Adhesion: Past, Present, and Future - Dental Asia - November/December 2019
Adhesion: Past, Present, and Future - Dental Asia - November/December 2019
Adhesion: Past, Present, and Future - Dental Asia - November/December 2019
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outline their past evolution and their current
onding agents were tentatively state.
introduced in the early 1970s.
Since then, the evolution of
adhesive techniques has
transformed the scope of dental
practice. Arguably, the high impact of bonded,
appearance-transforming dental restoratives
has propelled the dental profession into its
greatest prominence in history. In fact, most
direct and indirect restorations are adhered
to natural tooth structure rather than Fig 2: Less than 17 MPa adhesion: polymerisation
forces cause resin to contract towards composite
cemented or mechanically retained. For more
centre pulling restorative material away from cavity
than 30 years, highly competitive research walls. (Courtesy Dr. Ray Bertolotti.)
and aggressive product development have
improved adhesives, initiating, and then
fueling, patient demands for conservatively
Fig. 1: Bonding agents evolve to fewer components,
improved oral appearance. fewer steps, and better chairside predictability.
The widespread demand and universal use of Dentists were inundated by successive
dental adhesives has largely been a function “generations” of adhesive materials in
of two factors: composite restorations are relatively rapid succession. While there is no
more aesthetic than their precursors, and the scientific basis for the term “generation” in
adhesive margin is more clinically predictable dental adhesives, and the classification is to Fig. 3.: More than 17 MPa adhesion: polymerisation
than a non-bonded interface. The rapid and some extent arbitrary, it has served a very contraction causes shrinkage of composite towards
cavity walls. (Courtesy of Dr. Ray Bertolotti.)
intensive development of better and easier useful purpose in the organisation of hundreds
dental adhesives has focused on simplifying of commercially available products into a Bond strength parameters
the clinical procedure; decades ago, resin small number of more comprehensible and Bonding interface strength is a critical
practitioners were faced with a veritable readily manageable categories. Generational consideration in selecting an adhesive. Some
chemistry set of materials to mix and match, designations assist in classifying the specific of the basic parameters are conclusively
in very specific sequences, in order to develop adhesive chemistries involved. They are also established and well accepted. Munksgaard
a suitable micromechanical bond between very useful in predicting the strengths of in 1985 and Retief in 1994 found that
the tooth and the restoration. Adhesion, the dentinal bond and the ease of clinical 17 MPa was the minimum required for
as defined by most current materials, is use. Generational classification benefits successful adhesion to tooth structure.
micromechanical attachment, not chemical both dentist and patient by simplifying the This figure represents the composite resin
bonding, to enamel and dentin. clinician’s chairside tasks and workflow. polymerisation contraction force. If adhesion
to either enamel or dentin is less than strength to the semi-organic dentin that is, that bonded not only to tooth structure, but
17 MPa, the polymerisation force of the by far, the greater concern (Fig. 4). (weakly) to dental metals and ceramics as
composite resin is greater than the force well. However, the issue of longevity was still
adhering the material to the enamel, dentin, “Bonding”, such as it was, was achieved major problem: intraoral adhesive retention
or both. As the polymerisation force causes through chelation to the calcium component with 3rd generation bonding agents decreased
the resin to contract toward the center of the of the dentin. Some tubular penetration significantly after three years. Interestingly,
composite, it pulls the restorative material did occur, but not enough to contribute to while patients reported significant levels of
away from the walls of the cavity, creating retention. Debonding at the dentinal interface posterior post-operative sensitivity, their
a small gap, (Fig. 2) which then allows was quite common within several months of increasing demands for tooth-coloured
micro-infiltration of bacteria and plaque placement.1 1st generation bonding agents restorations pushed many dentists to begin
that eventually cause marginal breakdown. were recommended for small, retentive providing routine posterior composite
