Resin Bonding To Sclerotic Dentin

Journal of Dentistry (2004) 32, 173196
www.intl.elsevierhealth.com/journals/jden
REVIEW
Resin bonding to cervical sclerotic dentin: A review

Franklin R. Taya,*, David H. Pashleyb
a
Paediatric Dentistry and Orthodontics, Faculty of Dentistry, University of Hong Kong, Prince Philip Dental
Hospital, 34 Hospital Road, Hong Kong, China
b
Department of Oral Biology and Maxillofacial Pathology, Medical College of Georgia, Augusta, GA, USA
Received 10 July 2003; accepted 15 October 2003
KEYWORDS Summary Several reports have indicated that resin bond strengths to noncarious
Sclerotic cervical sclerotic cervical dentine are lower than bonds made to normal dentine. This is
dentine; Resin; Adhesive thought to be due to tubule occlusion by mineral salts, preventing resin tag formation.
The purpose of this review was to critically examine what is known about the structure
of this type of dentine. Recent transmission electron microscopy revealed that in
addition to occlusion of the tubules by mineral crystals, many parts of wedge-shaped
cervical lesions contain a hypermineralised surface that resists the etching action of
both self-etching primers and phosphoric acid. This layer prevents hybridisation of the
underlying sclerotic dentine. In addition, bacteria are often detected on top of the
hypermineralised layer. Sometimes the bacteria were embedded in a partially
mineralised matrix. Acidic conditioners and resins penetrate variable distances into
these multilayered structures. Examination of both sides of the failed bonds revealed a
wide variation in fracture patterns that involved all of these structures. Microtensile
bond strengths to the occlusal, gingival and deepest portions of these wedge-shaped
lesions were significantly lower than similar areas artificially prepared in normal teeth.
When resin bonds to sclerotic dentine are extended to include peripheral sound
dentine, their bond strengths are probably high enough to permit retention of class V
restorations by adhesion, without additional retention.
q 2004 Elsevier Ltd. All rights reserved.
Introduction that our current knowledge on the variability of

