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Bonding agents
This lecture starts from slide 23

Slide 23
Now we continue with bonding agent, currently the bonding agent develop several times, each generation is better from previous one, the purpose of this development is to make steps that will be made less, so the time and percentage of fault will be less. So basically the idea of bonding agents is to use material that able to bond both to enamel and dentine and in the same time bond to composite resin that place on top. Earlier bonding agents based on silane coupling agents , did you remember in composite we talked about something we called filler and matrix together it's called silane coupling agents, it has hydrophilic end that capture the filler and hydrophobic end or arm that capture the resin matrix and we called it to the resin. Same thing in composite applied to bonding agents, so we want something to have an end or representation by (x) for example that will capture mineral content from hydroxyapatite and another end or another type of molecule that hold on collagen or organic component in dentine, so it can place both on enamel and dentine hold on to them then composite can be added and it can be chemically added. So this is basis of bonding agents it will bond to enamel, dentine, and then composite on top. Let's start with generations

Slide 24
The first generation is distributed in 1950,it's based as we said on silane coupling agent, if you don't remember what is the silane
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coupling agent you should go back to composite resin lecture, it's the agent that hold filler and matrix together. This generation is representation by M-R-X model.

M: methacrylate group (hydrophobic and can attach itself to collagen


and organic material in dentine)

R: hydrocarbon group X: glycerolphosphoric acid dimethacrylate (it holds hydroxyapatite


which is hydrophilic) So the first generation is not good because: this material shrink a lot when polymerize high rate of CTE (coefficient thermal expansion), so contraction and expansion is in high rate and the bonding is not good and microleakage will be very common, it's not good choice.

Slide 25, 26
Second generation appear in (late 60s early 70s), again similar concept to first generation, they try to deal with what we called smear layer. Now, we will introduced to hybrid layer, we said that hybrid layer is good layer, it's made from bonding agent that attach to enamel and dentine and composite together, so hybrid layer is good properly, another layer is called smear layer, smear layer is a layer that contain degree from enamel, dentine, food remnants, bacteria, it can flow up bone and dentinal tubule and prevent good bonding, so smear layer is not good and hybrid layer is good, that's why when place the acid (phosphoric acid), it is attendance to remove smear layer, open up dentinal tubule and clean the surface, so we want to clear smear layer . Before, they did not try to remove smear layer so the bonding was not good, Now in second generation bonding agent they attempt to deal

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with smear layer and try remove it, again same type of bonding agent to first generation, no improvement . Third generation, again similar to previous generation, but try to remove smear layer and modify it. So firstly generations were similar, bonding agent was not good enough, they started improving the bonding between enamel and dentine and composite during fourth generation. Now we said that smear layer is made of dentine particle or enamel particle and after cavity preparation it made of bacteria and some component of saliva.

Procedure in third generation agents

During third generation, they try to modify the smear layer or remove it by adding conditioner or acid or what we called a primer, several type of acid can be used, the purpose of all this acid is to remove a smear layer and to make a surface open and clean, after removal a smear layer they applying bonding agent then resin composite. So maybe this generation is better a little bit than first and second generation because a smear layer was removed.

Slide 27
This is representation of smear layer, it composed of saliva and bacteria, and this is dentinal tubule, so we can see how the smear layer flows on dentinal tubule and prevent any bonding agent or composite from going on, so the bond is not good between filling and smooth surface. So , first generation based on silane coupling agent , second generation and third generation is the same, but the problem is the smear layer, they try to remove it by several acid ,and now we are moving to talk about fourth generation where we start using phosphoric acid.
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Slide 28
During fourth generation we start using what we talk about it last time the total etch technique for enamel and dentine, in previous application, they only want to make etching for enamel and this will not provide good bonding between a tooth and composite. So now in fourth generation at that time, they said that they want to try etching both enamel and dentine, dentine has mineral content that can etch and dentinal tubule that you can open it and the bonding agent will go in (in beginning, they start to etch enamel only , but in fourth generation they try to etch both enamel and dentine to show how the bond strength is , and they found that when etching both enamel and dentine the mineral in dentine will go out by acid and bonding agent will go in dentinal tubule , so the composite will be hold better to tooth).. So etching will be done both to enamel and dentine , and you should make sure not to have over etched dentine , after etching it should be rinse and the surface should lightly dried , you should not to have dehydrated surface , and if you think that you have over dried dentine you can wet it by small piece of cotton before you applying bonding agent. Now they apply a material called the primer then followed by bonding agent and then composite, now the primer is hydrophilic, it can be flow over a surface and in the same time it has hydrophobic end that capture a bonding agent, nowadays we use only one bottle so we don't use a primer and bonding agent, the primer is added to bonding agent in one bottle.