If the bonding agent’s adhesive strength Class III and Class V cavities.2 When these fillings.7,8,9
to dentin and enamel exceed the 17 MPa of bonding agents were used for posterior
polymerisation contraction, the shrinkage occlusal restorations, post-operative 4th Generation: predictable adhesion -
of the composite is toward the walls of the sensitivity was common. 3
the tipping point
cavity, (Fig. 3) and no marginal gaps develop, The early 1990s transformed dentistry,
making marginal infiltration of bacteria and The 2nd generation adhesives were introduced and predictable adhesion was largely
oral fluids far less likely, preventing redecay in the early 1980s. The concept at that time responsible. 4th generation agents had a
and eventual breakdown. was to use the smear layer, which adhered to bond strength to dentin (17-25 MPa) that
the underlying dentin at a negligible 2-3 MPa, overcame the polymerisation shrinkage
1st to 3rd Generations as a bonding substrate.4 The weak 2-8 MPa that had bedeviled adhesive dentistry
In the late 1970s, dentistry was just beginning dentinal bonding strength of 2 generation
nd
previously. For the first time, dentists had
to look at adhesive. In fact, there were serious adhesives still required mechanical retention. a predictable adhesive that could compete
debates as to whether adhesives actually Restorations with dentinal margins had in longevity to traditional techniques, and
improved longevity. The 1 st generation extensive microleakage, and posterior most jumped at the opportunity. Aesthetic
adhesives were rather unsuccessful. Their occlusal restorations exhibited significant and cosmetic dentistry can date their growth
bond strength to enamel was high (generally, post-operative sensitivity. One-year retention and continuing popularity to the adhesives
all adhesive generations bond well to the rates were as low as 70%, making the long- from the 4th to 7th generations (Fig. 5). Post-
microcrystalline structure of enamel); term stability of 2nd generation adhesives operative sensitivity for posterior teeth was
unfortunately, their dentinal adhesion was problematic;. 5,6
still an issue (at 30%+), but it was finally
virtually non-existent, typically less than manageable enough that it encouraged many
2 MPa. In dental adhesion, it is the bond Revolutionary two-component primary/ dentists to switch from amalgam to direct
adhesive systems were introduced in the posterior composite fillings. 4th generation
late 1980s. An innovative application adhesion is characterised by hybridisation
process and significant clinical adhesive at the dentin-composite interface.
improvement (dentin bonding strength of
8-15 MPa), warranted their classification as
3rd generation adhesives. These advances
diminished the need for cavity retention
form. It is noteworthy that erosion, abrasion,
and abfraction lesions were treatable with
minimal tooth preparation, heralding the
dawn of ultraconservative dentistry.
Fusayama and Nakabayashi in Japan in the 7th Generation: one component, one step
1980s, introduced to North America and An innovative, simplified adhesive system,
popularised by Gwinnett and Bertolotti are the 7th generation, was introduced in 2002.
the innovative hallmarks of the 4th generation Just as the 5th generation bonding agents
adhesives.17,18 made the leap from earlier multi-component
systems to a rational and easy-to-use
Fig. 7: Components of 5th generation adhesives.
The products in this generation have three single bottle (plus etch), 7 th generation
or more components (Fig. 6). One is the 6 Generation: no separate etching step
th
simplified 6th generation materials into a
etch (typically 37% orthophosphoric acid). There were extensive efforts to eliminate single component, single bottle system
The other two or more ingredients must be the separate etching step, culminating in (Fig. 9). No-mix 7th generation adhesives
mixed and applied, in very precise ratios the introduction of 6th generation adhesives self-etch and self-prime and self-bond to
and sequences; this is easy at the bench, in 2000. These bonding agents have a streamline procedures with no technique
but rather more complicated chairside. The dentin-conditioning (surface etching) liquid sensitivity and no post-operative sensitivity;
number of precise ratios and mixing steps incorporated into one of their components. they represent the most advanced formulation
tend to confuse the process, increasing the The acid treatment of the dentin is self- of dentinal adhesives available.
