• > » CE COURSE The Current State of Adhesive Dentistry: A Guide for Ciinicai Practice FRANCIS K. MANÎÊ, DM0, PHD; FUSUN OZER, DDS, PHD; RICARDO WALTER, DDS, MSC; ALAN M. ATLAS, DMD; NAJEED SALEH, DMD; DIDIER DiETSCHI, DMD, PHD; AND MARKUS ß. BUTZ, DMD, PHD Abstract Adhesive cJerntistry is key to minimally invasive, esthetic, and tooth- preserving dental restorations. These are typically realized by bonding variocjs restorative materials, such as composite resins, ceramics, or even metal alloys, to tooth structures or other materials with composite resin luting agents. For optimal bond strengths and long-lasting ciinicai success, however, these materiai and tooth substrates require their respective pretreatment steps, based on their natures and compositions. Today, dental adhesion is used in almost all dental specialties. This article summarizes key aspects and guidelines for clinical success with adhesive dentistry and summarizes information presented at the 5"" International Congress on Adhesive Dentistry. Learning Objectives After reading this article, the readers should be able to: » Discuss the use of composite resins for direct restorations. » Explain the nature of the adhesive resin bond to dental materials. » Describe the most common clinical problems with bonded indirect posterior restorations. Introduced to restorative dentistry in the mid igsos,' adhesion to tooth structures and particularly dentin has evoived significaritly in recent decades. Yet, the complexity of the dentin substrate continues to challenge researchers in the development of the ideal dental adhesive systenn. One significant milestone was the introduction of the total-etch technique in the late 1970s.^ Despite initial concerns about potential damage of puipal tissues by phosphoric acid, this technique is still used today. Current adhesive systems are divided into two main categories: etch-and-rinse (total-etch) and self-etch (etch- and-dry). Etch-and-rinse systems comprise two or three steps and typically involve the use of phosphoric acid pretreatment of the dentin with subsequent infiltration of the demineralized coiiagen to form a hybrid layer.^ Self- etch systems are one- or two-step solutions of different pH levels that interact with the tooth structures via functional monomers.'' Nakabayashi et aP introduced the hybrid layer concept in 1982: its formation and quality is key in the establishment of proper adhesion. Both concepts have advantages and disadvantages in different ciinicai situations. Phosphoric acid with etch- and-rinse adhesives not only removes the layer of debris from tooth preparation (smear layer) but also opens the dentinal tubules and exposes the underlying collagen mesh. Exposed dentinal tubules are sealed by the adhesive resin. However, neither acetone nor ethanoi—vehicles in etch-and-rinse adhesive systems—provide complete infil- tration of the demineralized dentin. The exposed collagen fibrils may consequently suffer hydrolytic degradation by matrix metalloproteinase (MMPs), which has been the recent focus of extensive research.'' Application of chlorhexidine, benzalkonium chloride, or the antibacterial monomer methacryloyloxydodecylpyridinium bromide to prevent such degradation has not proven effective in the long term. [Meanwhile, self-etch adhesives seem not to be affected by MMPs to the same extent, which may be due to the fact that collagen is exposed to a lesser depth and is better infiltrated by the adhesive system. Self-etch adhe- sives, particularly two-step systems, have shown excellent bonding performance to dentin through implementation of functional monomers such as 10-methacryloyloxydecyl dihydrogen phosphate (MDP), which provides some chemical adhesion to hydroxyapatite. Without the use of phosphoric acid, however, the bond—especially to uncut enamel—may be compromised.' Therefore, self- etch adhesives are recommended particularly for cavities predominantly in dentin, while etch-and-rinse systems are preferred for indirect restorations and cavities that are mostly in enamel.^ The performance of bonding agents in the laboratory and even in controlled clinical trials may not necessarily translate to the clinical situation in the dental office. One influencing factor is operator experience and familiarity with a specific adhesive system.**'^ Recent multimode (uni- versal) adhesive systems may help minimize this problem as they can be used in both etch-and-rinse and self-etch modes. This feature can simplify the process and familiar- ize clinicians with new bonding systems. Another key factor for the successful implementation of November/December 2013 • Volume 34 Special Issue 9
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The Current State of Adhesive Dentistry:A Guide for Ciinicai PracticeFRANCIS K. MANÎÊ, DM0, PHD; FUSUN OZER, DDS, PHD; RICARDO WALTER, DDS, MSC; ALAN M. ATLAS, DMD; NAJEED SALEH, DMD;DIDIER DiETSCHI, DMD, PHD; AND MARKUS ß. BUTZ, DMD, PHD
AbstractAdhesive cJerntistry is key to minimally invasive, esthetic, and tooth-preserving dental restorations. These are typically realized by bondingvariocjs restorative materials, such as composite resins, ceramics, oreven metal alloys, to tooth structures or other materials with compositeresin luting agents. For optimal bond strengths and long-lasting ciinicaisuccess, however, these materiai and tooth substrates require theirrespective pretreatment steps, based on their natures and compositions.Today, dental adhesion is used in almost all dental specialties. This articlesummarizes key aspects and guidelines for clinical success with adhesivedentistry and summarizes information presented at the 5"" InternationalCongress on Adhesive Dentistry.