So in the past (the way that did the fourth generation): we made etching added primer added bonding agent and finally added composite So it was four steps
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Nowadays we make etching and wash and dry added bonding agent and finally added composite Where does the primer go? It will be incorporate in bonding agent so two in one. So it will be three steps When we reduced steps the time of work and percentage of fault will be less. As a summary, bonding agents pass in several development, in the first three generation they used component or material similar to silane coupling agent so one was hydrophilic and one was hydrophobic to hold to the tooth and composite, then in fourth generation they started using phosphoric acid to remove smear layer between the surface, followed by a little amount of primer which is hydrophilic because the tooth surface is hydrophilic, so we want something that able to flow and catch the tooth surface and bonding agent together, after the primer there will be another liquid which is a bonding agent then followed by composite, this is for four generation.

Slide 29
Now in fifth generation, fewer steps so better result because there is little chance of error (as we said when we increase the number of steps the time of work increase so the chance of error and contamination also increase), so what they did? They used similar material but the primer was added to bonding agent in one bottle so they removed one step from whole procedure, so they tried to penetrate dentinal tubule, hybrid layer will be formed and potential was improving.

Slide 30
This is (picture) the fifth generation material, this is a bonding agent that will be used in the lab and in the clinic, it's from 3M American
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company and it's called single bond adhesive because we used only one bottle that contain both a primer and bonding agent , and this mean that this liquid has both a hydrophilic and hydrophobic property, hydrophilic it can wet the surface of the tooth, hydrophobic it will bond to composite layer that will be added ( so we have compound that able the material to spread on the surface of the tooth because it is hydrophilic and also we have compound that can hold composite layer that will be added )

Slide 31, 32
Sometimes the primer is added or incorporated with acid etching (with phosphoric acid), so it's another way for fewer steps, so again for fewer steps primer will be incorporated either in adhesive or with phosphoric acid, commonly we use single bond adhesive where the primer is added to bonding agent, so this is the fifth generation . When the primer is added to acid and we applied it to the surface, there is no need for rinsing, so this is for example one advantage of self-etching primer so we don't need for rinsing and drying, and there will be less dangerous of drying or over drying the tubule. So the primer and acid put together in one bottle, and in the same time or after many seconds we added the bonded agent, or in other system we add the acid etch and wash and dry then we add the bonding agent , again fewer steps and less chance to error. This is (picture in slide 32) just example of different color available in market either bonding agent with primer or acid etch with primer in one bottle.

Slide 33
So this is just example of etched enamel or pores in enamel where the bonding agent is able to applied and flow in these pores to provide micromechanical retention

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Slide 34
To make acid etch tooth we want to dry it to apply the bonding agent on all the surface of the cavity, then we may use light curing in it and it will be set because it is light cure material, usually we make light curing for twenty seconds, then it will be hard and set and it will flow in pores and dentinal tubule and set.

Slide 35
Microleakage is common problem in composite because of polymerization shrinkage, now we said several outcomes of microleakage (staining, sensitivity, and recurrent caries). Now what will increase the chance of microleakage around composite? If you don't cure bonding agent properly, or don't provide isolation from contamination during acid etching, all of these factor will increase the chance of microleakage, so the more adhere or follow the steps actually then better chance of good adhesion between the tooth surface and composite

Slide 36
This picture represent microleakage so what did they do? They have the tooth ,they present the composite properly in one side ,and they also present composite to other side but there was contamination , they contaminate the tooth during procedure and then place it in solution contain dye to see if the dye can penetrate between the tooth and filling.. And then they look it under microscope, they noticed in side that there was no contamination the composite dens properly, there was no dye around it ,no microleakage, and where the filling was not made it properly for example the composite not cure properly , there will be penetration of dye, can you see the black area around composite, so there will be microleakage around filling and you may see bacteria and saliva around it, It's very common to see a black line around composite filling, and this represent staining due to microleakage.

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Slide 37
This is table in your book contains factors that prevent good bonding, we talk about some of them, we talk about some of them like contamination with blood or saliva or oil, oil can expel from hand piece onto tooth structure, it can prevent acid etching and bonding agent from contacting between enamel ad dentine, because it will form separated layer. Another factor is present of ZOE remnants, because we said that eugenol prevent proper setting of composite, so if we have remnants from temporary filling, and we don't remove it or clean the surface properly, it will prevent good setting of composite and lead to microleakage. There have many example of thing that prevents good bonding between composite and tooth surface, so we should know them, we talk about most of them in the lecture. But the most important factor is: moisture control Follow the instruction with regard to the time that should cure both bonding agent and composite. So if we follow these steps with regard to acid etching, drying, bonding agent curing, composite layering, incremental and curing, you will minimize the chance of microleakage and minimize shrinkage.

