Biomechanical impact of labiolingual diameter on endodontically treated anterior teeth with crown restoration under occlusal loading.

OBJECTIVE: To evaluate the effect of the labiolingual diameter and construction of an endodontically treated (ET) anterior tooth with crown restoration on stress distribution and biomechanical safety under occlusal loading. METHODOLOGY: Three-dimensional finite element models were generated for maxillary central incisors with all-ceramic crown restorations. The labiolingual diameters of the tooth, defined as the horizontal distance between the protrusion of the labial and lingual surfaces, were changed as follows: (D1) 6.85 mm, (D2) 6.35 mm, and (D3) 5.85 mm. The model was constructed as follows: (S0) vital pulp tooth; (S1) ET tooth; (S2) ET tooth with a 2 mm ferrule, restored with a fiber post and composite resin core; (S3) ET tooth without a ferrule, restored with a fiber post and composite resin core. A total of 12 models were developed. In total, two force loads (100 N) were applied to the crown's incisal edge and palatal surface at a 45° oblique angle to the longitudinal axis of the teeth. The Von Mises stress distribution and maximum stress of the models were analyzed. RESULTS: Regardless of the loading location, stress concentration and maximum stress (34.07~66.78MPa) in all models occurred in the labial cervical 1/3 of each root. Both labiolingual diameter and construction influenced the maximum stress of the residual tooth tissue, with the impact of the labiolingual diameter being greater. A reduction in labiolingual diameter led to increased maximum stress throughout the tooth. The ferrule reduced the maximum stress of the core of S2 models (7.15~10.69 MPa), which is lower compared with that of S3 models (19.45~43.67 MPa). CONCLUSION: The labiolingual diameter exerts a greater impact on the biomechanical characteristics of ET anterior teeth with crown restoration, surpassing the influence of the construction. The ferrule can reduce the maximum stress of the core and maintain the uniformity of stress distribution.

Exploring the use of pulsed erbium lasers to retrieve a zirconia crown from a zirconia implant abutment.

BACKGROUND: Removal of cement-retained implant fixed restorations when needed, can be challenging. Conventional methods of crown removal are time consuming and costly for patients and practitioners. This research explored the use of two different types of pulsed erbium lasers as a non-invasive tool to retrieve cemented zirconia crowns from zirconia implant abutments. MATERIALS AND METHODS: Twenty identical zirconia crowns were cemented onto 20 identical zirconia prefabricated abutments using self-adhesive resin cement. The specimens were divided into two groups for laser assisted crown removal; G1 for erbium-doped yttrium aluminum garnet laser (Er:YAG), and G2 for erbium, chromium-doped yttrium, scandium, gallium and garnet (Er,Cr:YSGG). For the G1, after the first crown removal, the specimens were re-cemented and removed again using the Er:YAG laser. Times needed to remove the crowns were recorded and analyzed using ANOVA (α = 0.05). The surfaces of the crown and the abutment were further examined using scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS) analyses. RESULTS: The average times of zirconia crown removal from zirconia abutments were 5 min 20 sec and 5 min 15 sec for the Er:YAG laser of first and second experiments (G1), and 5 min 55 sec for the Er,Cr:YSGG laser experiment (G2). No statistical differences were observed among the groups. SEM and EDS examinations of the materials showed no visual surface damaging or material alteration from the two pulsed erbium lasers. CONCLUSIONS: Both types of pulsed erbium lasers can be viable alternatives for retrieving a zirconia crown from a zirconia implant abutment. Despite operating at different wavelengths, the Er:YAG and Er,Cr:YSGG lasers, perform similarly in removing a zirconia crown from a zirconia implant abutment with similar parameters. There are no visual and elemental composition damages as a result of irradiation with pulsed erbium lasers.

Effect of ageing and endodontic treatment on the thermal stability of human dentin.

BACKGROUND: Human dentin is a highly calcified tissue of mesenchymal origin with a heterogeneous structure. Its morphology is constantly remodelled throughout the life span of the tooth, as well as under the influence of external stimuli. OBJECTIVE: The aim of the present study was to obtain information about the thermal changes in the crown and root dentin specimens of vital and devitalized teeth. METHODS: The investigated samples were divided into 6 groups, depending on the patients' age and dentin location (crown, root). An additional group of endodontically treated teeth was created. The methods of choice were were combined thermal analysis (DTA-TG(DTG)-MS and gas chromatography-mass spectrometry. RESULTS: After heating up to 1200 °C, endo- and exothermal effects were observed. The effects' dynamic was the same for all samples. The differences were in the samples' weight after the experiment, with root dentin showing the greatest mass loss percentage. CONCLUSIONS: The observed mass loss differences could be attributed to the presence of impurities in the dentin, as well as alterations in the collagen matrix. Ageing and endodontic treatment could catalyse the accumulation of such changes and affect the microstructure of the mineralized tissue.