clinical bonding substrates is so limited compared
The efficacy of current adhesive systems is often with the progress achieved in adhesive technology.
evaluated based upon their ability to bond to sound This review examined the ultrastructure and bond-
dentine. Although many dentists bond to sound ing characteristics of one type of abnormal bonding
dentine, a variety of pathological dentin substrates substrate noncarious sclerotic dentine. Essentially,
are encountered in the clinical practice, which it compared the obstacles in bonding to sound vs.
include carious and sclerotic dentin. It is ironic sclerotic dentine. It will be seen that there is a
tremendous difference in substrate morphology as
*Corresponding author. Tel.: 86-852-28590251; fax: 86- well as that of the resin dentine interfaces created
852-23933201. by bonding to such substrates. The recent introduc-
E-mail address: kfctay@hknet.com tion of contemporary self-etching primers and
0300-5712/$ - see front matter q 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2003.10.009
174 F.R. Tay, D.H. Pashley
the timely all-in-one adhesives are redefining interface, regional tensile bond strength to cervical
adhesive dentistry. Because these simplified sclerotic root dentine with some contemporary
adhesive systems are easy to use, we have placed adhesives was found to be 20 45% lower than those
extra emphasis on the interfaces created by these bonded to artificial wedge-shaped lesions created in
agents on sclerotic cervical dentine. normal cervical root dentine.40,42 This was attrib-
uted to: (a) the presence of sclerotic casts within
dentinal tubules that precluded optimal resin
infiltration into the dentinal tubules, and/or (b)
Noncarious cervical sclerotic dentine the presence of a surface hypermineralised layer
that is more resistant to acid-etching. It was
Noncarious cervical sclerotic lesions was described
postulated that an adhesive strategy that involved
by Zsigmondy in 18941 as angular defects, and by
micromechanical interlocking by the formation of a
Miller in 19072 as wasting of tooth tissue that was
resin dentine interdiffusion zone combined with
characterised by a slow and gradual loss of tooth
resin-tag formation into the dentinal tubules would
substances resulting in smooth, wedge-shaped
be less effective when applied to the hyperminer-
defects along the cemento-enamel junction. The
alised sclerotic dentine.42,44 Contrary to these
multifactorial etiology of these cervical lesions has
findings, a recent study suggested that phosphoric
been extensively reviewed.3 9 There is increasing acid-etching was detrimental to the bonding of
evidence of the possible role of eccentric occlusal sclerotic dentine, and that sclerotic dentine that
stress in the pathogenesis of these hard tissue was treated with a hydrophilic primer exhibited
defects.10 18 Recent studies on simulation of better marginal adaptation of resin composites than
wedge-shaped cervical lesions using various finite similarly primed normal dentine.45 These authors
element analytical models of cuspal flexure con- recommended that the layer of sclerotic dentine be
firmed the contribution of stress induction in these preserved for optimal bonding in cervical lesions.
so-called abfraction lesions.19 22 Unrestored, Scanning electron microscopy of such surfaces,
angular, wedge-shaped lesions demonstrated even with the use of field emission-type micro-
severe stress concentration that varied with the scopes, does not provide sufficient detail to under-
location of the teeth in the oral cavity, with the stand the complex subsurface structures, or to
highest stress contractions around the maxillary reveal how well these structures are demineralised
incisors and premolars. These stresses were only during etching.28,43 This information is best
partially relieved after these lesions were restored. obtained using transmission electron microscopy
Sclerotic dentine is a clinically relevant bonding (TEM). In this review, extensive TEM examinations
substrate in which the dentine has been physiologi- were used to evaluate biologic variations in
cally and pathologically altered, partly as the sclerotic cervical dentine. This is not an exhaustive
bodys natural defense mechanism to insult, and review of the literature on noncarious cervical
partly as a consequence of colonisation by the oral lesions or in resin-bonding to sclerotic dentine.
microflora. Partial or complete obliteration of the Rather, it is an attempt to summarise a number of
dentinal tubules with tube- or rod-like sclerotic studies that provide a rationale for why resin bonds
casts is commonly observed.23 28 Depending on the to sclerotic, noncarious, wedge-shape cervical
degree of clinical sensitivity of the lesion, various lesions are lower than those made to normal
levels of tubular patency were observed, with most dentine at those same sites. This review will be
dentinal tubules being occluded within the insensi- divided into two sections. In Section 1, microstruc-
tive transparent dentine regions.25,27,29 34 tural changes that exist in noncarious, sclerotic
In the absence of undercut retention, cervical cervical dentine will be summarised. This is
sclerotic dentine was found to be more difficult to followed by a review on the application of adhesive
adhere to than normal dentin both in vitro and in resins to this altered bonding substrate.
vivo, even with increased etching time.35 39 Recent
studies showed that the sclerotic casts that
obliterated the dentinal tubules were still present
after acid-conditioning of the sclerotic dentine,
Microstructural changes in sclerotic
resulting in minimal or no resin tag formation. dentine
Furthermore, the zone of resin-impregnated sclero-
tic dentine was found to be thinner than those Tubular occlusion
observed in normal dentine.25,27,40 43
Due to the thinness of hybrid layers in sclerotic In dentine sclerosis, tubular obliteration with
dentine, and the complexity of the resin-bonded rhombohedral, whitlockite crystallites (Fig. 1A)
Resin bonding to cervical sclerotic dentin: A review 175
Figure 1 (A) SEM micrograph of the body of a sclerotic Figure 2 (A) SEM micrograph of sclerotic casts that
lesion showing a dentinal tubule that was heavily blocked the dentinal tubular orifices (pointer) along the
occluded with whitlockite crystallites (pointer). The surface of a shiny sclerotic lesion. (B) TEM micrograph
adjacent tubules were almost completely obliterated taken from an undemineralised section of the surface of a
with peritublar dentine. (B) A higher magnification view bonded sclerotic lesion. Tubules were obliterated with
of the rhombohedral whitlockite crystallites (pointers) sclerotic casts that consisted of electron-dense crystal-
that were present within another dentinal tubule in the lites. They were surrounded by a tube-like sheath
sclerotic lesion. P: peritubular dentine; I: intertubular (pointer). A thin, electron-dense, hypermineralised
dentine. layer was also evident along the surface of the lesion
(open arrow) (from Tay et al., 2000,57 with permission).
has been well documented at an ultrastructural that probably represented a mineralised form of the
level.27,31,34,46 48 A high degree of variation could lamina limitans of the dentinal tubule (Fig. 2B).
be observed even within a single lesion. While some
tubules may be completely devoid of, or sparsely
occluded with crystallites, others may be heavily Hypermineralised surface layer in shiny
obliterated with crystallites and/or peritubular sclerotic lesions
dentine (Fig. 1B). Toward the surface of the lesion,
these crystallites were reduced in size and formed Unlike tubular occlusion, the presence of a surface
columns of agglomerates that completely plug the hypermineralised layer in natural cervical sclerotic
tubular orifices. They were often referred to as wedge-shaped lesions has only been elucidated
sclerotic casts (Fig. 2A). At an ultrastructural level, through the use of microradiography30 and FTIR
these tiny, electron-dense crystallites were sur- photoacoustic spectroscopic analysis.32 Although it
rounded by a tube-like membranous structure26,27 has been speculated that the hypermineralised
layer is devoid of collagen fibrils,37 the ultrastruc-