Slide 38
Now we said that there is many ways of testing bond strength between material, you need to go back to shear strength mean and tensile strength mean. We said that tensile strength is stress that stretch the material, shear mean sliding the material from each other.
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So they use director of force to try and separate composite from enamel and dentine ,and to measure amount of force that need to separate them, the higher the force the better bonding strength. Now when we need examine material regard bonding to the tooth, what we will do? we put material (filling) on tooth surface, then we applied force either tensile or shear strength on it and try to separate the filling from enamel and dentine, the higher force we need to separate them the higher bonding strength (proportional relationship). So either shear strength or microshear strength or tensile strength is applied to know the bond strength between composite or glass inomer cement and tooth surface.

Slide 39
We talk about amalgam bonding in amalgam lecture where we try to use a bonding agent and composite between amalgam and tooth surface to minimize microleakage, but we said that this way is not acceptable because it will not make different. So they try to use bonding agent under amalgam to improve bond strength between amalgam and tooth surface, but in research they found that this way will not make different, and not increase bond strength, so it is not commonly use because it will take a lot of time, so just use amalgam from normal use, because your amalgam now if you adapt well to cavity, it will shrink to very small amount and not cause to microleakage.

Slide 40
Last coupling pages of your the chapter talk about how we can use bonding agent and composite to correct practice of porcelain on crown and bridge, the only that you should know not the procedure, just you should know the material. Now in case of crown and bridge which is made of porcelain (made of ceramic, it's esthetic and very strong material, it's the material that we
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use in making of crown), sometimes a small piece of it can be fracture because it's brittle material, now when small piece of it fracture, you don't have to replace the whole crown again because it is very expensive, one way to solve this problem is repairing it by composite and correct the defect. So some patient have crown, the outer part of it is made from porcelain that make it very good and esthetic, sometimes a small piece of it fracture because it is brittle, so we don't need to replace the whole crown it will cost (150-200) JD that's very expensive, so we can use composite to replace the fracture part . So underneath porcelain there is a metal, so if part of porcelain is broken, the metal will be shown that's not esthetic, so to solve this problem you can use composite, so you need to use slightly different material, you need to etch the metal and remnants part of porcelain, but acid that we used here is different, it's not phosphoric acid (phosphoric acid use in enamel and dentine), in case of porcelain repair they used hydrofluoric acid. So I need you to know the acid that you we use in porcelain repairing or etching is hydrofluoric acid, then silane or bonding agent is applied, then composite is added, so similar step but slightly different material ( the acid we used in etching ).

Slide 41
We talk about fissure and pit sealant when we talk about glass inomer cement, we said that some of pit and fissure based on GIC, ad some of them based on resin, similar to composite resin but a little amount of filler, they don't have a lot of filler in order to be able to flow So these material can be successful, it's used properly, they need it to be able to flow and wet the surface properly, so there can flow over pit and fissure and close them up. They have usually resin based pit and fissure sealant, it has good strength and very successful, it's very strong material so it can handle occlucal force.
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There also can be used in other procedure, one of them we called it PRR (preventive resin restoration), which mean we need to use your hand piece to open pit and fissure (very shallow cavity 1mm), then it filled with composite, on composite we can applied pit and fissure sealant. So there will be very shallow cavity, if you think the pit and fissure is not cleaned, or might have caries, so you can open it with hand piece pair, then filled with resin, and in the top we put the pit and fissure sealant , this procedure is called PRR . So if we want to use fissure and sealant alone, no need for use hand piece pair, and fissure should be clean, no carious, no staining, so immediately applied fissure and pit sealant. So these two ways are different from each other, when we dont have caries or staining we make acid etching then applied pit and fissure sealant immediately on surface, but in PRR we make shallow cavity by hand piece pair then we add resin and in the top we add pit and fissure sealant .

Slide 42
We talked about glass inomer cement bonding, we said that after cavity preparation, you need to apply the conditioner, which is made from polyacrylic acid, so we apply it for few second, and then we rinse and dry and GIC is placed, on top of GIC we need to apply varnish or bonding agent to protect it from contamination or dehydration, and the bond is chemical between GIC and tooth surface.

THE END Done by: Manar Malkawi

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