Learning ObjectivesAfter reading this article, the readersshould be able to:
» Discuss the use of composite resins for directrestorations.
» Explain the nature of the adhesive resin bondto dental materials.
» Describe the most common clinical problemswith bonded indirect posterior restorations.
Introduced to restorative dentistry in the mid igsos,' adhesionto tooth structures and particularly dentin has evoivedsignificaritly in recent decades. Yet, the complexity of thedentin substrate continues to challenge researchers in thedevelopment of the ideal dental adhesive systenn. Onesignificant milestone was the introduction of the total-etchtechnique in the late 1970s.̂ Despite initial concerns aboutpotential damage of puipal tissues by phosphoric acid, thistechnique is still used today.
Current adhesive systems are divided into two maincategories: etch-and-rinse (total-etch) and self-etch (etch-and-dry). Etch-and-rinse systems comprise two or threesteps and typically involve the use of phosphoric acidpretreatment of the dentin with subsequent infiltration ofthe demineralized coiiagen to form a hybrid layer.̂ Self-etch systems are one- or two-step solutions of different pHlevels that interact with the tooth structures via functionalmonomers.'' Nakabayashi et aP introduced the hybrid layerconcept in 1982: its formation and quality is key in theestablishment of proper adhesion.
Both concepts have advantages and disadvantages indifferent ciinicai situations. Phosphoric acid with etch-and-rinse adhesives not only removes the layer of debrisfrom tooth preparation (smear layer) but also opens thedentinal tubules and exposes the underlying collagenmesh. Exposed dentinal tubules are sealed by the adhesiveresin. However, neither acetone nor ethanoi—vehicles inetch-and-rinse adhesive systems—provide complete infil-tration of the demineralized dentin. The exposed collagenfibrils may consequently suffer hydrolytic degradation
by matrix metalloproteinase (MMPs), which has beenthe recent focus of extensive research.'' Application ofchlorhexidine, benzalkonium chloride, or the antibacterialmonomer methacryloyloxydodecylpyridinium bromide toprevent such degradation has not proven effective in thelong term. [Meanwhile, self-etch adhesives seem not to beaffected by MMPs to the same extent, which may be dueto the fact that collagen is exposed to a lesser depth and isbetter infiltrated by the adhesive system. Self-etch adhe-sives, particularly two-step systems, have shown excellentbonding performance to dentin through implementationof functional monomers such as 10-methacryloyloxydecyldihydrogen phosphate (MDP), which provides somechemical adhesion to hydroxyapatite. Without the useof phosphoric acid, however, the bond—especially touncut enamel—may be compromised.' Therefore, self-etch adhesives are recommended particularly for cavitiespredominantly in dentin, while etch-and-rinse systemsare preferred for indirect restorations and cavities thatare mostly in enamel.^
The performance of bonding agents in the laboratoryand even in controlled clinical trials may not necessarilytranslate to the clinical situation in the dental office. Oneinfluencing factor is operator experience and familiaritywith a specific adhesive system.**'̂ Recent multimode (uni-versal) adhesive systems may help minimize this problemas they can be used in both etch-and-rinse and self-etchmodes. This feature can simplify the process and familiar-ize clinicians with new bonding systems.
Another key factor for the successful implementation of
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adhesive dentistry in clinical practice is the understandingthat any type of bonding surface contamination fromsaliva, blood, sulcus, or other fluids significantly affectsresin bonds in a negative way.'° Isolation of the operatingfield through use of a rubber dam or similar means is,therefore, a necessity.
it is fair to say that the search for the "ideal" dental adhe-sive system is ongoing. Based on the current literature, anadhesive should: 1) minimize phosphoric acid pretreatmentof dentin and only require selective etching of enamel; 2) bea mild self-etch with a universal adhesive monomer such asMDP; 3) be solvent free; and 4) have antibacterial properties.
COMPOSITE RESINS FORDIRECT RESTORATIONSComposite restorative materials have been steadily evolv-ing since R.L. Bowen introduced them in the last century."Their applications include anterior and posterior restora-tions both direct and indirect, and luting agents for alltypes of indirect restorative materials.
Patient demand for tooth-colored esthetic and minimallyinvasive restorations, as well as environmental concernsabout mercury, are slowly reducing the use of amalgamfor direct posterior restorations and replacing amalgamwith composite resin.