tural features of this layer were only verified
recently. Fig. 3A is a toluidine blue-stained,
undemineralised thin section taken from the dee-
pest part of a wedge-shaped defect that is least
accessible to tooth brushing. In the preparation of
the specimen, the surface of the lesion was not
cleaned and was fixed in Karnovskys fixative prior
to the embedding protocol for TEM preparation. A
surface layer of stained, unmineralised filamentous
bacteria could be seen, beneath which was an
approximately 15 mm thick hypermineralised layer.
Figure 4 (A) Undemineralised TEM micrograph of a

bacterium (B) within the hypermineralised layer (HM).
The intermicrobial matrix (i.e. the material between
adjacent bacteria) was mineralised and contained plate-
like crystallites (pointer) (from Tay et al., 2000,57 with
permission).
Mineralised bacteria could vaguely be discerned

within this layer. The corresponding undeminera-
lised TEM image (Fig. 3B) shows that both the
mineralised plaque zone and the surface layer of
the lesion are hypermineralised with respect to the
underlying sclerotic dentine. At a higher magnifi-
cation (Fig. 4), plate-like minerals could be recog-
nised within intermicrobial matrix.
The ultrastructure of the surface hyperminer-
alised layer is highly variable within the deepest
part of the wedge-shaped lesions. This can be
better discerned using demineralised TEM sec-
tions. It is interesting to observe that such a
layer is still retained after complete deminerali-
sation of the underlying sclerotic dentine. Fig. 5A
shows a thick, continuous, dense hyperminera-
lised layer that contained two different species
of bacteria. One species was trapped within this
layer, while the other was found to grow on the
surface of this layer. The hypermineralised layer
in Fig. 5B, on the other hand, consists of several
thin, discontinuous layers that were sandwiched
among different species of bacteria. This suggests
that changes in the microecology of the oral
Figure 3 (A) Light microscopic image of an undeminer- environment may have resulted in the colonisa-
alised section taken from the deepest part of an tion of different species of bacteria at sequential
untreated noncarious cervical sclerotic lesion. B: stained, periods. Each colony of bacteria was, in turn,
unmineralised bacteria; HM: hypermineralised surface mineralised prior to the deposition of the next
layer of the lesion; SD: intact sclerotic dentine; Pointers:
colony. It is pertinent to point out that both
mineralised bacteria ghosts. (B) Corresponding unstained
TEM micrograph of the undemineralised section. The specimens, from which Fig. 5A and B were taken,
hypermineralised nature of the surface layer (HM) could were brushed cleaned with a mixture of chlor-
be recognised by comparing its electron density with the hexidine and pumice prior to laboratory proces-
underlying sclerotic dentine (SD) (from Tay et al., 2000,57 sing. Both appeared as clean, highly shiny lesions
with permission). when examined under magnification lens.
The presence of colonising bacteria on the

