i. Surface hardening:
 application of 10% stannous fluoride for 30 seconds
 Sodium fluoride paste will aid also in surface hardening and
reduce tooth sensitivity.
ii. Remineralization:
 to prevent destruction of enamel and dentin
 Dentifrices and solutions containing calcium fluoride traces
phosphates are capable of causing surface changes.
iii. Prevention and care of periodontal tissues
 Relief of traumatic occlusion.
 Proper selection and use of tooth brush
iv. Desensitization to decrease hypersensitivity by:
 Paste which contains equal parts of sodium fluoride and
kaoline in glycerin base
 Siloxane ester which contain 10% strontium chloride and
1.5% formaline

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b) Restorative approach:
 Indicated in large lesions
 Metallic and non metallic restorations depending on the location and
the extent of eroded area.
 No need for protective base because of the limited depth.
 Dentin should be painted with varnish to decrease postoperative
hypersensitivity.

V. Abfraction:
 A special form of wedge-shaped defect at the cementoenamel
junction of a tooth.
 Observed on a single tooth.
 Hypothesized to be the result of eccentrically applied occlusal
forces leading to tooth flexure.
 According to the tooth flexure theory, masticatory or
parafunctional forces in areas of hyber-or malocclusion may lead to
strong tensile, compressive or shear stress.
 The forces are focused on the CEJ, where they provoke
microfractures in enamel and dentin.
 Resulting wedge-shaped defects have sharp rims.

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VI. Trauma & fracture :

1. Definition:
Loss of tooth structure due to trauma.
2. Etiology of trauma:
Trauma is commonly caused be the following:
 Falls
 Sports or athletics.
 Blows from foreign bodies
 Fights.
 Car or bicycle accidents
 Injuries during convulsive seizures (e.g. epilepsy)
 Battered child syndrome (the most difficult and yet the most
important to diagnose)
3. Trauma can produce these local injuries:
 Lacerations to lips, tongue and gingival tissue.
 Alveolar fractures so that a number of teeth become mobile
within a block of bone.
 Complete or partial subluxation of a tooth.
 Root fracture.
 Damage to apical blood vessels without fracture.
 Fracture of the crown of the tooth involving enamel alone,
enamel and dentine or exposure of pulp.
 Only the last one listed will be discussed in detail here.

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4. Examination and diagnosis of trauma:

 The crowns of the teeth are examined for fractures, pulp exposure,
and color changes. Displacement or looseness of teeth should be
noted, together with abnormalities of the occlusion.
 The vitality of the injured and adjacent (and usually the opposing)
teeth must be tested and preapical radiographs must always be
taken to look for tooth fracture.
 At subsequent recall visit the color of the tooth and further vitality
test and periapical radiographs will show whether the pulp has
remained vital or not.
5. Types of fracture can be:
a) Enamel fracture:
 the best solution would be enamel recontouring, smoothing
the edges and peripheries of the defect, may be sufficient
treatment in most cases.
b) Enamel and dentin fracture without pulpal involvement treated
by either tooth fracture reattachment or composite restorations:
Tooth fracture reattachment offer several
advantages over restorations with composite
resins:
 Better esthetics.
 Long lasting esthetics.
 Better emotional and social response from the
patient.
 A simple and faster technique in many cases.

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 Tooth fracture reattachment techniques:

 Dentist must dip the dental fragment in a vessel with water
immedialy.
 Instruct the patient about the advantages and disadvantages
offered by the procedure.
 Analyze clinically and radiographically the remaining tooth
structure (root fracture, pulp exposure, amount of exposed dentin,
pulp condition)
 Analyze the fragment regarding degree of dehydration and
degree of adaptation.
 Isolation of the operative field.
 Fragment attached using gutta percha rod or sticky wax just to
hold it.
 Cleaning of the dental fragment and coronal remnant with
pumice-water slurry.
 Cleaning of the exposed dentin with 3% H2O2 for 10 seconds.
 Protection of the exposed dentin with a CAOH liner.
 Acid etching for 1 min for both fragment and the coronal
remnant.
 Washing for 40 seconds by air/water spray.
 Application for adhesive resin to etched enamel on both
fragment and coronal remnant.
 Proper seating of the fragment before polymerization of the
resin.
 Union line evaluated few days after reattachment.
 If clearly seeen with deterioration in esthetics.
 Line can be masked by a small chamfer then will be veneered
with a microfilled resin.

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 Restoration with composite resin:

 Diagnostic data collected just as for dental fragment

reattachment.
 Proper cleansing of the tooth with a pumice/water slurry
 Field isolation
 Beveling along the whole cavosurface angle.
 Matrix selection and adaptation should offer adequate
reproductiono of the original anatomy with minimal excesses
(crown former or angle shaped transparent matrices)
 Etching of enamel surface by acid
 Bonding agent application
 Composite resin insertion will be incrementally made
 Proper finishing and polishing.

VII. Acquired developmental conditions:

Teeth do not always develop normally, and there are a number of
defects in tooth structure or shape which occur during development
and become apparent on eruption. Such teeth are often unsightly or
promo to excessive tooth wears, and thus they may require
restoration to improve appearance or function or to protect the
underlying tooth structure

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a. Enamel hypoplasia:
1) Definition:
A defect in enamel due to improper matrix formation caused by injury to
ameloblast
Hypoplastic enamel results from the production of a reduced amount of matrix
which matures normally; thus, the enamel is pitted or thin but normal hardness

2) Characteristic features;
Range from isolated pits to wide spread linear defects or
depressions
 Loss of a segment in the enamel
 Different colors from the surrounding enamel
 Discoloration will increase with time
3) Causes:
 Systemic disorders: vit A, C and D deficiences, hypocalcimia or
microbial process as in syphilis.
 Localized disorders: resulting from periapical infections or
traumatic intrusion of the preceeding deciduous tooth.
 Fluorides: excessive amounts of fluoride could poison the
ameloblasts.
4) Treatment modalities:
 If minimum, restore the defects with direct tooth colour
resinious materials.

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 If the defect is at the occluding or contact area, restore the tooth

with metallic or cast restoration.
 If the lesions are discoloured, vital bleaching can be attemped.
 If the lesion is completely disfiguring, both in colour and in
contour and not occluding; laminated composite or ceramic
veneers are the treatment of choice.

b. Enamel hypormineralisation:
1. Definition:
 Hypomineralizaed enamel results when a normal amount of matrix fails to
achieve full mineralization. The affected enamel has a normal shape and thickness
but has an opaque chalky white appearance.
 Improper mineralization of the enamel matrix due to destruction of
ameloblasts.

2. Characteristic feature:
 Affected area has normal shape and thickness but it appears
chalky, soft and stainable
 If it is predisposed to attrition and abrasion, it can be easly
chipped.
3. Causes:
 Ameloblasts are specialized cells that are vulnerable to the effects
of generalized systemic conditions such as the infectious diseases of

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childhood. Alternatively, they may be damaged by adverse local

conditions such as trauma or infection of a deciduous predecessor.
 The usual consequence of damage to the ameloblasts is the
formation of either hypoplastic or hypomineralized enamel.
4. Treatment modalities:
 If a diagnosis is made in the early tooth's life and the defected
areas are localized, small and unstained, mineralization of the
enamel surface should be made using periodic fluoride applications.
 In the severe cases vital bleaching, laminated veneering and
porcelain fused to metal are the treatment to be used.

VIII Hereditary condition:

The inherited conditions which may result in defects in tooth number
shape, size, of structure are hypodontia, Microdontia, amelogenensis
imperfecta, and dentitiogenesis imperfecta. Fortunately the two last
conditions are rare

Hypodontia, Microdontia
Hypodontia (sometimes known as Oligodontia) is a condition usually
with a strong family history, in which some teeth do not form at all. It
may be associated with microdonitia, where some teeth are abnormal in
shape or size. However, the enamel is normal in texture and colour.
Third molars, upper and lower second premolars, and upper lateral
incisor teeth are the most commonly affected. Of the three, the upper
lateral incisor teeth, and other incisors and canines where they are
affected, are the most important to the operative dentist.
In Hypodontia it may be necessary to alter the shape of' adjacent teeth
by restorations or crowns with or without preparatory orthodontic
treatment, to improve the patient's appearance.

