Criteria for the Replacement of Restorations: Academy of Operative Dentistry European Section.

The replacement of a restoration is one of the most common procedures in dentistry. However, the criteria for such intervention, excluding catastrophic failure and persistent discomfort and pain, continue to be the subject of considerable debate. The decision-making process remains subjective on the part of the treating clinician, while the evidence base for refurbishment and repair rather than replacement for the management of defective and failing restorations continues to grow and strengthen. This article, prepared as an Academy of Operative Dentistry European Section consensus publication, reviews existing criteria for the replacement of restorations and encourages practitioners to shift, if not already doing so, to considering the replacement of a restoration as a last resort rather than as a prudent action to be taken if in any doubt about clinical acceptability. Further research in the area, spanning the risk assessment of defective and failing restorations and new diagnostic tools and processes, together with work to enhance the evidence base of restoration repair vs replacement, would be of immense value.

Immediate versus one-month wet storage fatigue of restorative materials.

Immediate finishing is a highly desirable property of restorative materials. In general, the resin composites, the polyacid-modified resin composites and resin-modified glass-ionomers are finished immediately after light-curing. For the conventional glass-ionomers a waiting period of 24 h is recommended. Therefore, the objective of this study was to investigate whether immediate finishing and application of cyclic loading under water spray on resin-modified glass-ionomers, a conventional glass-ionomer, a polyacid-modified resin composite and a resin composite are reflected in their Young's modulus and fatigue resistance after 1-month wet storage compared with a control group that could mature untroubled for 1 month. From this study, it could be concluded that there is a material-dependent response on immediate finishing. For the conventional glass-ionomer, the waiting period of 24 h is highly advisable. The resin composite suffered more than the other test materials. A second statement is that one must be cautious by the extrapolation of findings obtained on quasi static tests (Young's modulus) towards dynamic properties (flexural fatigue limit).

The impact of composite structure on its elastic response.

The non-destructive determination of Young's modulus of dental composites by means of the fundamental period was found to be reliable and accurate. Post-polymerization effects could clearly be detected. Exponential regression analysis showed a correlation coefficient of 0.92, after logarithmic transformation, with volumetric filler content. The high accuracy and reliability of the measurements themselves are reflected in low standard deviations. The results are in excellent agreement with those of other investigations. Furthermore, the ease and speed of operation make this new procedure a powerful laboratory tool for material-testing and practical large-scale investigations.

Morphological aspects of the resin-dentin interdiffusion zone with different dentin adhesive systems.

Cross-sections of resin-dentin interfaces were etched with an argon-ion beam to make their substructure detectable by scanning electron microscopy. The dentin adhesive systems were categorized morphologically into three groups, and an attempt was made to clarify their adhesive mechanism. The first group of products removed the smear layer. The argon-ion bombardment clearly disclosed a hybrid or resin-impregnated dentin layer. It is hypothesized that conditioning with acidic or chelating agents demineralized the dentin surface-layer to a certain depth, leaving behind a collagen-rich mesh-work. Hydrophilic monomers are then believed to alter this collagen-fiber arrangement in a way that facilitates penetration of the adhesive resin, resulting in a mechanical, intermingled link between collagen and the adhesive resin. The second group preserved the smear layer. In this case, the dentinal tubules were obliterated with globular particles at their orifices and remained patent underneath these smear plugs. This type of adhesive system aims at the incorporation of the smear layer into the hydrophilic monomers, which have an affinity for the organic and/or inorganic components of the underlying dentin. Finally, a third, small group only partly dissolved the smear layer, creating a thin resin-impregnated dentin layer and a resin-impregnated smear plug. This study clearly showed that the application of recent adhesive systems induced structural changes in the dentin surface morphology, creating a retentive interface, called the inter-diffusion zone, between the deep, untouched dentin layers and the composite filling material. This resin-dentin interdiffusion zone offers bonding sites for copolymerization with the resin composite and, concurrently, might have protective potential for the pulp tissues.

The surface roughness of enamel-to-enamel contact areas compared with the intrinsic roughness of dental resin composites.