surface of sclerotic wedge-shaped lesions is
consistent with the report of Spranger.6 The
microecology beneath bacterial plaque changes
over time depending on the metabolism of the
microorganisms. This results in substantial pH
fluctuations along the tooth surface.49 Bacterial
products may trigger gingival inflammation with
an increased rate of sulcular fluid flow, which in
turn, provides nutrition for the microorganisms. If
a plentiful supply of fermentable carbohydrates is
available, the microbes release organic acids that
will lower the plaque pH and tend to deminer-
alise the underlying dental hard tissue. When the
carbohydrate source is depleted, the local pH
rises due to salivary buffering, and remineralisa-
tion of the dental hard tissue and mineralisation
of the dental plaque can proceed. In the absence
of carbohydrates, these bacteria may remain
viable for prolonged periods,50 utilising glyco-
gen-like intracellular polysaccharide as a metab-
olisable source of carbon during periods of
nutrient deprivation.51 They may also metabolise
amino acids and other nitrogenous substrates,
creating ammonia and other basic chemicals that
may elevate plaque pH and promote mineralis-
ation and, perhaps, hypermineralisation.52
Along the occlusal wall of the wedge-shaped
lesions, both the surface bacterial layer and the
hypermineralised layer are usually thinner, with
the latter between 1 and 2 mm thick. Similarly, the
gingival wall of a wedge-shaped lesion, which is
usually more accessible to tooth brushing, is usually
devoid of bacteria. However, a very thin surface
hypermineralised layer may sometimes be observed.
Such a layer, if present is around 200 300 nm thick
and may be readily discerned in undemineralised
sections by its increased electron density, as well as
the characteristic arrangement of the crystallites,
which will be discussed in Section 3.3.
Figure 5 Variation in the ultrastructure of the hyper-
mineralised layer in noncarious cervical sclerotic lesions.
(A) This demineralised TEM micrograph showed a hyper- Mineral distribution
mineralised layer (HM) within the deepest part of a
wedge-shaped lesion that was about 14 mm thick.
Minerals present within the hypermineralised layer
Bacteria colonies were trapped inside this layer (open
arrow). Another species of bacteria (arrowhead) accu-
are larger in size compared with those within the
mulated along the surface of the hypermineralised layer. underlying sclerotic dentin (Fig. 6A). Unlike crystal-
Dentinal tubules were not occluded with sclerotic casts lites within the underlying dentine that are randomly
and were also filled with bacteria (pointer) (from Kwomg arranged, those that are found in the hyperminer-
et al., 2002,42 with permission). (B) Another demineralised layer are longitudinally aligned along the c-
alised TEM micrograph showing a complex, intact, hybrid axis of the crystallites. This is clearly demonstrated
structure that consisted of several discontinuous, hyper- in Fig. 6B. Orientation of the crystallites along their
mineralised layers (pointers) that were sandwiched c-axis in the surface hypermineralised layer is
among different colonies of bacteria (A, B, C and D). analogous to the induction of cellular orientation
The entire complex is about 18 mm thick. SD: sclerotic by low-level electrical currents53 and the alignment
dentine.
of filler particles within resin composites under
STEM/EDX analysis
Hypermineralisation implies that the density of the

mineral within the surface layer of the defect is
higher than that of the underlying sclerotic dentine.
This is confirmed by a qualitative STEM/EDX line
scan of the calcium and phosphorus distribution
longitudinally across the surface layer of the
defect into the underlying sclerotic dentine
(Fig. 7A and B). Also evident in the line scan is the
presence of a region of decreasing calcium and
phosphorus counts along the top 500 nm of the
hypermineralised layer that is attributed to partial
Figure 6 (A) Crystallites (pointer) with the hyperminer-

alised layer (HM) were plate-like and were aligned along
the c-axis. They were also larger than those (arrowhead)
present within the underlying sclerotic dentine (SD). (B)
The characteristic orientation of crystallites along their
c-axis was also evident in a thick hypermineralised layer
taken from the deepest part of another wedge-shaped
lesion. The lesion surface was etched by a self-etching
primer, with blunting and rounding of the partially
dissolved crystallites.
the application of an electric field.54 Dentine is only

mildly piezoelectric compared with bone.55 How-
ever, piezoelectric potentials have been reported to
be generated when teeth are subjected to parafunc-
Figure 7 (A) Brightfield STEM image showing the
tional loading.6 Some have speculated that polaris-
location of a line scan that was performed across the
ation of the remineralised crystallites caused by
surface hypermineralised layer of a noncarious cervical
piezoelectric potentials created during eccentric sclerotic lesion (from Tay et al., 2000,57 with permission).
tooth flexure results in their attraction and repulsion (B) Qualitative energy dispersive line scans showing the
by dipole interaction. Dipole interaction competes distribution of calcium and phosphorus along
with randomisation caused by Brownian motion the adhesive, the surface hypermineralised layer of the
and alignment occurs as the dipole interaction lesion and the underlying intact sclerotic dentine (from
predominates.56 Tay et al., 2000,57 with permission).
demineralisation by a self-etching primer (Clearfil crystallites without additional ZAF correction.