However, questions remain about the clinical long-termperformance of direct composite-resin restorations; clinicaltrials to evaluate novel dental composites are expensive andarduous to complete." Underperforming composite materi-als, patient noncompliance, and operator error are mainreasons for failure, leading to secondary caries, fracture,marginal deficiencies, wear, and postoperative sensitivity.'^
For anterior composite restorations, loss of retention isno longer a main reason for failure, provided dependableadhesive systems are used correctly.^^ Instead, marginaldeterioration and discoloration have become primary rea-sons for replacement. They are mainly caused by improperadhesive technique, subgingival placement on root dentinor cementum, overfinishing of the restoration, incorrectmaterial selection, and inadequate oral hygiene.
Posterior composite restorations are subject to greaterfailure due to masticatory forces, difficulty of placement,and secondary caries, especially in the long term." Cariesrisk plays a significant role in restoration survival. A 12-year prospective study concluded that large four- tofive-surface composite restorations have better survivalthan amalgam restorations of the same size in patientswith low risk for caries." Patients at high risk for caries andbruxism have significantly higher failure rates in shorterperiods than patients with low risk.''' The effect of oralhygiene and nutrition has not been sufficiently studiedbut may also play a significant role in restoration survival.
Current trends suggest simplification of the placementtechnique with low-shrinkage-stress bulk-fill composite
'' These new materials have varying properties
and are often applied as flowable base materials veneeredwith more viscous hybrid composite resins or inserted in4-mm to 5-mm thick increments and cured in one step toeliminate time-consuming layering techniques. To date,scant evidence is available to validate material placementin one layer. The recommended placement techniquecontinues to be small increments to allow for flow of thecomposite material away from free space and toward abonded substrate."* This technique ensures an optimalconversion rate upon photopolymerization and a restora-tion with superior physical properties.
An advanced system for evaluating the clinical perfor-mance of contemporary composite materials and bondinginterfaces applies noninvasive, nondestructive, high-resolu-tion cross-sectional light-wave imaging technology calledswept-source optical coherence tomography (SS-OCT).'̂ '̂ ^With this technology, Nazari et aP' demonstrated superiorcavity adaptation of a new stress-decreasing compositeresin placed up to 3 mm in depth compared with conven-tional flowable composite.
Rapid developments in resin composite technologiesand formulations have made direct composite restorationshighly predictable, as long as materials and applicationtechniques are properly selected and applied.
THE ADHESIVE RESIN BONDTO DENTAL MATERIALSCompositesAdhesion between two composite resin layers is achieved inthe presence of an oxygen-inhibited layer of the unpolymer-ized resin. Successful bonding depends on establishinga surface with a high number of unreacted vinyl groups(C=C) that can then be cross-polymerized to the resin inthe bonding composite.^^ Because already polymerizedcomposites contain fewer free radicals on their surfaces,several methods have been suggested to improve thecomposite-composite adhesion. Surface roughening withairborne particle abrasion, etchants such as acidulatedphosphate fluoride, hydrofluoric acid, or phosphoric acidwith the use of intermediate adhesive resins (lARs) eitherin a siiane and/or an adhesive system have been recom-mended. The preferred method is a combination of airabrasion, application of a siiane coupling agent and an lAR.̂ ^
CeramicsThe popularity of all-ceramic restorations has increasedsignificantly in recent years due to better esthetics anddurability. The two major categories of all-ceramic materialsare: silica-based (ie, feldspathic, leucite-reinforced, andlithium disilicates) and non-silica-based (ie, zirconia oryttria stabilized zirconia, alumina) high-strength ceram-ics. The clinical success of either resin-bonded or repairedceramic restorations depends on the quality and durabilityof the bond between the composite resin and ceramic.This bond typically depends on the surface topography
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of the substrate, surface energy, and chemical interactionwith the resin.^*
Silica-Basecd CeramicsF-lydrofluoric acid (FHF) etching followed by applicatioriof a silane coupling agent is recommended for use withglassy matrix ceramics. '̂'•^^ FHF selectively dissolves theglass or weak crystalline components of the ceramic andproduces a porous, irregular surface of increased wettabil-ity. Application of a silane coupling agent on the etchedceramic surface increases the chemical adhesion betweenthe ceramic and resin materials by coupling the silica (sili-con oxides) in glassy matrix ceramics to the organic matrixof resin materials by means of siloxane bonds.
Silica-based ceramics are brittle. Therefore, bluntsurface-roughening methods such as air-particle abrasionor grinding, which cause microcracks and may ultimatelylead to fractures, should be avoided.
A clinical example of a resin-bonded silica-based ce-ramic (porcelain laminate veneers) restoration is depictedin Figure T and Figure 2.