Effects of anterior tooth crown inclination on occlusal relationship-A study in three-dimensional reconstruction.

OBJECTIVE: This study aims to analyze the relationship between the central incisor crown inclination and occlusal relationship via three-dimensional study. METHODS: Ten Chinese volunteers with normal occlusion were selected from physical examination of college students. Lateral cephalograms and CT scans were taken, and the CT data were imported into Simplant pro 11.04 to reconstruct three-dimensional model. In the three-dimensional model, every tooth was separated independently. The upper and lower central incisors were moved labial inclination(up) or lingual inclination(down) and then the upper and lower tooth were aligned based on the central incisor's position according to the principles of Andrew's six keys. Four groups were set up with different changes of central incisors. The upper and the lower arch were aligned again based on the moved central incisors. After every motion, the mesio-distal distances of upper and lower canines and first molars were recorded. All data were analyzed using t-test via SPSS19.0, and the significance level was set at 5%. RESULTS: The results showed that the mesio-distal distances of occlusal relationship were different from normal occlusal relations, when either upper incisor crown inclination or lower incisor crown inclination was changed, and both upper and lower incisor crown inclination were moved in same or opposite direction. According to the statistical analysis, there was no significant difference when the changes of U1-L1 were no more than 10° (P > 0.05). But there was statistically significant difference (P < 0.05) when changes of U1-L1 were more than 20°. CONCLUSIONS: The incisor crown inclination has influence on the establishment of occlusal relationships. The bigger difference upper and lower incisor crown inclination has, the more deviations from the normal occlusal relationship exist.

A Force on the Crown and Tug of War in the Periodontal Complex.

The load-bearing dentoalveolar fibrous joint is composed of biomechanically active periodontal ligament (PDL), bone, cementum, and the synergistic entheses of PDL-bone and PDL-cementum. Physiologic and pathologic loads on the dentoalveolar fibrous joint prompt natural shifts in strain gradients within mineralized and fibrous tissues and trigger a cascade of biochemical events within the widened and narrowed sites of the periodontal complex. This review highlights data from in situ biomechanical simulations that provide tooth movements relative to the alveolar socket. The methods and subsequent results provide a reasonable approximation of strain-regulated biochemical events resulting in mesial mineral formation and distal resorption events within microanatomical regions at the ligament-tethered/enthesial ends. These biochemical events, including expressions of biglycan, decorin, chondroitin sulfated neuroglial 2, osteopontin, and bone sialoprotein and localization of various hypertrophic progenitors, are observed at the alkaline phosphatase-positive widened site, resulting in mineral formation and osteoid/cementoid layers. On the narrowed side, tartrate-resistant acid phosphatase regions can lead to a sequence of clastic activities resulting in resorption pits in bone and cementum. These strain-regulated biochemical and subsequently biomineralization events in the load-bearing periodontal complex are critical for maintenance of the periodontal space and overall macroscale joint biomechanics.

Incisor inclination and perceived tooth colour changes.

INTRODUCTION: Social attractiveness is influenced by a variety of different smile-related factors. We evaluated whether the degree of upper central incisor proclination can result in tooth colour change. METHODS: Forty young adult subjects (20-25 years) in good health with a complete sound dentition were selected. The subjects were seated in standardized light conditions with an above-directed light source. Their natural head position was stated as 0 degrees. To mimic the range of possible anterior torque movements they were asked to tilt their heads upward +15 degrees (upward tilting) and downward -15 degrees (downward tilting). Frontal macro photographs, parallel to the Frankfort plane of the patient's natural head position were taken at the three head angulations (+15, 0, and -15 degrees ). Photographs were analysed for colour differences at the centre of the incisor clinical crowns with a CIE L*a*b* colour model based software. A paired t-test was used to test for significance between each value for each inclination. RESULTS: Differences were found between the CIE L*a*b* colour values for: upward tilting, downward tilting, and -15 to +15 degrees (total tilting) except for b* values for downward tilting. As the inclination of the subject's head changed downward, the upper incisors were retroclined and the CIE L*a*b* values indicated a darker and less green but redder colour component. As the inclination of the subject's head changed upwards the upper incisors were proclined and the L*a*b* values indicated a lighter and less green and yellow but redder and bluer colour component. CONCLUSIONS: Proclination of upper incisors caused lighter tooth colour parameters compared to retroclined incisors and colour changes. Orthodontic change of upper incisor inclination may induce alterations on how tooth colour is perceived.