Liner Bond 2V; Kuraray Medical, Inc., Tokyo, Japan) The Ca/P ratios of the crystallites within the
that was used to bond to sclerotic lesions.57 hypermineralised layer and the underlying dentine
Quantitative energy dispersive X-ray spectra of the approach the theoretical value of 1.67 calculated for
elemental content of crystallites present within (a) hydroxyapatite.58 The larger apatite crystallites
the surface hypermineralised layer, (b) the under- observed in the surface hypermineralised layer are
lying intertubular dentine, and (c) within the dentinal similar to larger apatite crystallites reported in
tubules of the wedge-shape defect are shown in remineralised carious dentin59,60 and cementum.61
Fig. 8.57 As the analysis was performed using 70 nm Conversely, the Ca/P ratio of crystallites from
thick undemineralised sections, this enabled esti- the sclerotic casts within the dentinal tubules is
mation of the calcium/phosphate ratio of these slightly lower than the calculated value of 1.50 for
Figure 8 Energy spectra from different locations of a noncarious cervical sclerotic lesion. (a) Spectrum showing
composition of crystallites within the surface hypermineralised layer. (b) Spectrum of crystallites within the underlying
intact sclerotic dentine. (c) Spectrum of crystallites occupying the lumen of a dentinal tubule. Spectra were obtained
using a 7 nm probe for 200 live seconds at 200 kV. The relative concentration of Ca, P and Mg, and the calculated Ca/P
ratios are shown in the table beneath the spectra (modified from Tay et al., 2000,57 with permission).
tricalcium phosphate.58 The additional presence of

about 5% magnesium suggests that these crystallites
are whitlockite (Mg substituted b-tricalcium phos-
phate).
Status of the collagen fibrils within

the surface hypermineralised layer
An intriguing question that has remained unan-

swered is whether the surface hypermineralised
layer is devoid of collagen.36 Using special staining
for collagen, it can be seen that the supporting
matrix for the crystallites within the hyperminer-
alised layer consists of a bed of denatured collagen
(Fig. 9A). The transition from denatured collagen
(gelatin) to intact collagen with cross-banding is
evident at the base of the hypermineralised layer,
where some of the collagen fibrils are observed to
unravel into microfibrillar subunits. 57 This
transition from banded collagen to denatured
microfibrils is further illustrated beneath a layer
of bacteria in Fig. 9B, in which unraveling of
collagen fibrils created a network of microfibrillar
strands that no longer showed cross-banding.
It is possible that colonisation of bacteria along
the surface of the wedge-shaped defect results in
the production of acidic and enzyme by-products
that demineralise and denature the collagen fibrils
(Fig. 9B). Diffusion of the enzymes from the
demineralised surface downwards probably
accounts for the transition from completely
denatured collagen to unraveled microfibrils and
finally intact collagen within the underlying sclero- Figure 9 (A) TEM micrograph from a demineralised
tic dentine. The loss of phosphoproteins62 and specimens, showing that the supporting matrix of the
subsequent remineralisation of the surface bed of hypermineralised layer (HM) consisted of a bed of
denatured collagen under the possible influence of denatured collagen microfibrils(arrow). These subunits
piezoelectric charges generated from eccentric of collagen were formed by unraveling of collagen fibrils
flexural deformation6 may result in the character- (arrowhead). Within the underlying sclerotic dentine
istic orientation of the crystallites within the (SD), intact banded collagen fibrils could be seen
denatured microfibrillar matrix of the surface (pointers) (from Tay et al., 2000,57 with permission). (B)
hypermineralised layer. A thin hypermineralised layer (HM) beneath a layer of
bacteria (B) showing the transition from intact, banded
collagen fibrils into denatured collagen (gelatine),
Summary of the microstructural changes
appearing ultrastructurally as microfibrillar strands (poin-
in noncarious sclerotic cervical dentine ter). SD: sclerotic dentine.
Sclerotic dentine is an abnormal bonding sub-

strate that exhibits a high degree of variability of bacteria, apart from demineralising the den-
both in terms of occlusion of the dentinal tubules tine, also denatures the existing collagen matrix,
as well as the thickness of the surface hypermi- resulting in a bed of denatured collagen. This
neralised layer. The latter, in particular is may act as a scaffold upon which the deminer-
invariably associated with bacteria. It is possible alised dentin may be subsequently remineralised.
that bacteria are involved in the pathogenesis of The formation of the hypermineralised layer is
the hypermineralised layer. That is, dentine may probably also enhanced by the presence of high
first require demineralisation before it can be concentrations (10 ppm) of fluoride ions.63 65 As
hypermineralised. Also, mineral crystallites can- denaturing of the collagen fibrils probably
not accumulate without a scaffold. The presence removes some of the restrictions on the size of
crystallite formation, this may enable larger