likelihood of technique sensitivity, thereby limiting, and the etch by-products are
reducing actual bonding strength. permanently incorporated into the dental- Eliminating mixing uncertainty eliminates
restorative interface. No rinsing is required. technique sensitivity. No etching step is
There is virtually no post-operative sensitivity. required. The priming and bonding of tooth
Some of the early 6th generation adhesives surfaces are accomplished simultaneously,
bonded well to dentin, but the unetched, significantly simplifying the adhesive
unprepared enamel bond interface was procedure. 7 th generation adhesives are
prone to early failure. These issues have been predictable one-step, one-bottle systems
addressed with the current 6th generation for the complete etching and bonding of all
Fig. 6: Components of 4th generation adhesives. products that are on the market. enamel and dentin surfaces with no rinsing.
5 Generation: more predictable,
th Excellent dentin bonding (18-35 MPa) and
two components similar micromechanical adhesion strength
Within five years, in the mid 1990s, the highly to both prepared and unprepared enamel
popular 5th generation dental adhesives were allow effective use for direct and indirect
introduced. Their major advance was that composite.
they had only two components: the etch and
a pre-mixed adhesive (Fig. 7). Etching is still “Moist” bonding is not required. 7th generation
required but there is no mixing, and thus, adhesives are insensitive to the amount
less possibility for error. The bond strength Fig. 8: Components of 6th generation adhesives. of residual moisture (not contaminating
to dentin is 20-25+ MPa; not as high as the saliva) or dryness on the surface of the
4th generation, but not as variable either. These adhesives are characterised by the preparation. The acid-base reaction of the
These adhesives are indicated for all dental absence of a separate etch component 7th generation creates its own moisture at
procedures (except self-curing resin cements (Fig. 8). There are typically two (sometimes the restorative interface. The bond strength
and composites). They adhere well to enamel, more) components that must be mixed prior to both dentin and enamel are essentially the
dentin, ceramics and metal, and post- to use or applied in a specific sequence; either same, regardless of the moisture or lack of
operative sensitivity is significantly reduced. protocol can cause some confusion. moisture on the prepared surfaces.
8th Generation: What does it look like? 10. Holtan JR, Nyatrom GP, Renasch SE, Phelps
RA, Douglas WH. Microleakage of five dentinal
There has been no quantum leap advancement adhesives. Op Dent 1993;19:189-193.
in adhesion technology in more than 17 11. Fortin D, PerdigaoJ, Swift EJ. Microleakage
of three new dentin adhesives. An J Dent
years! The simple reason is that adhesives
1994;7:217-219.
are so predictable and effective that there 12. Linden JJ, Swift EJ. Microleakage of two dentin
has been little incentive to support research adhesives. Am J Dent 1994;7:31-34.
13. Barkmeier WW, Erickson RL. Shear bond
and development. The existing adhesives strength of composite to enamel and dentin
are well-known, universally accepted, and using Scotchbond multi-purpose. Am J Dent
1994;7:175-179.
represent a very sizable market worldwide. 14. Bouvier D, Duprez JP, Nguyen D. Lissac M. An in
vitro study of two adhesive systems: third and
fourth generations. Dent Mater 1993;9:355369.
Some manufacturers have claimed to 15. Gwinnett AJ. Shear bond strength, microleakage
introduce 8 th generation adhesives, but and gap formation with fourth generation dentin
bonding agents. Am J Dent 1994;7:312-314.
on closer inspection, they turn out to be
16. Swift EJ, Triolo PT. Bond strengths of Scotchbond
earlier generation adhesives reconfigured multi-purpose to moist dentin and enamel. Am J
for marketing purposes. By consulting the Dent 1992;5:318-320.