High-Strength CeramicsAlumina- (AI^Oj) and zirconia-based (ZrOp ceramics aretypically used for copings and frameworks that are veneeredwith feldspathic porcelains or composites, full-ceramicrestorations, or implant components due to their excellentmechanical properties. '̂*'̂ ^ The high strength allows for ce-mentation with conventional cements. If adhesive bonding isselected for final insertion, however, some unique propertieshave to be considered. The blo-inert high-crystalline andlow-glass structure makes high-strength ceramics corrosion-and acid-resistant, rendering adhesion protocols applied forsilica-based ceramics ineffective.^*^ The preferred surfacetreatment method is air-particle abrasion with aluminum
oxide, which removes loose contaminated layers, and theroughened surface provides some degree of mechanicalinterlocking with the adhesive material. Application ofa special ceramic primer containing an acidic adhesivemonomer such as MDP provides superior bond strengths toair-abraded high-strength ceramic surfaces.^^ Alternatively,silica coating followed by silanization or chemical activationseems similarly successful.^*'̂ ^
The selective infiltration-etching technique by heattreatment has been recently proposed to improve zirconiabonding. The surface is coated with a glass-containingconditioning agent (composed of silica, alumina, sodiumoxide potassium oxide, and titanium oxide) and heatedabove its glass-transition temperature. After cooling, theglass is dissolved in an acidic bath, creating a poroussurface and achieving promising bond strengths.^'
METAL-FREE ENDODONTIC POSTSThe primary purpose of a post is to retain the coronal res-toration in an endodontically treated tooth with extensiveloss of coronal structures. Prefabricated fiber-reinforcedpolymer (FRP) posts have become very popular because ofsatisfactory clinical results as well as reduction in treatmenttime and cost.̂ '̂̂ ^ They are usually luted with resin cementsto increase retention and mechanical performance of therestored teeth while reducing the risk of root fracture.
The FRP posts are made of carbon or silica fiberssurrounded by a matrix of polymer resin, usually epoxyresin. Because fiber posts are passively retained in theroot canal, the effectiveness of the adhesive cement andluting procedure plays an important role. Ideally, the in-tracoronal dentin is treated with etch-and-rinse adhesivesand ethylenediaminetetraacetic acid (EDTA).^°
The organic component of fiber posts, generally epoxyresin, has a high degree of conversion and crosslinks.
Fig 1. Preoperative intraoral view of failing composite res-torations in the two maxillary central incisors. In addition,the patient was dissatisfied with the esthetics of the maxil-lary incisors.
Fig 2. Postoperative intraoral view after restoration of allmaxillary incisors with minimally invasive adhesively bondedporcelain laminate veneers. Clinics by Dr Markus B, Blatz;dental technology by Cusp Dentai Laboratory, Boston, MA,
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This poiymer matrix is virtually unable to react witin tinemonomers of resin cements.^' A silane coupling agent istypically applied to the post surface to enhance adhesion.
The recently developed resin-based self-adhesive ce-ments eliminate the multiple and technique-sensitivetooth- and material-pretreatment steps. They have alsobecome popular for cementation of fiber posts.^^ Self-adhesive resin cements contain multifunctional hydrophilicmonomers with phosphoric acid groups, which can reactwith hydroxyapatite and also infiltrate and modify thesmear layer. They can offer bond strengths comparableto etch-and-rinse systems.
METAL ALLOYSThe development of techniques for adhesion of compositeresins to metallic substructures has greatly expanded re-storative treatment options. Early techniques relied solelyon mechanical retention of composite resin to the metal-lic substrate through retentive perforations or meshes.̂ ^Macro-mechanical retention techniques yielded unreliablebond strengths, gap formation, and microleakage at thebonding interfaces.^" Micromechanical retention tech-niques began with pretreatment of metal-bonding surfaceswith air-particle abrasion,^" which became increasinglysuccessful when combined with resin cements containingspecial adhesive monomers (MDP) to also provide truechemical bonds.^=
Other efforts to improve metal-composite bonds haveincluded various etching techniques'^ and acidic adhesivemonomers^' that chemically bond to oxides on base-metalalloys. The nonreactive surface of noble metal alloys pre-sented a special challenge, which led to the development ofelectrochemical plating of tin, oxidation, and acid pickling.
Treating metal alloy surfaces with silica intermediatesand silane coupling agents began in 1984.^^ Silica wasintroduced onto the metal surface from application ofsilicon dioxide (SiO^) in a flame. Other systems embedsilica-coated aluminum particles into the metal surfacethrough air-particle abrasion.^^^o The silica coat is thentreated with silane, which acts as a coupling agent be-tween the metal surface and resin. These techniques haveproven successful to both base and noble metal alloys.