The purpose of this study was to determine the surface roughness of enamel-to-enamel contact areas in order to provide a standard for comparison with surface characteristics of commercially available composite restorative materials. In addition, the inherent surface roughness of resin composites was evaluated profilometrically after a toothbrush abrasion procedure. A one-sided t-test analysis was performed to outline significant differences between the surface roughness value of enamel facets and that of the respective composite samples. A surface roughness of 0.64 +/- 0.25 micron (mean +/- S.D.) was found for the enamel-to-enamel contact areas.

Comparative physico-mechanical characterization of new hybrid restorative materials with conventional glass-ionomer and resin composite restorative materials.

The recently developed hybrid restorative materials contain the essential components of conventional glass ionomers and light-cured resins. The objective of this study was to determine several physical and mechanical properties of eight such materials in comparison with two conventional glass ionomers, one micro-filled, and one ultrafine compact-filled resin composite. The two resin composites and two of the three polyacid-modified resin composites could be polished to a higher gloss than the conventional as well as the resin-modified glass ionomers. After abrasion, surface roughness increased for all materials, but not at the same extent, being the least for the conventional resin composites and one polyacid-modified resin composite, Dyract. In contrast to the later resin composites, of which the surface roughness is principally determined by the presence of protruding filler particles above the resin matrix, roughness of conventional and resin-modified glass ionomers results from both protruding filler particles and intruding porosities. The mean particle size of the hybrid restorative materials fell between the smaller mean particle size of the resin composites and the larger one of the conventional glass ionomers. The micro-hardness and Young's modulus values varied substantially among all eight hybrid restorative materials. For all the resin-modified glass-ionomer restorative materials, the Young's modulus reached a maximum value one month after mixing and remained relatively stable thereafter. The Young's modulus of the conventional and the polyacid-modified resin composites decreased slightly after one month. The conventional glass-ionomer materials undoubtedly set the slowest, since their Young's modulus took six months to reach its maximum. The flexural fatigue limit of the hybrid restorative materials is comparable with that of the micro-filled composite. From this investigation, it can be concluded that the physico-mechanical properties vary widely among the eight hybrid restorative materials, indicating that these materials probably have yet to achieve their optimum properties. Their mechanical strength is inadequate for use in stress-bearing areas, and their appearance keeps them from use where esthetics is a primary concern.

Quantitative in vivo wear of human enamel.

In this study, the attrition wear, also called occlusal-contact-area wear, of human enamel was measured quantitatively with a computerized three-dimensional measuring technique over a period of four years. Tooth replicas from a clinical trial were used. A running-in wear period after restorative treatment, followed by steady-state wear, was suggested. The average steady-wear rate on occlusal contact areas was about 29 microns per year for molars and about 15 microns per year for premolars.

Characterization of composite resins by NMR and TEM.

This investigation demonstrated that the monomer composition of the investigated restorative resins varied from brand to brand. The NMR analysis showed that most filling materials contained the bis-GMA, iso-bis-GMA, and TEDMA monomers in varying concentrations. The high TEDMA monomer concentration in the smooth-surface composites and, in one case (Isopast and Isocap), the total absence of the bis-GMA system are clearly evident. We can, therefore, expect that the clinical properties of the microfilled, smooth-surface materials cannot be generalized inside the group, and that they will differ from those of the conventional composites. The use of submicron filling particles in the matrix phase is also present in some conventional materials.

Stiffness increase during the setting of dental composite resins.

Changes in the dynamic Young's modulus under flexure of self-cured and light-cured composite resins during setting were demonstrated to reflect accurately the condition of the curing composite resins. The rate of stiffness increase during setting varied considerably with the product, and the light-cured composite resins generally showed a faster rate of increase of stiffness. In the initial stage, the Young's moduli were very low, especially for the self-cured composite resins. This accounts for the damage (adhesion disruption and cross-linking interruption) that can be inflicted on a freshly placed composite resin filling that is not yet mechanically stabilized. Therefore, such fillings are vulnerable to aggressive distortion for at least 10 to 15 minutes after placement.

Clinical status of ten dentin adhesive systems.