Cellular and molecular mechanisms of tooth root development.

The tooth root is an integral, functionally important part of our dentition. The formation of a functional root depends on epithelial-mesenchymal interactions and integration of the root with the jaw bone, blood supply and nerve innervations. The root development process therefore offers an attractive model for investigating organogenesis. Understanding how roots develop and how they can be bioengineered is also of great interest in the field of regenerative medicine. Here, we discuss recent advances in understanding the cellular and molecular mechanisms underlying tooth root formation. We review the function of cellular structure and components such as Hertwig's epithelial root sheath, cranial neural crest cells and stem cells residing in developing and adult teeth. We also highlight how complex signaling networks together with multiple transcription factors mediate tissue-tissue interactions that guide root development. Finally, we discuss the possible role of stem cells in establishing the crown-to-root transition, and provide an overview of root malformations and diseases in humans.

Importance of tubule density to the fracture toughness of dentin.

OBJECTIVE: The fracture toughness of dentin is critical to the prevention of tooth fracture. Within the tooth crown, the mechanical properties of dentin are influenced by spatial variations in the density and diameter of the dentin tubules with distance from the pulp. There are also relevant changes to the microstructure of dentin with age. In this investigation the importance of tubule density to the fracture toughness of dentin was evaluated in "young" and "old" age groups. METHODS: The variations in microstructure (density and diameter of tubules) from young and old donor teeth were studied by means of optical microscopy. RESULTS: A reduction in the density and diameter of tubules was identified to occur with aging. An approach previously proposed to study the mechanical behavior of porous materials was used to model the fracture toughness of coronal dentin in terms of the tubule characteristics. Results were then compared with published results from previous studies. CONCLUSIONS: The model predictions were consistent with experimental results for the fracture toughness of dentin from young donor teeth, but overestimated the values that have been reported for "old" dentin.

Violet and blue light-induced green fluorescence emissions from dental caries.

BACKGROUND: The objective of this laboratory study was to compare violet and visible blue LED light-elicited green fluorescence emissions from enamel and dentine in healthy or carious states. METHODS: Microscopic digital photography was undertaken using violet and blue LED illumination (405 nm and 455 nm wavelengths) of tooth surfaces, which were photographed through a custom-made stack of green compensating filters which removed the excitation light and allowed green fluorescence emissions to pass. Green channel pixel data were analysed. RESULTS: Dry sound enamel and sound root surfaces showed strong green fluorescence when excited by violet or blue lights. Regions of cavitated dental caries gave lower green fluorescence, and this was similar whether the dentine in the lesions was the same colour as normal dentine or was darkly coloured. The presence of saliva on the surface did not significantly change the green fluorescence, while the presence of blood diluted in saliva depressed green fluorescence. CONCLUSIONS: Using violet or blue illumination in combination with green compensating filters could potentially aid in the assessment of areas of mineral loss.

Comprehensive analyses of how tubule occlusion and advanced glycation end-products diminish strength of aged dentin.

In clinical dentistry, since fracture is a major cause of tooth loss, better understanding of mechanical properties of teeth structures is important. Dentin, the major hard tissue of teeth, has similar composition to bone. In this study, we investigated the mechanical properties of human dentin not only in terms of mineral density but also using structural and quality parameters as recently accepted in evaluating bone strength. Aged crown and root dentin (age ≥ 40) exhibited significantly lower flexural strength and toughness than young dentin (age < 40). Aged dentin, in which the dentinal tubules were occluded with calcified material, recorded the highest mineral density; but showed significantly lower flexural strength than young dentin. Dentin with strong alignment of the c-axis in hydroxyapatite exhibited high fracture strength, possibly because the aligned apatite along the collagen fibrils may reinforce the intertubular dentin. Aged dentin, showing a high advanced glycation end-products (AGEs) level in its collagen, recorded low flexural strength. We first comprehensively identified significant factors, which affected the inferior mechanical properties of aged dentin. The low mechanical strength of aged dentin is caused by the high mineral density resulting from occlusion of dentinal tubules and accumulation of AGEs in dentin collagen.