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In microdontia it is often possible to alter the shape of the affected teeth.

Amelogenesis imperfecta
This is a condition associated with extensive abnormalities of enamel
formation. At least two different clinical patterns are recognized.
Generalized hypoplasia of' the enamel involves a defect of matrix
formation, although the matrix present appears normally mineralized. In
it's severe form the defect results in thin enamel with teeth appearing
yellow because the underlying dentine shows through. A less severe
form of the defect presents as granular or pitted enamel surface which
may pick up stain.
In contrast, generalized hypormineralization of the enamel involves a
normal amount of matrix formation, but its subsequent maturation is
faulty and incomplete. The quantity of the enamel is normal but the
tissue is frequently soft friable, and easily lost. This enamel may appear
stained and darkened or dull and chalky white.

Dentinogenisis imperfecta
There is deficient formation of dentine and the condition is
characterized by an opalescent discoloration of the teeth, which are
prone to early fracture and excessive wear.
Radiographs typically show pulpal obliteration and shortened roots with
small bulbous crowns.

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Summarize
Therapy concept of non-carious cervical lesion in general:

Preventing tooth wear:

Prevention clearly depends primarily on making an accurate
diagnosis of the cause. Some erosive causes, once identified are easy
to prevent; others are more difficult.
For example, a patient with an erosive dietary food, such as sucking
lemons may be willing to forget the habit, but chronic alcoholics are
much less likely to change for the sake of their teeth alone.
Attrition due to nocturnal bruxism may be helped by occulsal
adjustment to remove interferences which trigger the grinding, and
in other cases and acrylic bite
Plane is provided for use at nights. This may reduce the grinding
habit and will absorb the wear with the acrylic being replaced
periodically.
Abrasion may be prevented by changing the abrasive activity, for
instance the method of' tooth-brushing and/or the toothpaste used.
The management of tooth wears:
Unlike caries tooth wear is an irreversible process. Management
should have the objective of maintaining a functional comfortable
dentition of good appearance.
So the emphasis should be on prevention and monitoring in the early
stages, avoiding the temptation of placing restorations until they are
necessary.
They become necessary only when the patient becomes concerned
about the appearance, or the teeth become sensitive or the dentist
becomes concerned about physical changes such as changes in
occlusal vertical dimension or pulp exposure.

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If restorations are placed while the wear is progressing, particularly

in erosion, they may accelerate rather than slow down the rate of
wear in the surrounding tooth tissue. In advanced Cases, crowns are
required.
So, the management of non carious lesion in general should be in the
following descending order:
1) Desensitization with varnishes or potassium oxalate.

2) Fluorides application with or without ionophoresis.

3) Desensitizing dentifrices  1- 3 months.

4) Adhesive restorative treatment  Bonded restorations:

i) The adhesive restorative treatment is necessary if:

 The structural integrity of the tooth is threatened.
 The tooth (dentin) is hypersensitive.
 The defect is esthetically unacceptable.
 Pulpal exposure is likely.
ii) The main goal in this process has been to obtain an intimate
adaptation with cavity interfaces to resist microleakage and the influx
of the oral irritantswhich may lead to post-operative sensitivity,
interfacial staining and recurrent caries.
iii) For effective etching of matured enamel in older patients, and uncut
enamel surfaces, higher acid concentration should be used.
iv) Failure to bevel and properly acid etch the enamel margin can result
in boundary failure.
vi) Mechanical retention through establishing a well-defined cervical
groove in shallow V-shaped and U-shaped cervical lesions may be
required.

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vii)This restorative treatment includes:

A) Glass ionomer cement, Conventional, resin modified or poly acid

modified cement:
 Especially effective for treating noncarious cervical lesions
 In older patients who often experience reduced salivary flow
 Releasing fluoride ions from these cements into the underlying
dentin will prevent tooth decay.
B) Composite resin:
 Composite resin with reduced elastic modulus is the best material
recommended
 Masticatory forces are transferred through the cusp 3 and are
concentrated at the fulcrum of the linguo-cervical region of the
tooth.
 With this type of resin much of the transferred energy is absorbed
by the restoration rather than to the dentin
restoration interface (bond is less challenged)
 Micro filled composite is the material of choice
in the cervical area
 Strong phosphoric acid concentrations have
been investigated for conditioning highly
sclerotic dentin. Tubular orifices can be opened
with these agents, and extensive tag
development into dentin tubules has been noted.
C) Open or closed sandwich technique:
 Resin composite applied with glass ionomer cement and dentin
bonding agent

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 Composite resin restorations with dentin bonding agent and glass

ionomer cement liner seem to be better retained than the composite
resin restorations applied with only dentin bonding agent
 GIC liner transmits some flexion to the whole restoration allowing
it to compensate for stress that exceeded the bond strength.
D) Composite or porcelain veneers:
 If the labial surfaces are involved
 Both rely on the principles of enamel and dentin bonding.
 Advantages of porcelain veneers are there esthetics and durability; in
addition, porcelain veneers are able to cover eroded incisal margins.
5) Crown and bridgework:
 An extensive defect that needs repairing of the vertical dimension
requires bridgework for antagonistic occlusal reconstruction.

6) Occlusal adjustments and night guard fabrication:

 May be the most significant advice
 The correction of potential hyperocclusion of the tooth in question
"before" starting the actual restorative procedure
 The level of contact should be equalized in centric relation using
articulating paper.

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Adhesion
Chapter 4 Adhesion

Introduction

G.V. Black described the retention of restorations based upon cavity design
and undercut dentin. Additional tooth structure needed to be removed to
fulfill the requirements for retention of the restorative material, even after
the caries removed, because of the limitations of the restorative materials
available at the time (as dental amalgam).

With the use of adhesive systems, there has been a significant change in the
principles of cavity preparation design, from the traditional principles of
“extension for prevention” described by G.V. Black to a more carious
lesion-centered approach. One of the greatest benefits of this conservative
approach is that it allows the clinician to maintain as much tooth structure as
possible. Since then, many significant advances in the development of dental
adhesives have been accomplished. The adhesives currently available offer
reliable adhesion between restorative materials and tooth structure (enamel
or dentin).

Enamel and Dentin Bonding: An Historical Perspective

In 1955, initial advancement was made by a pedodontist, Buonocore

described a clinical technique that utilized diluted phosphoric acid to etch
the enamel surface for 30 seconds, resulted in a microscopically roughened,
porous surface and provided for retention of self-cured acrylic resins. The
resin mechanically locked to the microscopically roughened enamel surface,
forming small “tags” as it flowed into the 10-to-40-micrometer-deep enamel
microporosities and then polymerized.

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Chapter 4 Adhesion

Definitions

Adhesion / Bonding: Two surfaces are held together by interfacial forces

which may consist of valence forces or interlocking forces or both.

Adhesive / Adherent: It is a material, frequently a viscous fluid, which

joins two substrates together and solidifies, and therefore is able to transfer a
load from one surface to the other.

Adherend: It is the surface or substrate that is adhered.

Diagrammatic representation of dental adhesive system, where Adherend 1 is enamel,

dentin or both. Adhesive is bonding agent, Adherend 2 is composite resin

Adhesive Strength: It is the measure of the load-bearing capacity of an

adhesive joint.

Adhesive Failure: The bond that fails at the interface between the two
substrates.

Cohesive Failure: The bond that fails within one of the substrates, but not at
the interface.