Current development of adhesion to noble dental alloyshas focused on the use of functional monomers, especiallythose containing sulfur."" Multifunctional adhesives for bothnobie and base metal alloys typically contain monomerswith functional groups, such as sulfur, amino, and carboxyl,and have demonstrated high and durable bond strengths.^^
INDIRECT ADHESIVE RESTORATIONSIN POSTERIOR TEETHBonded indirect tooth-colored restorations for posteriorteeth are excellent examples of the significant develop-ments and improvements that have been made in adhesivedentistry, as they combine distinct clinical protocols with
Flowable liner (CDO)
Dentin Sealing(Dual Bonding/IDS)
Flowable liner (CMR)
Fig 3. Diagrammatic illustration of a modern concept for"Indirect Adhesive Restorations in the Posterior," present-ed by Dr. Didier Dietschi, The different layers indicate theconcepts of dual bonding/immediate dentin sealing (IDS),cavity design optimization (CDO), and cervical marginrelocation (CMR),Fig 4. Preoperative view of defective tooth-colored res-torations. Improper adaptation and open margins neces-sitate replacement.
modern adhesive technologies to tooth structures and indi-rect dental materials. The most common clinical problemswith bonded indirect posterior restorations include hardtissue conservation (cavity design might lead to signifi-cant loss of sound tissue), impression taking, and adhesivecementation (deep proximal preparations are a challengeand make working field isolation more difficult), as wellas provisional restorations. Conventional acrylic provision-als are time consuming and the cement contaminates theinterface, while simplified "soft" light-curing provisionalsare lost easily and trigger sensitivity due to leakage. Anoriginal treatment protocol to overcome these problems
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was introduced by Dietschi and Spreafico''^ in 1998 andincludes four main concepts, which are illustrated in Figure3 through Figure 10.
The first concept, dual bonding, relates to the substratetreatment.'"''''^ It was later referred to as immediate dentinsealing, which is to seal the dentin with a dentin bondingagent after the cavity is isolated with a rubber dam.'"' Thisprevents further tissue dehydration and contamination,and protects the tooth against sensitivity while improvingbond strength and stability of the adhesive interface.'"
Cavity design optimization (CDO)''^ limits removal ofsound tooth structure during preparation by applying aflowable composite liner to fill all undercuts and create anideal cavity geometry. The third concept, cervical margin re-location (CMR),^'"' is applied for deep proximal preparations(intrasulcular), which complicate impression taking andcavity isolation during cementation. After placing a matrix, afirst layer of flowable or restorative composite is applied toreposition the margin more coronally (Figure 6 and Figure7). A highly filled flowable composite or low-shrinkage flow-able base is recommended. Cementation is performed witha light-cure composite rather than a dual-cure compositefor optimal working time and control. Controlled adhesivecementation (CAC) has major advantages in complex cavitydesigns. Combined with the CMR technique, visual marginexamination and proper cement removal are simplified. Ahighly filled fine/microhybrid composite is recommended
Fig 5. Situation after removal of the failing restorations.Recurrent caries involved proximal areas, leading to ex-tensive proximal cavities. The remaining enamel is verythin or even absent along the cervical margins. A directapproach is not indicated due to cavity dimensions, mar-gin position, and dentin quality.
. A curved metal matrix is placed and fitted preciselyalong cervical margins. A highly filled flowable compos-ite is applied to relocate the proximal margin and fill allundercuts.Fig 7. Ail cavities were lined (dentin bonding agent andflowable composite). Enamel margins were refinished,
i cavities are ready for final imprr--'- -
O
Fig 8. Pressed and stained lithium disilicate ceramicrestorations on the master cast.Fig 9. Cementation with a light-cure composite materia(typically a microhybrid).
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Fig 10. Definitive restora-tions. The restorative ap-proach ensures optimalbiologic and physical in-tegration for predictableand reliable results.
Clinics by Dr. DidierDietschi.
for cementation, and its viscosity is reduced during res-toration placement with a special ultrasonic or sonic ce-mentation tip. Various studies have verified adequate lighttransmission and conversion rates for light-cure compositesunderneath ceramic inlays/onlays with proper curing lightsand exposure times."** =° The reduced restoration thickness(CDO concept) supports proper light transmission.
These clinical concepts address the most frequentdifficulties with indirect adhesive restorations in theposterior, leading to more predictable and improvedtreatment outcomes.^''"
SUMMARYToday, offering patients minimally invasive dentistry is notjust another treatment option, it Is an ethical obligation.Adhesive dentistry facilitates minimally invasive, esthetic,and tooth-preserving dental treatment and applies toalmost all dental materials and specialties. The varioustooth structures and dental materials, however, requirespecific bonding protocols for long-term clinical success,as discussed in this article. Adhesive techniques, technolo-gies, and clinical concepts are constantly being updatedand improved, shaping the future of the dental profession.