The Effect of Resin-modified Glass-ionomer Cement Base and Bulk-fill Resin Composite on Cuspal Deformation.

OBJECTIVES: This study investigated cuspal deformation in teeth restored with different types of adhesive materials with and without a base. METHODS: Mesio-occluso-distal slot cavities of moderately large dimension were prepared on extracted maxillary premolars (n=24). Teeth were assigned to one of four groups and restored with either a sonic-activated bulk-fill resin composite (RC) (SonicFill), or a conventional nanohybrid RC (Herculite Ultra). The base materials used were a flowable nanofilled RC (Premise Flowable) and a high-viscosity resin-modified glass-ionomer cement (RMGIC) (Riva Light-Cure HV). Cuspal deflection was measured with two direct current differential transformers, each contacting a buccal and palatal cusp. Cuspal movements were recorded during and after restoration placement. Data for the buccal and palatal cusp deflections were combined to give the net cuspal deflection. RESULTS: Data varied widely. All teeth experienced net inward cuspal movement. No statistically significant differences in cuspal deflection were found among the four test groups. CONCLUSIONS: The use of a flowable RC or an RMGIC in closed-laminate restorations produced the same degree of cuspal movement as restorations filled with only a conventional nanohybrid or bulk-fill RC.

Finite element method analysis of the periodontal ligament in mandibular canine movement with transparent tooth correction treatment.

BACKGROUND: This study used the 3D finite element method to investigate canine's displacements and stresses in the canine's periodontal ligament (PDL) during canine's translation, inclination, and rotation with transparent tooth correction treatment. METHODS: Finite element models were developed to simulate dynamic orthodontic treatments of the translation, inclination, and rotation of the left mandibular canine with transparent tooth correction system. Piecewise static simulations were performed to replicate the dynamic process of orthodontic treatments. The distribution and change trends of canine's displacements and stresses in the canine's PDL during the three types of tooth movements were obtained. RESULTS: Maximum displacements were observed at the crown and middle part in the translation case, at the crown in the inclination case, and at the crown and root part in the rotation case. The relative maximum von Mises and principal stresses were mainly found at the cervix of the PDL in the translation and inclination cases. In the translation case, tensile stress was mainly observed on the mesial and distal surfaces near the lingual side and compressive stress was located at the bottom of the labial surface. In the inclination case, tensile stress was mainly observed at the labial cervix and lingual apex and compressive stress was located at the lingual cervix and labial apex. In the rotation case, von Mises stress was mainly located at the cervix and inside the lingual surface, tensile stress was located on the distal surface, and compressive stress was detected on the mesial surface. The stress and displacement value rapidly decreased in the first few steps and then reached a plateau. CONCLUSIONS: Canine's movement type significantly influences the distribution of canine's displacement and stresses in the canine's PDL. Changes in canine's displacement and stresses in the canine's PDL were exponential in transparent tooth correction treatment.

Biomechanical effects of corticotomy approaches on dentoalveolar structures during canine retraction: A 3-dimensional finite element analysis.

INTRODUCTION: Corticotomy has proven to be effective in facilitating orthodontic tooth movement. There is, however, no relevant study to compare the biomechanical effects of different corticotomy approaches on tooth movement. In this study, a series of corticotomy approaches was designed, and their impacts on dentoalveolar structures were evaluated during maxillary canine retraction with a 3-dimensional finite element method. METHODS: A basic 3-dimensional finite element model was constructed to simulate orthodontic retraction of the maxillary canines after extraction of the first premolars. Twenty-four corticotomy approach designs were simulated for variations of position and width of the corticotomy. Displacement of the canine, von Mises stresses in the canine root and trabecular bone, and strain in the canine periodontal ligament were calculated and compared under a distal retraction force directed to the miniscrew implants. RESULTS: A distal corticotomy cut and its combinations showed the most approximated biomechanical effects on dentoalveolar structures with a continuous circumscribing cut around the root of the canine. Mesiolabial and distopalatal cuts had a slight influence on dentoalveolar structures. Also, the effects decreased with the increase of distance between the corticotomy and the canine. No obvious alteration of displacement, von Mises stress, or strain could be observed among the models with different corticotomy widths. CONCLUSIONS: Corticotomies enable orthodontists to affect biomechanical responses of dentoalveolar structures during maxillary canine retraction. A distal corticotomy closer to the canine may be a better option in corticotomy-facilitated canine retraction.