17. Gwinnett AJ. Moist versus dry dentin; its effect on
Adhesive Classification Table (Fig. 10), it is shear bond strength. Am J Dent 1992;5:127129.
easy to assign every existing adhesive to one 18. Pashley DH. The effects of acid etching
Fig. 11: What is the 8th generation adhesive? on the pulpodentin complex. Oper Dent
of the four generations from 4th to 7th. 1992;17:229242.
These chemistries are already available to the
Given the trends described above, it can dental profession: self-etching, self-priming,
be readily seen that each “generation” has and self-bonding one-step resin cements
About the author
simplified the adhesion process significantly: and post-and-core composites. The next
fewer components, fewer steps, less chairside major evolution of dental adhesives, the 8th Dr. George Freedman
is a founder and past
time, easier use, and better predictability. generation, will see the elimination of this
president of the
treatment process as a separate step. The American Academy of
only task that remains is to incorporate Cosmetic Dentistry,
a co-founder of the
these 8th generation adhesives into direct
Canadian Academy
restorative materials. It is only a matter of for Esthetic Dentistry
time. DA and the International
Academy for Dental
Facial Esthetics, and
References: a Diplomate and Chair of the American
1. Harris RK, Phillips RW, Swartz ML. An evaluation Board of Aesthetic Dentistry. He is Adjunct
of two resin systems for restoration of abraded Professor of Dental Medicine, Western
Fig. 10: Adhesive Classification Table – determine areas. J Prosthet Dent 1974;31:537-546 University, Pomona, California and Professor
the classification of any adhesive. 2. Albers HF. Dentin-resin bonding. Adept Report and Program Director, BPP University, London,
1990;1:33-34.
How can a single-component, single-step, UK, MClinDent programme in Restorative and
3. Munksgaard EC, Asmussen E. Dentin-polymer
Cosmetic Dentistry. His most recent textbook
total-comfort process be improved upon? bond promoted by Gluma and various resins. J
Dent Res 1985;64:1409-1411.
is “Contemporary Esthetic Dentistry (Elsevier).
The answer is as simple as it is difficult to 4. Causlon BE, Improved bonding of composite He is the author or co-author of 14 textbooks,
develop: zero-step adhesives (Fig. 11). resin to dentin. Br Dent J 1984;156:93. more than 800 dental articles, and numerous
5. Joynt RB, Davis, EL Weiczkowski G, Yu XY. Dentin webinars and a Team Member of REALITY,
The only possible evolution is to eliminate bonding agents and the smear layer. Oper Dent and the International Editor-in-Chief of Dental
the remaining component and single step 1991;16:186-191. Tribune. Dr Freedman received the Irwin Smigel
6. Lambrechts P, Braem M, Vanherle G. Evaluation Prize in Aesthetic Dentistry (NYU College
entirely. The 8th generation adhesive will have
of clinical performance for posterior composite of Dentistry). He lectures internationally on
no bottle and no components, at least as a resins and dentin adhesives. Oper Dent aesthetic restorative dentistry, adhesion,
distinct, separate, clinical step. The adhesive 1987;12:53-78. composites, implants, oral health maintenance,
7. Christensen GJ. Bonding ceramic or metal porcelain veneers, 3D printing, and dental
will be incorporated into the restorative crowns with resin cement. Clin Res Associatees technologies. A graduate of McGill University in
material. As the practitioner inserts the Newsletter 1992;16:1-2. Montreal, Dr. Freedman is a Regent and Fellow
8. O’Keefe K, Powers JM. Light-cured resin cements
restorative composite resin, the contained of the International Academy for Dental Facial
for cementation of esthetic restorations. J Esthet
Esthetics and maintains a private practice
adhesive will etch, prime, and bond both the Dent 1990;2:129-131.
limited to Esthetic Dentistry in Toronto,
9. Barkmeier WW, Latta MA. Bond strength of Dicor
dentin and enamel surfaces, requiring only using adhesive systems and resin cement. J Dent Canada.
polymerisation to finalise the restoration. Res 1991;70:525. Abstract.