Ricardo Walter, DDS.MScAssistant Professor of Restorative Dentistry, Department ofPreventive and Restorative Sciences, University of PennsylvaniaSchool of Dental Medicine, Phiiadelpiiia, Pennsylvania
Alan M. Atlas, DMDClinical Professor, Department of Preventive and RestorativeSciences, University of Pennsylvania School of DentalMedicine, Philadelphia, Pennsylvania
NajeedSaleh,DMDProfessor of Clinical Restorative Dentistry, Director ofComprehensive Care Clinics, Department of Preventive andRestorative Sciences, University of Pennsylvania School ofDental Medicine, Philadelphia, Pennsylvania
Didier Dietsclii, DMD, PhDSenior lecturer, Department of Cariology & Endodontics,School of Dentistry, University of Geneva, Switzerland;Adjunct Professor, Department of Comprehensive Dentistry,Case Western University, Cleveland, Ohio
Marl<usB.Biatz,DMD,PhDProfessor of Restorative Dentistry, Chairman of the Department ofPreventive and Restorative Sciences, University of PennsylvaniaSchool of Dental Medicine, Philadelphia, Pennsylvania
About the AuthorsFrancis K. Mante, DMD, PhDAssociate Professor, Division of Restorative Dentistry, Directorof Biomaterials, University of Pennsylvania School of DentalMedicine, Philadelphia, Pennsylvania
fusun Ozer, DDS, PhDInstructor, Department of Preventive and RestorativeSciences, University of Pennsylvania School of DentalMedicine, Philadelphia, Pennsylvania
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6. Tjäderhane L, Nascimento FD, Breschi L, et al. Strategies to preventhydrolytic degradation of the hybrid layer - a review. Dent Mater.2013;29(10):999-10n.7. Ozer F, Biatz MB. Seif-etch and etch-and-rinse adhesive systems inciinicai dentistry. Compend Contin Educ Dent. 2013;34(l):12-14,16,18.8. Demarco FF, Correa MB, Cenci MS, et ai. Longevity of posteriorcomposite restorations: not oniy a matter of materials. Dent Mater.2012:28(1):87-101.9. Uniu N, Gunai S, Uiker M, et ai. infiuence of operator experi-ence on in vitro bond strength of dentin adhesives. J Adhes Dent.2012;14(3):223-227.10. Cobanogiu N, Uniu N, Ozer F, Biatz M. Bond strength of seif-etchadhesives after saiiva contamination at different appiication steps[pubiished oniine ahead of print January 17, 2013]. Oper Dent. 2013.http://dx.doi.org/10.2341/12-260-L.11. Ferracane JL. Resin-based composite performance: are there somethings we can't predict? Dent Mater. 2013;29(l):51-58.12. Goldstein GR. The iongevity of direct and indirect posterior restora-tions is uncertain and may be affected by a number of dentist-, patient-,and material-reiated factors. JFwti eased DenfPracf. 2O1O;1O(1):3O-31.13. Kubo S, Yokota H, Yokota H, Hayashi Y. Challenges to the ciinicaiplacement and evaiuation of adhesiveiy-bonded, cervical compositerestorations. Dent Mater. 2013:29(l):10-27.14. Opdam NJ, Bronkhorst EM, Loomans BA, Huysmans MC. 12-year survivai of composite vs. amaigam restorations. J Dent Res.2010;89(10):1063-1067.15. van de Sande FH, Opdam NJ, Rodoipho PA, et ai. Patient risk factors'influence on survivai of posterior composites. J Dent Res. 2013:92(suppi7):78S-83S.16. liie N, Bucuta S, Draenert M. Bulk-fill resin-based composites:an in vitro assessment of their mechanicai performance [publishedoniine ahead of print Aprii9, 2013]. Oper Dent. 2013. http://dx.doi.org/10.2341/12-395-L.