Modifying the biomechanical response of mouthguards with hard inserts: A finite element study.

PURPOSE: To investigate the influence of a high elastic modulus material insert on the stress, shock absorption and displacement of mouthguards. METHODS: Finite element models of a human maxillary central incisor with and without mouthguard were created based on cross-sectional CT-tomography. The mouthguard models had four designs: without insert, and middle, external, or palatal hard insert. The hard inserts had a relatively high elastic modulus when compared to the elastic modulus of ethylene vinyl acetate (EVA): 15 GPa versus 18 MPa. A non-linear dynamic impact analysis was performed in which a heavy rigid object hit the model at 1 m/s. Strain and stress (von Mises and critical modified von Mises) distributions and shock absorption during impact were calculated as well as the mouthguard displacement. RESULTS: The model without mouthguard had the highest stress values at the enamel and dentin structures in the tooth crown during the impact. It was concluded that the use of a mouthguard promoted lower stress and strain values in the teeth during impact. Hard insertion in the middle and palatal side of the mouthguard improved biomechanical response by lowering stress and strain on the teeth and lowering mouthguard displacement.

Incisor crown bending strength correlates with diet and incisor curvature in anthropoid primates.

Anthropoid incisors are large relative to the postcanine dentition and function in the preprocessing of food items. Previous analyses of anthropoid incisor allometry and shape demonstrate that incisor morphology is correlated with preferred foods and that more frugivorous anthropoids have larger and more curved incisors. Although the relationship between incisal crown curvature and preferred foods has been well documented in extant and fossil anthropoids, the functional significance of curvature variation has yet to be conclusively established. Given that an increase in crown curvature will increase maximum linear crown dimensions, and bending resistance is a function of linear crown dimensions, it is hypothesized that incisor crown curvature functons to increase incisor crown resistance to bending forces. This study uses beam theory to calculate the mesiodistal and labiolingual bending strengths of the maxillary and mandibular incisors of hominoid and platyrrhine taxa with differing diets and variable degrees of incisal curvature. Results indicate that bending strength correlates with incisal curvature and that frugivores have elevated incisor bending resistance relative to folivores. Maxillary central incisor bending strengths further discriminate platyrrhine and hominoid hard- and soft-object frugivores suggesting this crown is subjected to elevated occlusal loading relative to other incisors. These results are consistent with the hypothesis that incisor crown curvature functions to increase incisor crown resistance to bending forces but does not preclude the possibility that incisor bending strength is a composite function of multiple dentognathic variables including, but not limited to, incisor crown curvature.

Contribution of donor and host mesenchyme to the transplanted tooth germs.

Autologous tooth germ transplantation of immature teeth is an alternative method of tooth replacement that could be used instead of dental implants in younger patients. However, it is paramount that the dental pulp remain vital and that root formation continue in the transplanted location. The goal of this study is to characterize the healing of allogenic tooth grafts in an animal model using GFP-labeled donor or host postnatal mice. In addition, the putative stem cells were labeled before transplantation with a pulse-chase paradigm. Transplanted molars formed cusps and roots and erupted into occlusion by 2 wk postoperatively. Host label-retaining cells (LRCs) were maintained in the center of pulp tissue associating with blood vessels. Dual labeling showed that a proportion of LRCs were incorporated into the odontoblast layer. Host cells, including putative dendritic cells and the endothelium, also immigrated into the pulp tissue but did not contribute to the odontoblast layer. Therefore, LRCs or putative mesenchymal stem cells are retained in the transplanted pulps. Hertwig's epithelial root sheath remains vital, and epithelial LRCs are present in the donor cervical loops. Thus, the dynamic donor-host interaction occurred in the developing transplant, suggesting that these changes affect the characteristics of the dental pulp.

The effect of vertical bracket positioning on torque and the resultant stress in the periodontal ligament--a finite element study.