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Chapter 4 Adhesion

Abbreviations Commonly Used for Resin Chemicals:

Bis-GMA Bisphenol glycidyl methacrylate

HEMA 2-Hydroxyethyl methacrylate
TEGDMA Triethylene glycol dimethacrylate
4-META 4-Methacryloxyethyl trimellitate anhydride
UDMA Urethane dimethacrylate
Phenyl-P 2-(Methacryloxy) ethyl phenyl hydrogen phosphate

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Chapter 4 Adhesion

Requirements for
Adhesion

1. Good substrate wetting, a low „contact angle‟.

2. A clean substrate.

Wetting: It is an expression of the attractive forces between molecules of

adhesive (adherent) and the adherend. It depends on two factors:

• Cleanliness of the adherend: Cleaner the surface, greater is the adhesion.

"The contamination of the tooth surface by saliva, blood, or other protein

substances reduces the surface energy of the substrate and impairs the wetting
by the liquid adhesive ".

• Surface energy of the adherend: More surface energy results in better

adhesion. Harder the surface is, higher will be the surface energy. This
means adhesive properties of the material will be higher.

"The surface tension of the liquid bonding agent must always be less than the
surface energy of the enamel or dentin".

Contact Angle: It is the angle formed between the surface of a liquid

drop and its adherend surface. Stronger the attraction between adhesive
(adherent) and adherend, smaller is the contact angle.

"Zero contact angle is the best to obtain wetting".

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Chapter 4 Adhesion

(A)

(B) (C)
Lesser is the contact angle, better is the adhesion

(A) Good wetting; (B) Partial wetting; (C) Non wetting

A good wetting ensures good adhesion

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 Chapter 4 Adhesion

Mechanisms of Bonding

1. Micromechanical: Penetration of resin and formation of resin tags

within the tooth surface.
2. Adsorption: Chemical bonding to the inorganic component
(hydroxyapatite) or organic components mainly type I collagen of
tooth structure.
3. Diffusion: Precipitation of substances on the tooth surfaces to which
resin monomers can bond mechanically or chemically.
4. Combination: Of the previous three mechanisms.

"The enamel–composite bond falls into the first category: the tooth surface is
etched, dried, and free-flowing fluid resin placed and cured".

"Viscous glass ionomer cement may fall into the second and third categories:
because even without acidic conditioning of the tooth, conventional glass-ionomer
cements are inherently adhesive restorations when compared with the resin
composites".

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Chapter 4 Adhesion

Advantages of Adhesion

1. Conservation of tooth structure.

2. Reinforcement of remaining tooth structure.
3. Restoration retention.
4. Reduction or elimination of marginal microleakage.
5. Expansion the range of esthetic possibilities.

Clinical Indications for

Adhesives

1. Treatment of dentin hypersensitivity.

2. Bonded amalgam restorations.
3. Indirect adhesive restorations.
4. Repair of porcelain or composite.
5. To restore caries or fractured tooth structure
6. To alter the shape and color of anterior teeth
7. To restore pit and fissure lesions
8. To bond orthodontic brackets

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Chapter 4 Adhesion

9. To repair fractured composite, porcelain, amalgam or ceramometal

restorations
10. To desensitize exposed root surfaces
11. To bond prefabricated or cast posts
12. To seal apical restorations placed during endodontic surgery
13. To bond fractured pieces of anterior teeth
14. To bond conservative tooth replacement prosthesis and periodontal
splint

Advantages of Bonding

1. Bonds composite resin to tooth enamel and dentine

2. Minimizes removal of tooth structure
3. Minimizes chances of microleakage or nanoleakage
4. Beneficial in the management of dental hypersensitivity
5. Helps in cusp reinforcement after tooth preparation
6. Substantially reinforces remaining tooth enamel or dentine making
them less susceptible to fracture

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Chapter 4 Adhesion

Classification of
Adhesive Systems

I- According to bonding strategy:

1. Etch-and-rinse adhesive systems (Total-etch adhesive systems)
2. Self-etch adhesive systems (Etch-and-dry adhesive systems)
3. Glass ionomer adhesive systems

II- According to the clinical application steps

1. Three-step adhesive systems
2. Two-step adhesive systems
3. One-step adhesive systems
III- According to generations
1- First generation
2- Second generation
3- Third generation
4- Fourth generation
5- Fifth generation
6- Sixth generation
7- Seventh generation

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Chapter 4 Adhesion

First generation

 Hydrophobic monomers
 Acid etching is only for enamel (not dentin).
 Self cure bonding agent.
 Chemically :- composed of suface active monomers NPG-
GMA(N-phenylglycine glycidyle methacrylate)which is
theoritically can chelate with calcim present on the tooth
surface to generate water resistant chemical bond.
 Disadvantages
 First-generation bonding agents ignored the smear layer.
 They had very low bond strength of 2–3 MPa.
 The bond strength would decrease over a period of time.
 Individual components lacked stability during storage.
 Exampels : - Cervident
- Cosmic bond

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Chapter 4 Adhesion

Second generation
1- Second generation

 Phosphorous-ester monomers enhanced surface wetting

 claimed chemical bond to calcium smear layer predominately
intact
 fear of etching dentin
 Low bond strengths : 2 to 8 MPa
 It was phosphate ester material (phynyle-p and HEMA )in
ethanol .
 Its mechanism of action was based on the polar interaction
between negatively charged phosphate group and positively
charged calcium ions in the smear layer.
 Smear layer was the weakest link in that system because of its
relatively loose attachment to underlying dentin surface.
 Resin bond were contain a hydrophobic groups that had a large
contact angels on the moist surfaces.
 It did not wet dentin well nor penetrate the entire depth of
smear layer to establish ionic bond

Second generation

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Chapter 4 Adhesion

Third generation
2- Third generation

Mechanism of action
 modified/altered smear layer
 mildly acidic hydrophilic monomer
 Removal of smear layer by chelating agent (EDTA) has given a
marked improvement in shear bond strength.
 in 1984 Kurary co. introduced the(Clearfil new bond) that was
Phosphate based material contain HEMA &ten carbon molecules and
For the first time long hydrophobic chian with short hydrophilic
chian.
 Advantages
 High bond strength of 8–15 MPa.
 Reduced chances of microleakage.
 Forms strong bond to wet and dry dentine.
 Disadvantages
 Bond strength reduced over a period of time.
 Chances of microleakage increase with time.
 Examples
 Scotchbond II

Third generation bonding agents involved alteration removal of smear layer by conditioning and
priming before bonding

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Chapter 4 Adhesion

Fourth generation

 Developed in early 1990s

 Based on total etch technique and moist bonding concept
 Based on concept of hybridization and hybrid layer formation
 Three steps application, i.e. Total etching + Application of
primer+ Application of bonding agent
 High bond strength

Mechanism of Bonding
 Fourth “generation” is characterized by the process of hybridization at
the interface of the dentin and the composite resin.
 Hybridization is the phenomenon of replacement of the hydroxyapatite
and water at the dentin surface by resin.
 This resin, in combination with the collagen fibers, forms a
hybrid layer. In other words, hybridization is the process of
resin interlocking in the demineralized dentin surface (Fig.
16.22).

Components of Fourth Generation Adhesives:

1. Conditioner (Etchant): Commonly used acids are 37 percent

phosphoric acid, nitric acid, maleic acid, oxalic acid, pyruvic acid,
hydrochloric acid, citric acid or a chelating agent, e.g. EDTA.
Use of conditioner/etchant causes removal or modification of the
smear layer, demineralizes peritubular and intertubular dentin and
exposes collagen fibrils.
2. Primer: Primers consist of monomers like HEMA (2-Hydroxyethyl
methacrylate) and 4-META (4-Methacryloxyethyl trimellitate
anhydride) dissolved in acetone or ethanol. Thus, they have both
hydrophilic as well as hydrophobic ends which have affinity for the
exposed collagen and resin respectively. Use of primer increases
wettability of the dentin surface, bonding between the dentin and
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resin, and encourages monomer infiltration of demineralized

peritubular and intertubular dentin.
3. Adhesive: The adhesive resin is a low viscosity, semi-filled
or unfilled resin which flows easily and matches the composite resin.
Adhesive combines with the monomers to form a resin reinforced
hybrid layer and resin tags to seal the dentin tubules.