17. El-Damanhoury H, Platt J. Poiymerization shrinkage stress kinet-ics and reiated properties of buik-fill resin composites [publishedoniine ahead of print Juiy 18, 2013]. Oper Dent. 2013. http://dx.doi.org/10.2341/13-017-L.18. Ferracane JL. Piacing dentai composites—a stressfui experience.Oper Dent. 2008:33(3):247-257.19. Makishi P, Shimada Y, Sadr A, et ai. Non-destructive 3D imaging ofcomposite restorations using opticai coherence tomography: marginaiadaptation of self-etch adhesives. J Dent. 2011;39(4):316-325.20. Sadr A, Shimada Y, Bista B, et al. Non-destructive non-staining3D analysis of marginai and internai micro-gaps. Poster presented at:5th internationai Congress on Adhesive Dentistry; June 14-15, 2013;Phiiadeiphia, PA. Abstract 84.21. Nazari A, Sadr A, Shimada Y, et ai. 3D assessment of void andgap formation in flowable resin composites using opticai coherencetomography. J Adhes Dent. 2013;15(3):237-243.22. Mair L, Padipatvuthikul P. Variabies related to materials and prepar-ing for bond strength testing irrespective of the test protocoi. DentMater 2010;26(2):el7-e23.23. Özcan M, Pekkan G. Effect of different adhesion strategies on bondstrength of resin composite to composite-dentin complex. Oper Dent.2O13:38(1):63-72.24. Biatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of theiiterature. J Prosthet Dent. 2003;89(3):268-274.25. Biatz MB, Sadan A, Maitezos C, et al. in vitro durability of the resinbond to feldspathic ceramics. Am J Dent. 2004;17(3):169-172.26. Biatz MB, Chiche G, Holst S, Sadan A. Influence of surface treatmentand simuiated aging on bond strengths of iuting agents to zirconia.Ouintessence Int. 2007;38(9):745-753.27. Manso AP, Silva NR, Bonfante EA, et ai. Cements and adhesivesfor aii-ceramic restorations. Dent Clin North Am. 2011;55(2):311-332.28. Stockton LW. Factors affecting retention of post systems: a literaturereview. J Prosthet Dent. 1999;81(4):380-385.29. Cheung W. A review of the management of endodonticaiiytreated teeth. Post, core and the final restoration. J Am Dent Assoc.2005;136(5):611-619.
30. Goracci C, Ferrari M. Current perspectives on post systems: aiiterature review./\usf Denf J. 2011;56(suppl l):77-83.31. Menezes M, Faria-E-Siiva A, Suva F, et ai. Etching a fiber post surfacewith high-concentration bieaching agents [published oniine ahead ofprint July 12, 2013]. Oper Dent. 2013. http://dx.doi.org/10.2341/12-270-L.32. Dimitrouli M, Geurtsen W, Lührs A. Comparison of the push-outstrength of two fiber post systems dependent on different types ofresin cements. Clin Oral investig. 2012;16(3):899-908.33. Rochette AL. Attachment of a splint to enamei of lower anteriorteeth. J Prosthet Dent. 1973;30(4 pt l):418-423.34. Ozcan M. Pfeiffer P. Nergiz I. A brief history and current status ofmetai-and ceramic surface-conditioning concepts for resin bonding indentistry Ouintessence int. 1998;29(ll):713-724.35. Aibers iHF Metal-resin bonding./\depf Reporf. 1991;2:29-36.36. Livaditis GJ. A chemicai etching system for creating micromechanicalretention in resin-bonded retainers. JProsfftetDenf. 1986;56(2):181-188.37. Tanaka T, Nagata K, Takeyama M, et al. 4-META opaque resin—anew resin strongly adhesive to nickel-chromium aiioy. J Dent Res.1981;60(9):1697-1706.38. Tiiier HJ. The Kulzer siiicoater method. Evaiuation from thescientific-materials science viewpoint [in German]. Zahntechnii< (Zur).1986:44(6):498-499.39. Hummel SK, Pace LL, Marker VA. A comparison of two silicoatingtechniques. JProst/iodonf. 1994;3(2):108-113.40. Hansson O, Moberg LE. Evaluation of three siiicoating methodsfor resin-bonded prostheses. Scand J Dent Res. 1993;101(4):243-251.41. Taira Y, Kamada K. Effects of primers containing sulfur and phosphatemonomers on bonding type IV gold aiioy. J Dent. 2008;36(8):595-599.42. Kadoma Y Kojima K, Tamaki Y, Nomura Y. Water durabiiity of resinbond to pure goid treated with various adhesion promoting thiiranemonomers. Dent Mater J. 2OO7;26(l);29-37.43. Dietschi D, Spreafico R. Current ciinicai concepts for adhesivecementation of tooth-colored posterior restorations. Pract PeriodonticsAesthet Dent. 1998;10(l):47-54.44. Dietschi D, Herzfeid D. In vitro evaiuation of marginal and internaladaptation of ciass II resin composite restorations after thermai andocciusai stressing. Eur J Orai Sei. 1998;106(6):1033-1042.45. Dietschi D, Monasevic M, Krejci i, Davidson C. Marginai and internaladaptation of class II restorations after immediate or deiayed compositepiacement. J Dent. 2002;30(5-6):259-269.46. Magne P. immediate dentin seaiing: a fundamentai procedure forindirect bonded restorations. J Esthet Restor Dent. 2005;17(3):144-154.47. Dietschi D, Olsburgh S, Krejci i, Davidson C. In vitro evaluation ofmarginai and internai adaptation after occiusai stressing of indirectclass il composite restorations with different resinous bases. Eur J OraiSei. 