BACKGROUND: The ideal built-in tip and torque values of the straight wire appliance reduce the need for wire bending and hence reduce chair time. The vertical position of the bracket on the tooth surface can alter the torque exerted on the tooth. This is a result of the altered surface curvature observed at each vertical position. To further clarify the role of vertical bracket positioning on the applied torque and the resultant stresses in the periodontal ligament (PDL), we designed a mandibular first premolar using finite element modeling. METHODS: Cone beam computed tomography of 52 patients (83 lower first premolars) was selected to be included in the study. Curvature was measured for points along the labial surface with increasing distances (0.5 mm increments) from the cusp tip by calculating the angle between tangents drawn from these points and the axis joining the cusp tip and the root apex. The mean values for each distance were calculated, and a finite element model was designed incorporating these mean values. The resultant stress and hydrostatic pressure in the PDL were calculated using finite element analysis. RESULTS: The labial surface of the mandibular first premolar demonstrated a 26.39° change from 2.5 to 6 mm from the cusp tip. The maximum Von-Mises stress and hydrostatic pressure in the PDL were observed at the root apex for all of the bracket positions, and these values demonstrated, respectively, a change of up to 0.059 and 0.186 MPa between two successive points. CONCLUSIONS: It can be concluded that the variation in the vertical position of the bracket can have an important effect on the torque and subsequently on the stresses and pressures in the PDL.

Three-dimensional analysis using finite element method of anterior teeth inclination and center of resistance location.

OBJECTIVE: To locate the centre of resistance of consolidated units of four and six anterior teeth during retraction. METHODS: Twelve three-dimensional (3D) models were designed in SolidWorks of the anterior segment with four and six teeth and their supporting structure. A proper force system was applied in each model to retract the teeth bodily. The exact location of the centre of resistances (CRes) was determined. It was found that the path of CRes change in four-tooth and six-tooth units according to the anterior teeth torque. RESULTS: A posterior shift of the CRes by increasing the inclination of teeth was shown. However, vertical position has a fluctuant behaviour. First it moves apically, then it moves incisally. Furthermore, results suggest that in en masse retraction, translation can be achieved with a smaller amount of moment-to-force ratio than in four-incisor retraction. In other words, for bodily retraction of anterior incisor segments, we should apply force in a more apical position. CONCLUSION: Different anterior torques between 7 and 35 degrees, cannot affect the CRes position dramatically. The area of CRes shifting is 0.92 mm (anterioposteriorly) x 0.74 mm (superior-inferiorly) in the six-tooth unit in the teeth model and 0.85 mm (anterioposteriorly) x 0.82 mm (superior-inferiorly) in the teeth and bone model. In the four-tooth model, the area of CRes shifting is 0.97 mm (anterioposteriorly) x 0.93 mm (superior-inferiorly) in tooth model and 0.77 mm (anterioposteriorly) x 0.87 mm (superior-inferiorly) in the teeth and bone model.

Segmented arch or continuous arch technique? A rational approach.

This study aims at revising the biomechanical principles of the segmented archwire technique as well as describing the clinical conditions in which the rational use of scientific biomechanics is essential to optimize orthodontic treatment and reduce the side effects produced by the straight wire technique.

Cuspal deflection and cervical microleakage scores to determine the adhesive potential of universal bonding systems.

OBJECTIVES: To assess the adhesive performance of three universal bonding systems (self-etch and total-etch protocols) with cuspal deflection and cervical microleakage score. METHODS: Fifty-six standardised sound maxillary premolar teeth with uniform mesio-occlusal-distal (MOD) cavities were randomly allocated to six groups. Restoration with resin-based composite (RBC) was performed in conjunction with a universal bonding system facilitated by a quartz-tungsten-halogen light-curing-unit. The dependent variable was the universal bonding protocol (self-etch or total-etch). Buccal and palatal cuspal deflections were recorded at 0, 30, 60 and 180s post-irradiation using a twin channel deflection measuring gauge. Following restoration, the teeth subjected to 500 thermocycles, immersed in a 0.2% basic fuchsin dye for 24h, sectioned and examined for cervical microleakage. RESULTS: Comparing between bonding protocol (self-etch or total-etch), a decrease in total cuspal deflection and a concomitant increase in cervical microleakage were evident when employing the total-etch compared with the self-etch protocol for two of the three universal dental adhesives. CONCLUSIONS: The 'Adhesion-Decalcification concept' suggests a trend towards 'mild self-etch' adhesives. Differences in adhesive performance (cuspal deflection and cervical microleakage) between the teeth restored using the self-etch or total-etch protocols is suggested to be a result of the pH of the self-etch solutions. 'Mild self-etch' (pH∼2.0) adhesives out-performed ultra-mild (pH>2.5) or strong (pH<1.5) self-etch solutions. CLINICAL SIGNIFICANCE: Poorly performing adhesives could be identified using the cuspal deflection and cervical microleakage protocol reported which could save the complications encountered clinically with Class II RBC restorations.