Laboratory testing of dentin adhesive systems still requires corroboration by long-term clinical trials for their ultimate clinical effectiveness to be validated. The objective of this clinical investigation was to evaluate, retrospectively, the clinical effectiveness of earlier-investigated dentin adhesive systems (Scotchbond, Gluma, Clearfil New Bond, Scotchbond 2, Tenure, and Tripton), and to compare their clinical results with those obtained with four modern total-etch adhesive systems (Bayer exp. 1 and 2, Clearfil Liner Bond System, and Scotchbond Multi-Purpose). In total, 1177 Class V cervical lesions in the teeth of 346 patients were restored following two cavity designs: In Group A, enamel was neither beveled nor intentionally etched, as per ADA guidelines; in Group B, adjacent enamel was beveled and conditioned. Clinical retention rates definitely indicated the improved clinical efficacy of the newest dentin adhesives over the earlier systems. With regard to adhesion strategy, adhesive systems that removed the smear layer and concurrently demineralized the dentin surface layer performed clinically better than systems that modified the disorderly layer of smear debris without complete removal. Hybridization by resin interdiffusion into the exposed dentinal collagen layer, combined with attachment of resin tags into the opened dentin tubules, appeared to be essential for reliable dentin bonding but might be insufficient by itself. The additional formation of an elastic bonding area as a polymerization shrinkage absorber and the use of a microfine restorative composite apparently guaranteed an efficient clinical result. The perfect one-year retention recorded for Clearfil Liner Bond System and Scotchbond Multi-Purpose must be confirmed at later recalls.

Comparative SEM and TEM examination of the ultrastructure of the resin-dentin interdiffusion zone.

The resin-dentin interdiffusion zone produced by a dentin-adhesive system that removes the smear layer and concurrently decalcifies superficial dentin was morphologically examined by both scanning and transmission electron microscopy. Cross-sectioned resin-bonded dentin discs were etched with an argon-ion beam to make the resin-dentin interface observable by SEM. For the TEM examination, the sections were partly decalcified by an aqueous EDTA solution to facilitate ultramicrotomy and to disclose the ultrastructure of the interdiffusion zone. Both SEM and TEM confirmed the presence of the resin-dentin interdiffusion zone as the junction between the deep unaltered dentin structure and the restorative resin. Within the interdiffusion zone, three sublayers with characteristic ultrastructure and staining were identified by TEM. An upper diffuse black layer contained few structural features. Underneath, partially-altered collagen fibrils were closely packed, mostly running parallel with the interface and perpendicular to the dentinal tubules. Their outline was electron-dense, forming tunnel-like structures. At the base of the upper layer, several stained projections were found to bulge out into the underlying collagen network and appeared to be confined by obstructive, parallel-running collagen fibrils. Finally, the third dense layer, containing hydroxyapatite crystals, demarcated the superficially demineralized dentin layer from the deeper unaltered dentin. Resin diffusion into the decalcified dentin surface layer was evident, but diminished with depth, presumably reducing deeper resin impregnation into the interfibrillar spaces. The citric acid dentin-pretreatment probably caused denaturation of the superficial collagen fibrils. Its decalcifying effect gradually weakened with depth, leaving behind hydroxyapatite crystals at the base of the interdiffusion zone.(ABSTRACT TRUNCATED AT 250 WORDS)

Unreacted methacrylate groups on the surfaces of composite resins.

The unreacted methacrylate groups on the surface of conventional composites and microfilled composites were studied by means of multiple internal reflection infrared spectroscopy. The influences of polymerization time, temperature, and the effect of polishing were studied. We also attempted to relate the results of some mechanical tests to the degree of chemical unsaturation measured in the different resins. All surface treatment and manipulative variables caused a decrease in double bond content and interfacial bond strength.

The relationship between test methodology and elastic behavior of composites.

Comparisons were made of the Young's moduli obtained with tests that impose static, low-frequency, or high-frequency elastic deformations on dental composite systems. The frequency of the imposed stress was reflected in the absolute value of Young's modulus. However, the values obtained at different test frequencies could be compared and understood by taking into account this frequency dependence. It was thus found that the composite structure largely determined the type of reaction to the imposed stress. The fundamental period test permitted the greatest differentiation in the elastic behavior of the investigated composites.