 Examples :
1. Scotchbond multipurpose (3M)
2. Optibond FL (Kerr)
3. Clearfil liner bond-2 (Kuraray).
 Advantages
 Ability to form a strong bond to both enamel and dentin.
 High bond strength to dentin (17–25 MPa)
 Ability to bond strongly to moist dentin
 Can also be used for bonding to substrates such as porcelain and
alloys (including amalgam).
 Disadvantages
 Time consuming
 More number of steps
 Technique sensitive

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 Dentinal substrate after acid etching. The smear layer has been removed and both the peritubular and intertubular
dentin are demineralized. The collagen fibers are exposed and bathed in water. This substrate is highly hydrophilic and
particularly sensitive to dehydration. The blue coloration represents the water content of the structures illustrate

 Dentinal substrate after priming. The water has been replaced by hydrophilic resins (primers) that have impregnated the
collagen fibers. The solvent of the primer can be organic (alcohol or acetone) or inorganic (water). Priming with water
based primers is a relatively slow process, while organic solvents will displace water more rapidly (convective movement).
Evaporation of the solvent will leave the collagen fibers coated and stiffened by the resins. The substrate has changed
from hydrophilic to hydrophobic. The red coloration represents the extent of primed dentin

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 Dentinal substrate after adhesive resin application. The hydrophobic resin diffuses slowly into the dentinal tubules and
impregnates the intertubular dentin. If resin penetration is not complete, it will leave non-infiltrated areas of
demineralized dentin and non-adherent resin plugs. These defects are responsible for poor sealing of the dentin and
rapid degradation of the adhesive interface.

 Dentinal substrate after polymerization of the adhesive resin. The polymerized resin has completely infiltrated
the demineralized dentin and offers effective protection to the pulp-dentin complex

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Fifth generation

Fifth-generation DBAs were made available in the mid-1990s. They are also
known as “one-bottle” or “one-component” bonding agents. In these agents
the primer and adhesive resin are in one bottle. Basic differences between
fourth and fifth generation is the number of basic components of bottles.
Fourth generation bonding system is available in two bottles, one primer and
other adhesive, fifth generation dentin bonding agents are available in one
bottle only
Advantages
• High bond strength, almost equal to that of fourth generation adhesives, i.e.
20 to 25 MPa
• Little technique sensitivity
• Reduced number of steps
• Bonding agent is applied directly to the prepared tooth surface
• Reduced postoperative sensitivity.
Disadvantages
• Lesser bond strength than fourth generation bonding agents.
Examples of fifth generation DBA:
– Prime and Bond (Dentsply)
– Single bond (3M)

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Sixth generation

These were made available in 2000. In fifth-generation, primer and adhesive

are available in single bottle, and etchant in separate bottle. In sixth
generation etching step is eliminated, because in sixth generation etchant,
primer and bonding are available in single solution.
Most self-etching primers are moderately acidic with a pH that ranges
between 1.8 and 2.5. Because of the presence of an acidic primer, sixth
generation bonding agents do not have a long shelf-life and thus have to be
refreshed frequently.
 Types of Sixth Generation Bonding Agents
Sixth generation bonding agents are of two types:
i. Self-etching primer and adhesive:
• Available in two bottles:
– Primer
– Adhesive
• Primer is applied prior to the adhesive
• Water is the solvent in these systems.

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ii. Self-etching adhesive

• Available in two bottles:
– Primer
– Adhesive
• A drop from each bottle is taken, mixed and applied to the tooth surface,
 example
Prompt L-pop
Mechanism of Bonding

In these agents as soon as the decalcification process starts, infiltration of the

empty spaces by the dentin bonding agent is initiated

 Advantages
 Comparable adhesion and bond strengths to enamel and dentin.
 Reduces postoperative sensitivity because they etch and prime
simultaneously.
 It etches the dentin less aggressively than total etch products.
 Demineralized dentin is infiltrated by resin during the etching process.
 Since they do not remove the smear layer, the tubules remain sealed,
resulting in less sensitivity.
 They form a relatively thinner hybrid layer than traditional product,
which results in complete infiltration of them demineralized dentin by
the resin monomers. This results in increased bond strength.
 Much faster and simpler technique.
 Less technique sensitive as fewer number of steps are involved for the
self-etch system.

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 Disadvantages
• pH is inadequate to etch enamel, hence bond to enamel is weaker as
compared to dentin.
• Bond to dentin is 18 to 23 MPa.
• Since they consist of an acidic solution, they cannot be stored and
have to be refreshed.
• May require refrigeration.
• High hydrophilicity due to acidic primers.
• Promote water sorption.
• Limited clinical data.

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Seveth generation

They achieve the same objective as the sixth generation systems

except that they simplified multiple sixth generation materials into a
single component, single bottle one-step self-etch adhesive, thus
avoiding any mistakes in mixing. Seventh generation DBAs have
shown very little or no postoperative sensitivity. However, due to
complex mixed solution, they are prone to phase separation and
formation of droplets within their adhesive layers.

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Adhesive Systems

Etch & Rinse Self-Etch

3-step 2-step 2-step 1-step

Etching: It is the process of selective demineralizing the substrate (removal

of minerals from enamel/dentin) and creating the spaces that are responsible
for micromechanical bonding between tooth and restorative resin.

Primer / Adhesive promoting agents: They are hydrophilic monomers that

are capable of increasing surface wettability.

Bonding Agents: They are hydrophobic monomers that penetrate within

the demineralized surface and polymerize forming the micromechanical
retention.

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Etch-and-Rinse Adhesives (Total-Etch)

(TE)

 Concept:

This strategy is based on an exchange process, in which minerals are

removed from the dental hard tissues (enamel/dentin) forming porosities,
then resin monomers are infiltrated, polymerized and micromechanically
interlocked in these porosities.

 Classification according to steps of application:

3-step application

-It is the most conventional form that involves three steps:

 Application of the acid etch.
 Followed by the primer (adhesion promoting agent).
 Then the bonding agent (adhesive resin).

Etch Primer Bonding Agent

-It is the most effective approach to achieve efficient and stable bonding to
enamel.

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-Although the 3-step etch-and-rinse adhesives are considered as the „gold

standard‟ but, they are time consuming, and technique sensitive.

-
2-step application

-Simplified 2-step system (one-bottle system) involves:

 Separate etching step.
 The priming step and bonding agent step are become into one single
solution.

Etch Primer & Bond Agent

-It is more simple and user friendly technique.

-By blending primer and bonding agent components in a single solution,
simplified 2-step adhesives become hydrophilic in nature, more prone to
water sorption and more susceptible to hydrolytic degradation.

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1.Etching Step:

-Type of etchant: Phosphoric acid

-Concentration: 35% - 37%

-Form: Liquid or gel

(Etchant in gel form allows better control during application compared

to liquid form).

-Application:

 By means of brush or syringe

 20 seconds on enamel
 15 seconds on dentin

-Followed by: Rinsing procedure

 For complete removal of the etchant and its byproducts, smear layer
and smear plugs.

(Insufficient washing leaves debris that interferes with the flow of resin
into the pores).

-Isolation: Of the working field is essential by rubber dam

(Water, blood, and oil contamination will affect bonding so working with
a rubber dam in place is highly recommended to avoid contaminating
etched surfaces. If any sort of contamination occurs, repeat the
procedure). ENAMEL
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Composition:
 It is a highly mineralized homogenous tissue, which is formed of 95%
inorganic hydroxyapatite crystals, 4% water and 1% organic
substance.
 The hydroxyapatite crystals arranged together forming enamel prisms
which surrounded by prism sheath. There is interprismatic substance
between the prisms which is less in mineralization.