crystallites to be formed during the process of
remineralisation. The unique arrangement of the
crystallites further suggests the complex role of
parafunctional stress on the formation of the
surface hypermineralised layer in these natural
wedge-shaped lesions.15,23 The presence of bac-
teria, mineralised bacterial matrices, hypermi-
neralised surfaces and mineral occluded tubules
makes sclerotic cervical dentine a unique multi-
layered bonding substrate. This implies that
bonding studies that attempt to generate hyper-
mineralised dentine in vitro by immersing par-
tially demineralised dentine in a remineralising
solution containing a high fluoride content66,67 do
not simulate the actual bonding conditions that
Figure 10 Dentine collagen fibrils from a hybrid layer
clinicians are likely to encounter when bonding to that was produced using a total-etch technique. Inter-
noncarious cervical sclerotic dentine. fibrillar channels (pointers) must be maintained open for
optimal resin infiltration. This is achieved using a wet
bonding technique.
Bonding adhesive resins to sclerotic

dentine Self-etch technique
Current dentine adhesives employ two different Recent developments in dentine bonding have
means to achieve the goal of micromechanical reintroduced the concept of utilising the smear
retention between resin and dentine.68 70 The first layer as a bonding substrate, but with improved
method, the total-etch or etch and rinse technique, formulations that could etch through the smear
attempts to remove the smear layer completely via layer and beyond, into the underlying dentine
acid-etching and rinsing. The second approach, the matrix. Failure to etch beyond the smear layer,
self-etch technique, aims at incorporating the smear exemplified by some of the early adhesives that were
layer as a bonding substrate. applied directly to the smear layer, resulted in weak
bonds due to the complete absence of a hybrid layer
in underlying intertubular dentine.78,79 Contempor-
Total-etch technique ary self-etch adhesives have been developed by
replacing the separate acid-conditioning step with
Most self-priming, single-bottle adhesives available increased concentrations of acidic resin monomers.
to-date attempt to bond to dentine that is etched Two-step self-etching primers combine etching and
with inorganic or organic acids. Following rinsing of priming into a single step. The primed surfaces are
the conditioners, retention is accomplished by subsequently covered with a more hydrophobic
means of resin-infiltration into the exposed, demi- adhesive layer that is light-cured. In the presence
neralised collagen matrix to form a hybrid layer of of water as an ionising medium, these adhesives that
resin-impregnated dentine.69 71 Systems containing etch through smear layers and bond to the under-
hydrophilic primer resins solvated in acetone or lying intact dentine.80,81 The recent introduction of
ethanol were found to produce higher bond strength single-step (all-in-one) self-etch adhesives rep-
when acid-conditioned dentine was left visibly moist resents a further reduction in bonding steps that
prior to bonding.72 Pioneered by Kanca,73 this eliminates some of the technique sensitivity and
technique is often referred to as wet bonding. practitioner variability that are associated with the
The benefit of wet bonding stems from the ability of use of total-etch adhesives.82 84
water to keep the interfibrillar channels within the When applied to sound dentine, the milder self-
collagen network from collapsing during resin- etch adhesives produce a hybridised complex
infiltration.74,75 These channels, which are about (Fig. 11) that consists of a surface zone of hybridised
20 nm wide when fully extended, (Fig. 10) must be smear layer and a thin, subsurface hybrid layer in the
maintained open to facilitate optimal diffusion of underlying intertubular dentine.85 87 Despite the
resin monomers into the demineralised intertubular presence of a hybrid layer that was generally below
dentine.76,77 2 mm thick, high initial bond strengths have
on sound dentine may likewise be applicable to

sclerotic dentine. Acid pre-conditioning prior to
the application of a self-etching primer may thus be
a viable technique when bonding to sclerotic
dentine.42 It has been shown that the hybrid layer
morphology after self-etching or wet bonding in
uninstrumented sclerotic dentine is substantially
different from those observed in sound, abraded
dentine.
Obstacles in bonding to acid-etched,