Improved filler-matrix coupling in resin composites.

Ineffective silane coupling between filler and matrix within dental composites is prone to accelerated in vivo degradation. In this study, we examined to what degree a procedure involving chemical decontamination of filler prior to silanization could improve the filler-matrix bonding, and thus the physico-mechanical properties, of composites. X-ray photoelectron spectroscopy revealed that filler-matrix coupling largely depended upon siloxane bridge (Si-O-Si) formation between the silica surface and the silane molecule, rather than on intermolecular bonding between adjacent silane molecules. Pre-silanization decontamination based upon boiling silica in 0.05-5% sodium peroxodisulfate, followed by ultrasonic rinsing in acetone, most effectively decontaminated filler. Consequently, it significantly improved the bonding of silane molecules to silanol groups at the silica surface. Experimental composites produced following pre-silanization decontamination of filler revealed a diametral tensile strength that was resistant to degradation by thermocycling.

Evidence of chemical bonding at biomaterial-hard tissue interfaces.

For many years, glass-polyalkenoate cements have been described as possessing the unique properties of self-adherence to human hard tissues, such as bones or teeth. However, direct experimental evidence to prove the existence of chemical bonding has not been advanced. X-ray Photoelectron Spectroscopy (XPS) was used to analyze the chemical interaction of a synthesized polyalkenoic acid with enamel and synthetic hydroxyapatite. For both enamel and hydroxyapatite, the peak representing the carboxyl groups of the polyalkenoic acid was detected to have significantly shifted to a lower binding energy. De-convolution of this shifted peak disclosed two components with a peak representing unreacted carboxyl groups and a peak suggesting chemical bonding to hydroxyapatite. On average, 67.5% of the carboxyl groups of the polyalkenoic acid were measured to have bonded to hydroxyapatite. XPS of hydroxyapatite also disclosed its surface to be enriched in calcium and decreased in phosphorus, indicating that phosphorus was extracted at a relatively higher rate than calcium. Analysis of these data supports the mechanism in which carboxylic groups replace phosphate ions (PO4(3-)) of the substrate and make ionic bonds with calcium ions of hydroxyapatite. It is concluded that an ultrathin layer of a polyalkenoic acid can be prepared on a hydroxyapatite-based substrate by careful removal of non-bonded molecules. With this specimen-processing method, XPS not only provided direct evidence of chemical bonding, but also enabled us to quantify the percentages of functional groups of the polyalkenoic acids that bonded to calcium of hydroxyapatite.

Chemical characterization of the resin-dentin interface by micro-Raman spectroscopy.

The chemical nature of the interface between dentin and adhesive resin materials was characterized by micro-Raman spectroscopy. The resulting chemical profiles were correlated with photomicrographs obtained by SEM after an argon-ion-beam etching treatment of the sample surface. Two commercially available dentin adhesive systems, of which one was also applied with a different conditioning agent, were investigated. Raman spectra, which were recorded along line scans across the interface with a step increment of 1 micron, revealed that resin effectively penetrated 4 to 6 microns deep into the superficially decalcified dentin zone. Across the interface, a gradual transition from resin to dentin over the interdiffusion zone with a mixed contribution of both substances was noticed. Finally, resin appeared to penetrate to the entire decalcification depth of dentin regardless of the aggressiveness of the conditioning procedure.

Assessment by nano-indentation of the hardness and elasticity of the resin-dentin bonding area.

The hardness and Young's modulus of the successive layers across a resin-dentin bonding area were determined by nano-indentation for four commercially-available dentin adhesive systems, of which two were also applied with a different conditioning agent. With a computer-controlled nano-indentation technique, minute triangular indentations were made within a small area of a few micrometers' diameter at a load of a few milli-Newtons. The load and displacement of the indenter were continuously monitored during the loading-unloading sequence, so hardness and Young's modulus could be computed as a function of the indenter geometry and the applied load. The hardness of the resin-dentin interdiffusion zone was significantly lower than that of unaltered dentin. A gradient of moduli of elasticity was observed from the rather stiff dentin over a more elastic resin-dentin interdiffusion zone and adhesive resin layer to the restorative composite. That gradient was more substantial in those systems that produced relatively thick adhesive resin layers or supplementally provided a filled low-viscosity resin as an intermediate layer between the adhesive resin and the bulk restorative composite. Such an elastic bonding area might have a strain capacity sufficient to relieve stresses between the shrinking composite restoration and the rigid dentin substrate, thereby improving the conservation of the dentin bond and, as a consequence, the marginal integrity and retention of the restoration.