Composition of enamel by weight

Etching time: 20 seconds

Effect of etching:
 Cleaning enamel surface from contaminants
 Removing the outer fluoridated enamel layer
 Demineralization (removal of minerals creating microporosities)
 Transformation of the smooth enamel surface into an irregular and
rough surface
 Increasing the enamel surface free energy (about 72 dynes/cm) thus
increasing its wettability

The endpoint of etching: Enamel appears clinically frosty white

after rinsing and dryness.
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Factors Affecting Etching:

• Type of acid used in either gel or liquid form

• Concentration of acid
• Time of etching
• Whether enamel is fluoridated or demineralized
"Teeth with mild fluorosis may need up to 120 seconds. Severely mottled
teeth may require longer than 120 seconds".
• Whether enamel is freshly cut or unprepared
" Freshly cut enamel etches faster than unprepared enamel".
• Type of dentition, i.e. primary or permanent
"The average time to etch primary teeth is usually longer than for
permanent teeth".

Etching patterns:

Type I etching pattern: Involves the dissolution of prism cores without

dissolution of prism peripheries.

Type II etching pattern: (It is the opposite of type I) The peripheral enamel
(interprismatic enamel) is dissolved, but the cores are left intact.

Type III etching pattern: Etching is less distinct than the other two
patterns. It includes areas that resemble the other patterns and areas whose
topography is not related to enamel prism morphology.

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Difference in appearance of etched and unetched enamel rods

Unetched enamel Etched enamel

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DENTIN

Bonding to dentin has been referred to be a less reliable and predictable

technique when compared to enamel bonding. This is because of
morphological, histological and compositional differences between the two
substrates.

Challenges in Dentin Bonding:

 Dentin composed of a network of tubules filled with fluid that connect

the pulp with the dentino-enamel junction (DEJ).
 A hypermineralized dentin called peritubular dentin lines the tubules.
 A less mineralized dentin called intertubular dentin (between the
tubules) contains organic material primarily type I collagen fibrils.
 Hydroxyapatite crystals are randomly arranged in the organic matrix.

Composition of dentin by weight

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 Dentin is an intrinsically hydrated tissue, penetrated by tubules filled

with fluid.
 Movement of this fluid from the pulp to the DEJ is a result of a slight
but constant pulpal pressure that has a magnitude of 25-30 mm Hg.
 This fluid makes the exposed dentin surface moist and hydrophilic.

 Dentin is a dynamic structure characterized by its changing

microstructure due to its physiologic and pathologic alterations
(sclerotic dentin, caries affected dentin) where demineralization is
more difficult.
 Adhesion can be affected by the varying anatomical location of
dentin after tooth preparation (superficial, intermediate and deep
dentin).

 Definition: Thin porous layer which is composed of hydroxyapatite

crystals and altered denatured collagen. It is formed when a tooth
surface is prepared using hand or rotary instruments, the cutting debris
are adhered on enamel/dentin surface due to the friction and heat
forming a smear layer.
 Debris that fill and occlude the orifices of dentinal tubules are called
smear plug.
 The morphology and the thickness of the smear layer depend on the
type of the instrument and on the site of the dentin.

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 Advantages of the Smear Layer: It acts as a barrier

-It decreases dentin permeability by nearly 90%.

-Resists fluid movement.

Smear layer and smear plugs

Magnified presentation of smear layer and smear plugs

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Smear layer and smear plugs

Resin composites shrink when they polymerize, creating stresses Comment [U1]:

(polymerization stresses) within the composite mass. Unrelieved

stresses in the composite lead to internal bond disruption and marginal
gaps around the restorations that increase microleakage.
 Depending on the configuration of the preparation (C-factor: which is
defined as the relation between the number of bonded and unbonded
surfaces), polymerization stresses within the resin composite are
relieved by flow from the unbonded surface.
 When a restoration is exposed to wide temperature variations in the
oral environment, the restoration undergoes volumetric changes. This
occurs because the linear coefficient of thermal expansion of the resin
composite is about four times greater than that of the tooth structure
resulting in microleakage.

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Microleakage: It is defined as “ the passage of ions, molecules, fluids or bacteria

and their toxins between restoration margins and tooth preparation walls.
Microleakage has been reported as the cause of postoperative hypersensitivity of
restored teeth, discoloration at the margins of cavities and restorations, recurrent
caries, and pulp inflammation.

Etching time of dentin: 15 seconds

Effect of etching on dentin:

 Removing the smear layer and smear plug
 Opening of dentinal tubules resulting in dentinal fluid movement so,
increasing the wetness and postoperative sensitivity
 Demineralization of dentin surface (both intertubular and peritubular
dentin)
 Exposure of collagen fibers and decreasing dentin surface energy
(44.8dynes/cm) due to the high protein content. Wetting of such a low
energy surface is difficult.

Unetched dentin Etched dentin

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SEM of etched dentin showing exposed collagen fibers

Disadvantages of etching on dentin:

Aggressive etching causes demineralization of dentin to a depth that might

inaccessible to complete resin impregnation and produces Nanoleakage.

Nanoleakage: The nano-sized leakage is present in gap free margins, where the
dentin bonding agent failed to infiltrate the full depth of demineralized dentin,
leaving the collagen fibrils un-enveloped and un-protected, also creating nano-
spaces that too small for bacterial invasion but allow the passage of water.

-The term “water trees” is associated with nano-porosities in the polymerized

adhesive layer. These water trees might be one of the factors responsible for
degradation of the bonding interface with time.

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Microleakage and Nanoleakage

 Rinsing:
 Copious amount of water for 10-20 second is used after etching of
both enamel and dentin so as to remove the etchants byproducts.
 If too little rinsing occurs: residual acid may over-etch the dentin or
the byproducts may block the narrow channels around the collagen
fibers and prevent resin infiltration.

 Drying:
 Air drying of enamel results in frosty white appearance.
 Air drying of dentin leads to decrease in volume of collagen by 65%
(collagen collapse), loss of interfibrillar spaces and compromise resin
infiltration.
 Only blotting with minisponge or cotton pellet is enough for dentin
drying.

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2.Priming Step:

-Primers are called adhesive promoting agents.

-Function: Increasing surface wettability.

-Composition:

 Hydrophilic monomers such as 2-Hydroxy ethyl methacrylate

(HEMA) which is responsible for improving the wettability and
promoting the re-expansion of the collagen network.
 dissolved in organic solvents like acetone, ethanol or water.
The solvents are able to displace water from the dentin surface,
thus preparing the collagen network for the subsequent
adhesive resin infiltration.

-Application:

 It should be applied in multiple layers using a microbrush.

 By active rubbing motion for 10 seconds.
 Followed by gentle air drying after each layer to allow solvent
evaporation.
 Finally, the primed surface should appear glossy.

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ENAMEL

Effect of priming:

 Acid etched enamel doesn‟t need a separate primer application to

achieve effective bonding.
 On the other hand, primers can be applied on acid etched enamel
without harming the enamel bonding process.

DENTIN

Primer (adhesion promoting agent) is used to overcome the challenges of

dentin surface (hydrophilicity, low surface energy, and the sensitivity of
collagen fibers).

Effect of priming:

Dentin is changed from hydrophilic to hydrophobic state, promoting the

infiltration of the bonding agent monomers:

 Solvent (acetone and ethanol) can displace water from dentin surface
and the moist collagen network promoting and facilitating the
infiltration of bonding agent monomers through the nano-spaces of
the exposed collagen network.
 The evaporation of the solvent will leave the collagen fibers coated
and stiffened by the bonding agent resin monomers
(HEMA&TEGDMA).

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 Acetone based primers:

-Acetone has a very high vapor pressure.