2OO3;lll(l):73-8O.48. Besek M, Mörmann WH, Persi C, Lutz F. The curing of compos-ites under Cerec iniays [in German]. Schweiz Monatsschr Zahnmed.1995;105(9):1123-1128.49. Dietschi D, Marret N, Krejci I. Comparative efficiency of plasma andhalogen light sources on composite micro-hardness in different curingconditions. Dent Mater. 2003;19(6):493-500.50. Park SH, Kim SS, Cho YS, et ai. Curing units' ability to cure restor-ative composites and duai-cured composite cements under compositeoveriay. Oper Dent. 2004;29(6):627-635.51. Frankenberger R, Hehn J, Hajtó J, et ai. Effect of proximai boxelevation with resin composite on marginai quaiity of ceramic iniaysin vitro, din Orai investig. 2O13;17(l):177-183.52. Zaruba M, Göhring TN, Wegehaupt FJ, Attin T. influence of aproximal margin eievation technique on marginai adaptation of ceramiciniays. Acta Odontoi Scand. 2O13;71(2):317-324.53. Dietschi D, Argente A, Krejci I, Mandikos M. in vitro performance ofciass I and II composite restorations: a iiterature review on nondestruc-tive laboratory trials-part i. Oper Dent. 2013;38(5):E166-181.54. Dietschi D, Argente A, Krejci i, Mandikos M. in vitro performance ofciass I and il composite restorations: a iiterature review on nondestruc-tive laboratory trials—part il. Oper Dent. 2013;38(5):E182-200.
November/December 2013 • Volume 34 Special Issue 9
CONTINUING EDUCATION QUIZ
The Current State of Adhesive Dentistry:A Guide for (iinicai PracticeFRANCIS K. MANTE, DMD, PHD; FUSUN OZER, DDS, PHD; RICARDO WALTER, DDS, MSC; ALAN M. ATLAS,DDS; NAJEED SALEH, DHO; DIDIER DIETSCHI, DMD, PHD; AND MARKUS B. BLATZ, DMD, PHD
AEGIS Publications, LLC, provides 2 hours of Continuing Education creditfor this article. Course is valid from 12/03/2013 to 12/31/2016. Participantsmust attain a score of 70% on each quiz to receive credit. Participantsreceiving a failing grade on any exam wiil be notified and permitted totake one re-examination. Participants will receive an annual report docu-menting their accumulated credits, and are urged to contact their ownstate registry boards for special CE requirements.
By visiting compendiumce.com/go/adhesion, you can take the quiz for$16 and print your certificate immediately or you can fill out and mail theAnswer Sheet below for $32. Allow approximately 2-3 weeks for process-ing. For more information, call 877-4-AEGIS-l.
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Complete this CE examination oniine at compendiumce.com/go/adhesion or mail/fax this page to AEGIS Communications.
ANSWER SHEET
1. Self-etch adhesives are recommended particularly forcavities predominantly in:A.deiitin. B. enamel.
ccementum. D. deciduous teeth.
2. Adhesion between two composite resin layers isachieved in the presence of an;A. oxygen-inhibited layer of the poiymerized resin.
B. oxygen-inhibited layer of the unpoiymerized resin.
C, oxygen-enriched iayer of the polymerized resin.
D. oxygen-enriched iayer of the unpoiymerized resin.
3. Successful bonding depends on establishing a surfacewith a high number of unreacted;A. yinyi groups.
B. calcium carbonate molecules.
c. esterine polymers.
D. hydroxyapatife chains.
4. All-ceramic materials that are non-silica-based include;A. feidspathic. B. ieucife reinforced.
c. iifhium disiiicafes. D.zirconia.
5. Hvdrofiuoric acid etching followed by application ofa silane coupling agent is recommended for what typeof ceramics?A. pressed B, high density
Ciow density D. giassy matrix
6. Silica-based ceramics are;A. compliant. B. brittle.
C. elastic D.siightiy flexible.
7. Alumina- and zirconia-based ceramics are typicallyused for copings and frameviori(s that are;A, out of occlusion. B. veneered.
C. subgingival. D. supragingival.
8. The preferred surface treatment method for alumina-and zirconia-based ceramics is;A. rinse wifh silane.
B. rinse wifh hyaiuronic acid.
c. rinse with phosphoric acid.
D. air-parficie abrasion viifh aluminum oxide.
9.Prefabricated fiber-reinforced polymer postsare usually luted with;A- ZnPO, B. glass ionomer.
c, resin cemenfs. o. eugenoi.
10. "Cavity Design Optimization" limits removal of soundtooth structure during preparation by applying what to fillall undercuts and create an ideal cavity geometry?A. a hybrid glass ionomer B. IRM
c. a flowable composite iiner D. calcium hydroxide
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