A TEM study of two water-based adhesive systems bonded to dry and wet dentin.

To keep the exposed collagen scaffold penetrable to resin, it has been recommended that the conditioned dentin surface be maintained in a visibly moist condition, a clinical technique commonly referred to as wet bonding. In this study, resin-dentin interfaces produced with two water-based adhesive systems--OptiBond (OPTI, Kerr) and Scotchbond Multi-Purpose (SBMP, 3M)--were compared by transmission electron microscopy, following the application of either a dry- or a wet-bonding technique. The hypothesis advanced was that the ultramorphology of the hybrid layer would differ depending on which bonding method was applied. A morphologically well-organized hybrid layer of collagen fibrils intermingled with resin in tiny interfibrillar channels was consistently formed by the OPTI system. The SBMP system was found to produce a hybrid layer with a more variable ultrastructure, less distinctly outlined collagen fibrils, and a characteristic electron-dense phase located at its surface. No major differences in hybrid layer ultrastructure were observed when the two adhesive systems investigated were bonded to either dry or wet dentin. When the adhesives were dry-bonded, no ultrastructural evidence of collapsed demineralized collagen, incompletely or not at all infiltrated by resin, could be detected. In addition, when the two adhesives were bonded to wet dentin, no signs of overwetting phenomena, that would have indicated that water was ineffectively removed, were apparent. It has been hypothesized that the amount of water provided with the hydrophilic primer solution of either of the two adhesive systems investigated suffices to re-hydrate and re-expand the gently air-dried and collapsed collagen network. Further research should be directed to determine whether this hypothesized self-rewetting effect can be extrapolated to other adhesive systems that provide water-based primers.

Adhesion to and decalcification of hydroxyapatite by carboxylic acids.

Fundamental to the processes of decalcification of or adhesion to mineralized tissues is the molecular interaction of acids with hydroxyapatite. This study was undertaken to chemically analyze the interaction of 1 mono-, 2 di-, 1 tri-, and 2 polycarboxylic acids with hydroxyapatite in an attempt to elucidate the underlying mechanism. Maleic, citric, and lactic acid decalcified hydroxyapatite, in contrast to oxalic acid and the two polycarboxylic acids that were chemically bonded to hydroxyapatite. Solubility tests showed that the calcium salts of the former were very soluble, whereas those of the latter could hardly be dissolved in the respective acid solutions. Based on these data, an adhesion/decalcification concept was advanced that predicts that carboxylic acids, regardless of concentration/pH, either adhere to or decalcify hydroxyapatite, depending on the dissolution rate of the respective calcium salts in the acid solution. This contrasting behavior of organic acids most likely results from their differential structural conformations.

Four-year water degradation of total-etch adhesives bonded to dentin.

Resin-dentin bonds degrade over time. The objective of this study was to evaluate the influence of variables like hybridization effectiveness and diffusion/elution of interface components on degradation. Hypotheses tested were: (1) There is no difference in degradation over time between two- and three-step total-etch adhesives; and (2) a composite-enamel bond protects the adjacent composite-dentin bond against degradation. The micro-tensile bond strength (microTBS) to dentin of 2 three-step total-etch adhesives was compared with that of 2 two-step total-etch adhesives after 4 years of storage in water. Quantitative and qualitative failure analyses were conducted correlating Fe-SEM and TEM. Indirect exposure to water did not significantly reduce the microTBS of any adhesive, while direct exposure resulted in a significantly reduced microTBS of both two-step adhesives. It is concluded that resin bonded to enamel protected the resin-dentin bond against degradation, while direct exposure to water for 4 years affected bonds produced by two-step total-etch adhesives.