-Acetone based primers are excellent on wet dentin which is called "Wet

bonding technique" where the primer should be applied to displace

all remaining surface moisture through evaporation of the solvent.

-Acetone based primers do not work on dried dentin; they are unable to
rewet dried dentin surface nor to re-expand and infiltrate a collapsed
collagen network.

-Disadvantages: acetone can evaporate from the package, changing the

concentration and also the efficacy of the bonding systems. To reduce this
problem special delivery systems (single dose) have been developed.

 Water based primers:

-Water based primers must be used on dry dentin which is called "Dry

bonding technique" and the surface is further air dried to evaporate as

much water as possible.

-Water as a solvent has excellent rewetting capacity and is able to infiltrate

and re-expand the collapsed collagen network.

 Ethanol (Alcohol) based primers:

-The properties of the alcohol as a solvent are located somewhere between

acetone and water. It has some capacity to work on dry dentin by

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increasing time of application, and on moist dentin by multiple layers

application.

Types of solvents in the primer

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3.Bonding (resin infiltration) Step:

-Composition:

 Solvent-free adhesive resin

 Hydrophobic monomers such as Bis-GMA or UDMA
 Some hydrophilic monomers such as TEGDMA to regulate
viscosity and HEMA as a wetting agent.

-Application:

 Spreading of the adhesive resin should be done by a

microbrush thinning rather than by air thinning.
 Applied for 20 seconds.
 Followed by gentle air to remove excess solvent and allow
resin infiltration within pores.
 Finally, light-cured.

-It is recommended that the adhesive resin be light cured before the
application of the resin composite. Because oxygen inhibits resin
polymerization, an oxygen inhibited layer of about 15 um will always
be formed on the top of the adhesive resin, even after light curing.
This oxygen inhibited layer offers sufficient double bonds for
copolymerization with the restorative resin.

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ENAMEL

Infiltration and polymerization of hydrophobic bonding agent monomers

into the pores created from enamel etching.

Forms of resin infiltration:

 Macro-tags fill the spaces surrounding the enamel prisms.

 Micro-tags result from resin infiltration within the tiny pores at the
cores of the etched enamel prisms.

Formation of microtags and macrotags when bonding agent is applied to etched

enamel surface

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DENTIN

Forms of resin infiltration:

 Infiltration and polymerization of hydrophobic bonding agent

monomers into the interfibrilar spaces of the collagen network
forming the hybrid layer.
 Infiltration and polymerization of hydrophobic bonding agent
monomers within the dentinal tubules forming resin tags.

Hybrid layer / Resin Reinforced Layer / Interdiffusion Zone:

It is a phenomenon of formation of resin interlocking in the demineralized

dentin surface (i.e demineralization of dentin, infiltration of adhesive resin
monomers and subsequent polymerization forming micromechanical
interlocking within intertubular dentin and surrounding collagen fibrils). This
layer is responsible for micromechanical bonding between tooth and resin.

Diagrammatic representation of hybrid layer and resin tags

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Hybrid layer

Hybrid layer

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 Technique Sensitivity (problems) of Etch-

and-Rinse adhesives:

1. "Postoperative hypersensitivity":
-Etching of dentin results in complete removal of smear layer and smear
plugs, opening of dentinal tubules and movement of dentinal fluid which
restrict the inward diffusion of adhesive.

2. "Sensitivity of dentin to over wetting or over dryness":

-It is related to the etching step itself and to the role of water in the bonding
protocol.

-The demineralized collagen network must be kept loosely arranged during

adhesive procedures in order to allow proper resin monomer infiltration.

-Water acts as a plasticizer for collagen, keeping it in an expanded soft state.

-Certain amount of water (moist dentin) is needed to prevent the collagen

network from collapsing and preserve the interfibrillar spaces. So only
blotting with minisponge or cotton pellet is enough.

3. " Risk of dentin overetching, leading to incomplete resin infiltration

within the demineralized microporous collagen network resulting in
nanoleakage and hydrolytic degradation".

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Incomplete resin infiltration

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Self-Etch Approach (Etch-and-Dry)

(SE)

 Concept:

-Self-etch adhesives were introduced to overcome the problems of the etch-

and-rinse adhesives.

-Self-etch adhesives do not require a separate etching step so:

- Elimination of acid etching:

 No risk for dentin over etching and exposure of collagen fibers
that will not be infiltrated with adhesive.
 No risk for removal of smear layer or smear plug.
 Elimination of opening the dentinal tubules so, no risk for
postoperative sensitivity and no risk for moisture contamination
of the adhesive.
- Elimination of rinsing and dryness:
 No risk for the possibility of over wet or over dryness and
collapse of collagen fibers.

-Self-etch adhesives contain acidic monomers such as carboxylic

or phosphate acid groups that simultaneously etch and prime the
dental substrate.

-Due to such acidic characteristics, self-etch adhesives are able to

dissolve the smear layer and demineralize the underlying enamel / dentin.

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No smear layer or smear plugs removal

 Advantages of SE over TE:

 More faster, simple and user-friendly
 less technique-sensitive
 Spontaneously demineralization and resin infiltration
 Reduce postoperative sensitivity

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 Classification according to the acidity or etching

aggressiveness of the acidic monomers:

Strong (pH > 1)

-This high acidity results in deep demineralization in both enamel and

dentin.

-The interfacial features produced by these adhesives on dental substrates

resemble those of etch-and-rinse systems, despite the fact that the products
originated from demineralization are not rinsed away.

Intermediate (pH ≥ 1.5)

-They produce hybrid layer with completely demineralized top and partially
mineralized base.

Mild (pH =2)

-In dentin, they cause superficial demineralization leaving residual

hydroxyapatite crystals attached to the collagen fibrils within the hybrid
layer, which acts as a receptor for chemical bonding with carboxylic acid
based monomers such as 4-MET or phosphate based monomers such as
Phenyle-P and 10 MDP.

-This two fold of bonding mechanism (i.e. micromechanical and chemical

adhesion) is believed to be advantageous in bonding effectiveness and
durability.

-In enamel, they result in poor demineralization and poor bonding.

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Ultra-mild (pH=2.7)

-Self-etch adhesives with low acidity and reduced the ability to dissolve the
smear layer and demineralize the underlying dentin surface.

-They can only very superficially expose collagen on dentin, creating a

characteristic nanometer-sized hybrid layer, which has been termed a nano-
interdiffusion zone.

-They have the ability to chemically bond to the mineral content of the
partially demineralized dentin.

Aggressiveness of Self-Etch adhesives

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 Classification according to the steps of

application:

2-Step Self-Etch

Form:

Two bottles one is self-etch primer (SEP) and the other is bonding agent.

Composition:

 SEP: It is hydrophilic acidic primer that includes a phosphonated

resin monomers and performs two functions simultaneously etching
and priming of enamel and dentin.

 Bonding agent: (hydrophobic monomers)

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Application:

-SEP is applied by a micro-brush for 20 seconds in rubbing motion every 10

seconds to remove the buffered byproducts.

-Then, gentle air for solvent removal.

-After that, application of bonding agent by a micro-brush for 10 seconds in

rubbing motion.

-Then, gentle air for solvent removal and finally light curing.

Advantages:

1. Separation between hydrophilic (SEP) and hydrophobic (bonding

agent) components so:
 Increase shelf life
 Decrease liability of phase separation

2. Two folds of adhesion (Micromechanical & chemical) so:

 Reliable and high bond strength to dentin

Disadvantages:

 Low bond strength to enamel. To overcome this problem, selective

etching is required.

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1-Step Self-Etch

It is called: "all-in-one" adhesives.

Form:

One bottle (responsible for simultaneously etching, priming and

bonding).

Application:

-Involves a single step, combining etching, priming and bonding into one
solution.

-It is applied by a micro-brush for 20 seconds in rubbing motion every 10

seconds to remove the buffered byproducts.