sound dentine
Adhesive strategies that rely mostly on microme-

Figure 11 The etching effect of a self-etching primer chanical retention are hampered by obstacles that
(Clearfil SE Bond, Kuraray) through a thick smear layer jeopardise effective infiltration of resin into dental
produced in sound dentine. The substructure of the smear tissues.97 In abraded sound dentine, the smear layer
layer consisted of loose, globular subunits (arrow) and is effectively removed in adhesive systems that
channels that were filled with water prior to resin (R)
utilise a separate acid-conditioning and rinsing step
infiltration (asterisk). The hybridised complex consisted
of a hybridised smear layer (Hs) and a thin hybrid layer (Fig. 12). In order to achieve optimal resin-infiltra-
(Ha) in intact dentine (D). tion, acid-etched demineralised dentine must be
suspended in water to prevent collapsing of the
interfibrillar spaces. This is effectively accom-
been reported for sound dentine.88 91 The more plished using the wet bonding technique. Interfacial
aggressive self-etch adhesives completely dissolve strength is dependent upon the ability of resins to
smear plugs and demineralise dentine to the extent engage the leading edge of demineralised inter-
that is comparable with phosphoric acid-etching.87 tubular dentine.98 102 The collagen matrix may thus
There has been some concern that mild self-etch be viewed as a diffusion barrier or obstacle for
adhesives may not be able to penetrate through resin-infiltration in acid-etched dentine.
thick smear layers, such as those produced clinically
by rough diamond burs.85 92 The use of adjunctive
phosphoric acid pre-conditioning has been
suggested as a means to improve bonding of self-
etching primers to sound dentine with thick smear
layers.93 96
Problems in bonding to sclerotic dentine
Irrespective of the use of a total-etch or a self-etch

technique, bonding to pathologically altered sub-
strates such as sclerotic dentine from noncarious
cervical lesions generally led to compromised
bonding.40 42,57 Reduced bonding efficacy was
attributed to a combination of factors that include
the obliteration of dentinal tubules with sclerotic
casts, the presence of an acid-resistant hypermi-
neralised layer, and the presence of bacteria on the
lesion surface. The presence of the hyperminer-
Figure 12 Application of Clearfil Liner Bond 2V (Kur-
alised layer, bacteria and the tubular mineral casts
aray) to sound dentine (from an artificial wedge-shaped
in sclerotic dentin are analogous to the presence of lesion) that was etched with 40% phosphoric acid for 15 s.
the smear layer and smear plugs in sound dentine, The smear layer was completely removed. The hybrid
being potential diffusion barriers for primer and layer (H) was about 5 mm thick. Arrow: base of hybrid
resin-infiltration. The concern that a self-etching layer; A: filled adhesive containing nanofillers; D: sound
primer may not etch through the superficial layers dentine (from Kwong et al., 2000,27 with permission).
Obstacles in bonding to acid-etched