-Then, gentle air for solvent removal.

-Finally light curing.

Advantages:

 More simple and user friendly

 Reduction of the number of application steps
 Reduction of manipulation time
 Reduction of technique sensitivity

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Disadvantages:
1. Because these adhesives must be acidic enough to be able to
demineralize enamel and penetrate dentin smear layers, the
hydrophilicity of their resin monomers (phosphates and carboxylates)
also is high which makes them liable to water degradation.

2. Consists of both hydrophobic and hydrophilic components, together

so:
 More prone to phase separation and entrapment of water droplets
in the adhesive layer
 Reduced shelf-life because of hydrolysis of monomers

3. Poor bonding to enamel. To overcome this problem adding a

preceding etching step (Selective etching) is beneficial for bond
strength to enamel.

Technique Sensitivity of 1-Step Self-Etch adhesives:

 "Low bond strength": due to their high hydrophilicity, they act as a

semipermeable membrane permitting water movement across the
adhesive layer leading to Nanoleakage or "water trees" causing
accelerated degradation.

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Total etch vs self-etch systems. Total etch technique involves complete removal of smear layer by simultaneous
acid etching of enamel and dentin. After total etching, primer and adhesive resin are applied separately or
together. Acid removes the dentin smear layer, raises surface energy and modifies the dentin substrate so that it
can be infiltrated by subsequently placed primers and resins. In self etch system, self etching primer is applied
on prepared tooth surface. Then demineralized dentin and smear layer is infilterated by resin during etching
process. In this smear layer is not removed and there is formation of continuous layer incorporating smear plugs
into resin tags

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Universal Adhesives (UA)

Definition:

-Single-bottle, no-mix adhesive system.

-It is called "Multi-mode" or "Multi-purpose" adhesives.

Function:

-They can be used in total-etch, self-etch, or selective-etch mode.

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Composition:

1. Multifunctional cross-linking monomers (10-MDP):

 They must be capable of reacting with a number of different
substrates (enamel/dentin).
 They must be able to copolymerize with chemically compatible resin-
based restoratives and cements.
 They must have some hydrophilic character in order to properly
“wet” dentin that has a significant water content, yet at the same time
be as hydrophobic as possible once polymerized to discourage
hydrolysis and water sorption over time.

2. Water: is required for dissociation (ionization) of the acidic

functional monomers.

3. Ethanol or Acetone:

 Enhances resin wetting and infiltration of tooth tissues.

 Aids in water removal and evaporation during the air-drying step.

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10-MDP (methacryloyloxy-decyl-dihydrogen phosphate):

-It is a functional monomer

 hydrophobic methacrylate group on one end
(capable of chemical bonding to methacrylate-based restoratives and
cements)
 hydrophilic phosphate group on the other end
(capable of chemical bonding to tooth tissues)

-It is Hydrophobic
 It has long carbon chain backbone
 It discourages water sorption and hydrolytic breakdown of the
adhesive interface
 Increase shelf-life.

-It bonds chemically with Ca in hydroxyapatite (HAP)

Stable, non-soluble MDP-calcium salts are deposited in self-assembled
nano-layers

-It is acidic monomer

To etch and demineralize tooth tissues

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10-MDP

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Glass-Ionomer Adhesives

(GI)

 Glass-ionomers are still considered the only materials that self-adhere

to tooth tissue.

 A polyalkenoic acid pre-treatment cleans the tooth surface; it removes

the smear layer and exposes collagen fibrils up to about 0.5-1 µm
deep (conditioning).

Conditioning: It is the process of cleaning the surface and activating

the calcium ions, so as to make them more reactive.

 Glass-ionomer components inter-diffuse and establish a micro-

mechanical bond following the principle of hybridization.

 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 hydrolytic degradation. Consequently, a two-fold
bonding mechanism is established, similar to that mentioned above for
mild self-etch adhesives.

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FACTORS AFFECTING ADHESION TO TOOTH STRUCTURE

I) Factors related to the tooth structure (adherend)

1. Physiological Effects:
a) Surface energy:
 The relative surface energy of human teeth is between 30-40 dynes/cm.
 This could be altered by heritage, diet, oral hygiene practices and
specific etching protocols applied during demineralization procedure.
 Upon etching enamel, its surface energy increases while etching dentin
results in limited increase in its surface energy.
 For an adhesive to flow easily over a treated surface, this latter should
possess a surface energy higher than the critical surface tension intercept
of the adhesive.

b) Capillary attraction:
 This governs the adhesive mechanism greatly due to the tubular nature of
dentin.
 Its amount will be according to the size of the tubules, their number and
their distribution.
 The communication between the tubuli and the oral environment will
create the movement of the dentinal fluid inside the dentinal tubules.

c) Osmotic pressure:

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 This plays a major role since diffusion or convection mechanisms are

allowed to occur in the presence of different concentrations.

2. Physico-chemical characteristics of enamel:

 Enamel is composed of 95 – 98 % by weight hydroxyapatite crystals
(inorganic contents) and the reminder is water and organic material.
 Operatively prepared surface expose enamel rods in tangential, oblique
and longitudinal planes.
 Irrespective of its depth and location, it is homogenous in structure
except for the prismless enamel on the outer surface.
 It is covered by an organic pellicle with low surface energy of 30
dynes/cm, thus requires its removal to allow: →
1. Creation of a high surface energy after etching which may reach up to
72 dynes/cm.
2. Increase the bonding area.
3. Increase the surface roughness.
 This is accomplished using different etchants as mentioned previously.

3. Physico-chemical characteristics of dentin:

 Dentin is composed of 70 -wt % hydroxyapatite crystals, 18-wt %
organic material and 12-wt % water.
 Dentinal tissue is heterogeneous in nature as the inorganic and organic
constituents are unevenly distributed in inter and peritubular dentin.
 Numerous tubules radiate from the pulp throughout the entire thickness
of dentin making it highly permeable.
 The diameter of the tubules decreases from 2.5 μm at the pulpal side to
0.8 μm at the DEJ and the number of the tubules decreases from

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45.000/mm2 near the pulp to about 20.000/mm2 near the DEJ with an
average of 30.000/mm2 in the middle.
 Another important consideration is that 96% of superficial dentin is
composed of intertubular dentin while only 12% are present near the
pulp (deep dentin).
 On the other hand, peritubular dentin represents 66% near the pulp
associated with 22% of the surface (area near the pulp) occupied by
water.
 Dentinal fluid or intrapulpal fluid pressure is estimated to be 25 – 30 mm
Hg.
 The high protein content is responsible for the low surface energy of
dentin, which accounts for 44.8 dynes/cm.
 This is required to be changed as mentioned previously to render it
receptive for adhesive application and bonding.
 There are also other different causes which furtherly complicate bonding
to dentin: →
a) Dentin type.
b) Dentin permeability.
c) Fluoride contents of dentin.
d) Dehydration.
e) Hypermineralization.

a) Dentin type:
 The amount of minerals will greatly influence the bonding mechanism.
 This could be reflected by:
1. Primary dentin.
2. Secondary dentin.
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3. Tertiary dentin →, which is produced in the pulp chamber at the lesion

site in response to an insult and its degree of mineralization, will be
different from other types.
4. Sclerotic dentin which is the result of the obliteration of the tubules by
mineral casts and apposition of peritubular dentin. It represents a
difficult substrate to which an adhesive could be applied.
 Dentin type is thus governed by a number of factors related to the
dentinal tubules characteristics which are:→
1. Length.

2. Width.

3. Location.

4. Direction in relation to external surface.

5. Peritubular dentin.

6. Intertubular dentin.

7. Age of patient.

b) Dentin permeability:
 It depends on several factors:→
1. Diameter and length of the tubules.

2. Viscosity of dentinal fluid.

3. Molecular size of substances dissolved in it.

4. Pressure gradient.

5. Surface area available for diffusion.

6. Patency of tubules.

7. Rate of removal of substances by pulpal circulation.

 Regional differences result in different dentinal permeability.

 Smear layer removal increases permeability and water competes for all
adhesive sites.
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 Controversy is present concerning the bond strength of adhesive resins

observed in deep and superficial dentin when the smear layer is removed
as deep dentin is more permeable than superficial dentin.

c) Fluoride content of dentin:

 Fluoride lowers the adhesive potentials thus its presence in dentinal
substrate by a certain saturation could affect the bonding mechanism due
to lowered surface energy.

d) Water Content:
 The vitality of dentinal substrate and hydration will allow provision of
sufficient internal wetness required to accomplish bonding between
adhesive resins and dentin.

e) Hypermineralization:
 Hypermineralization will complicate the adhesive mechanism as it
implies more aggressive etching and surface alteration to provide a
generously porous structure into which resins could be impregnated.

4. Presence of smear layer:

 The smear layer is defined as any calcific debris produced by
instrumentation of dentin, enamel or cementum.
 The burnishing action of the cutting instrument generates considerable
amounts of frictional heat locally and shears forces so that the smear
layer becomes adequately attached to the underlying tissues and can not
be rinsed off.

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 The morphology, composition and thickness of the smear layer are

largely determined by the type of instrument used, the method of rinsing
and the site of dentin at which it's performed.
 Its presence jeopardizes bonding and hence it was recommended to
remove it in recent adhesive systems to ameliorate the bond strength.

5. Contaminants:
a) Blood and/or saliva:
 Blood and saliva can create an environment that is detrimental for
bonding, thus the uses of a rubber dam or other dry-field aids are
necessary for bonding.

b) Moisture from hand piece or air / water syringes:

 Water from air rotor hand piece or air-water syringes could result
from:→
1. Lack of drying devices on air-lines coming from the compressor.

2. Condensation of water in air lines.

3. Leakage of water at the dental cart unit.

 This moisture could alter bonding and complicate the mechanism.

c) Oil from hand piece or air / water syringes:

 Oil comes from air- compressors, which are not well maintained.
 Oil filters are mandatory to avoid such leakage to occur.
 They are placed after the air compressor and before the air syringe or
hand piece.
 Observation of oil could be done by blowing air from the hand piece or
syringe into the surface of a rubber glove.
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 This contamination influences the adhesion procedure and thus, should

be avoided.

II. Factors related to the material used (adherent)

 There are a series of physical properties that are important in the

adherents provided:→

1. Indestructibility:
 The adhesive material should be stable hydrolytically and chemically to
provide strong bonding potentials.

2. Thermal coefficient of expansion:

 It should approach as much as possible that of tooth structure in order not
to create marginal gaps.

3. Dimensional stability:
a) During setting:→ it's imperative as expansion or contraction yields
different results than those, which are required.
b) After setting:→ hygroscopic expansion occurs and may contribute for the
relaxation of contraction stress.
→ This occurs during the days and weeks following
resinous placement that is after the dentin bonding may
have already failed.

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4. Modulus of elasticity and transfer of stress at the interface:

 The more the elastic capacity of the adhesive material the more the
stresses will be reduced at the interface.
 This explains why a thick layer is used to act as a shock absorber at the
interface, and overcome the polymerization contraction stresses of the
resinous restoratives.
 The adhesive resin plays a biomechanical role in the distribution of
functional stress throughout the whole tooth.
 Bonded restorations may strengthen weakened teeth.

5. Viscosity at the time of insertion:

 The more the fluidity of the adhesive resin the better will be the diffusion
and hence the creation of the bonding mechanism.

6. Adhesiveness, wetting and polarity towards tooth structure:

 Intimate molecular contact between the two parts (adherend and
adherent) is a prerequisite to develop strong adhesive joints.
 The adhesive should possess a low contact angle to provide adequate
wetting.
 The collagen phase of dentin is expected to allow primer and adhesive
resin to infiltrate it, so if a conditioner is used to provide a specific
polarity to the dentin, the primer must match this polarity to achieve
penetration.
 The same is true for the adhesive when applied to the primed surface.

7. Initial polymerization site:

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 Initiation of polymerization at the resin / tooth interface directing the

shrinking material towards the cavity wall rather than away from it is
advantageous.
 Initial setting in photocured resins occurs towards the light source and
consequently shrinkage will be directed towards it.
 On the other hand, in the autocured resins initial setting occurs in the
bulk of the material, which means again away from the cavity walls. It
was anticipated by Fusayama that initial setting of autocuring resins
starts at the dentinal wall, because of the locally higher temperature of
body heat, pulling the shrinking resin towards, rather than away from the
cavity wall.
 The theory was known as directed shrinkage theory but was not
substantiated.
III. Factors related to the cavity preparation performed

 All steps of cavity preparation influence greatly the bonding equation:

1. Adhesive cavity designs should be adopted.

2. The resistance and retention required should be estimated and built in

the preparation.
3. All carious tissue should be removed as bonding to diseased tissue

disgraces the bond strength greatly.

4. The walls should be adequately finished to provide smoothness.

5. Adequate debridment and toilet of the cavity accomplishment is required

to prepare the dentinal and enamel surfaces for the subsequently applied
resins.

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IV. Technique of restoration and skill of the operator

1. Use of rubber dam:

 It is an essential and mandatory requirement to avoid moisture
contamination during the bonding procedure.

2. The use of liners and bases:

 The presence of liners and bases will affect greatly the provided surface
area for bonding hence it was debated that if the use of calcium
hydroxide liner and other bases were profitable.
 In the state of the art, no application of liners is advocated and a direct
application of the adhesive resin is recommended to allow total
sealability of the opened tubules.
 Very limited sites imply the use of calcium hydroxide liners in situations
in great proximity to the pulp (remaining dentin thickness less than 0.5
mm).
 The presence of such lining or basing material will not allow bonding to
occur freely and will create several phases and interfaces with a
maintained opened dentinal tubules structure not sealed by adhesive
resins.
 This also reduces the C-factor, which is the ratio of bonded to unbonded
free restoration essential in the bonding mechanism as its increase is
beneficial.

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3. Constituents of temporary restorations:

 It was thought that contacting enamel or dentin with eugenol-containing
temporary restorations affected the substrate surfaces and provided
different bonding characteristics to resin than did virgin tooth structure.
 Lately, researches revealed that using the recent adhesive systems
subsequent to eugenol or non-eugenol containing temporary restoratives
yielded results approximating those in case of bonding directly to tooth
structure without temporization.
 Fresh eugenol placed on dentin or enamel just before bonding could be a
negative factor.
 Further investigations are required to answer a lot of questions arising
from these observations.

4. C-factor:
 Which is the ratio of bonded to free unbonded restoration.
 The higher the ratio of bonded to free resin surface, the less flow may
compensate for contraction stress, which is importantly applied to
enamel and dentin.
 The skill of the operator is a prime requisite and should be ordered high-
leveled skill operator due to the multi-factorial technique sensitive
adhesive procedures.
 A conceivable number of steps that should be attempted sequentially are
to be faithfully followed to provide clinically successful results.

5. Post-restorative care:
 High level of good oral hygiene is required in order not to allow plaque
accumulation with subsequent bond degradation.
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 Adequate home care measures should be instructed in conjunction with

prophylactic visits for patients to maintain their restorations serviceable.
 Use of non-alcohol containing mouthwashes.

V. Factors related to the oral environment

 The different environmental factors which include the cyclic occlusal

loads, the chemical degradation potentials, the pH and thermal
fluctuations, the oral microbes, humidity and the chewing habits are
all highly contributing factors that deprive us of a long term durable
bond.
 The complexity of mechanisms should be faced by a resinous material
that could comply readily with their aggressiveness and resist their
deteriorat

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