sclerotic dentine
Unlike sound dentine, application of the same

adhesive strategy to sclerotic dentine results in
substantial variation in both hybrid layer and resin
tag morphology. Potential obstacles of resin-infil-
tration into uninstrumented natural lesions include
the hypermineralised surface layer, an additional
partially mineralised surface bacterial layer and
intratubular mineral casts that are comparatively
more acid-resistant.23,25,27 As these inclusions vary
considerably along the occlusal, gingival, and the
deepest part of a wedge-shaped lesion, variation in
the ultrastructure of the resin sclerotic dentine
interfaces are possible in these different regions.
While it is reasonable to assume that the extent of
tubular occlusion (Fig. 13A) would vary according to
the severity of dentine sclerosis,103 both the
superficial bacterial and hypermineralised layers
are found to vary from site to site, being thicker
along the deepest part of the wedge-shaped
lesions.42 The surface hypermineralised layer was
usually thinner in gingival and occlusal surfaces
than in the apical or deepest part of the wedge-
shaped defects, and was often partially or com-
pletely dissolved when phosphoric acid is applied to
sclerotic dentine (Fig. 13A). As a result, the
thickness of the hybrid layers in the gingival and
occlusal sites were similar to those seen in acid-
etched sound dentin and remained fairly consistent
at about 5 mm. Bacteria, if present, tended to be
tenaciously attached to the dentine surfaces and in Figure 13 (A) Application of One-Step (Bisco) to acid-
the dentinal tubules, and were retained even after etched sclerotic dentine (SD). This stained undeminer-
rinsing (Fig. 13B). alised section was taken from the gingival aspect of a
Thicker diffusion barriers were found within the wedge-shaped lesion. Remnants of a very thin, electron-
deepest part of wedge-shaped lesions that ham- dense, hypermineralised layer (arrowhead) could be seen
on the surface of the hybrid layer (H). Some tubules were
pered the penetration of acids through the under-
occluded with sclerotic casts (pointers). Others were
lying intact sclerotic dentine. As a result, patent (arrows) and filled with adhesive resin (A). (B)
alterations in hybrid layer morphology and thick- Stained, undemineralised TEM section showing appli-
ness were seen in these regions. Considering that cation of a filled adhesive to the occlusal aspect of an
the mean thickness of the hybrid layer was about acid-etched, sclerotic lesion. Bacteria (pointers) were
5 mm in sound dentine as well as the gingival/oc- trapped on the hybrid layer (Hd) surface and in the
clusal aspects of natural sclerotic lesions, hybrid tubules. Other tubules were filled with sclerotic casts
layer morphology in the deepest part of the wedge- (arrows).
shaped lesions may be described as erratic in
appearance. whitlockite crystallites from the sclerotic casts may
One example is shown in Fig. 14A. The surface also be identified within dentinal tubules in the
hypermineralised layer from the deepest part of a underlying sclerotic dentine.
wedge-shaped lesion was about 3 mm thick and was Fig. 14B is a stained, demineralised TEM micro-
trapped within the resin sclerotic dentine inter- graph taken from the deepest part of another acid-
face. The phosphoric acid apparently etched etched, wedge-shaped natural sclerotic lesion.
through the hypermineralised layer and created a The surface obstacle layers were either absent or
hybrid layer of about 2 mm thick within the completely dissolved. Within the 50 mm wide region
underlying intact sclerotic dentine. Rhombohedral of the micrograph, the thickness of the hybrid layer
These eccentric hybrid layers in abnormal dentin

substrates have never been observed in bonded
sound dentine.
Unlike sound dentine in which the morphology of
the hybrid layer remains fairly consistent as long as
a wet bonding technique is used, extensive vari-
ations are found in different specimens or locations
within cervical sclerotic lesions. Fig. 15A and B are
Figure 14 (A) Undemineralised section taken from the

deepest part of a wedge-shaped natural lesion that was
etched with 40% phosphoric acid and bonded using
Clearfil Liner Bond 2V. Hh: hybridised hypermineralised
layer that contained bacteria remnants (pointer). Hd:
hybridised sclerotic dentine that was about 2 mm thick. A:
adhesive containing nanofillers; SD: sclerotic dentine. (B)
Demineralised TEM micrograph of an erratic hybrid
layer from the apex of a wedge-shaped lesion that was
Clearfil Liner Bond 2V. The thickness of the hybrid layer
Figure 15 (A) Undemineralised TEM micrograph from
varied from 2 mm (pointers) to 5 mm (Hd). A lateral
the deepest part of an acid-etched, natural lesion. The
extension of the hybrid layer could be seen below an area
hybrid layer (Hd) in intact sclerotic dentine (SD) was 5 mm
that was not infiltrated with adhesive resin (asterisk). A:
thick. This was reduced to 2 mm thick beneath the
adhesive; SD: sclerotic dentine.
hypermineralised layer (HM). The separation of the
in sclerotic dentine changed abruptly from 2 to hypermineralised layer (arrow) was an artefact produced
5 mm. This aspect of uneven etching may also during specimen processing. A: filled adhesive. (B)
Demineralised TEM micrograph of an erratic hybrid
be seen in areas in which the acid etches laterally
layer from the apex of a wedge-shaped lesion that was
within the subsurface sclerotic dentine,
producing lateral hybrid layer extensions that Clearfil Liner Bond 2V. The thickness of the hybrid layer
are separated from areas above that are not varied from being absent (arrow) when a hyperminer-
infiltrated with resin. This feature is distinct from alised layer (HM) was present, to 5 mm (Hd) where the
incompletely resin-infiltrated hybrid layers that are latter was thin and was eroded by bacteria (B). A:
observed in air-dried, acid-etched sound dentine. adhesive; SD: sclerotic dentine.
demineralised, stained TEM micrographs taken

from the deepest part of the same natural lesion.
Whereas a thin hypermineralised layer and the
presence of bacteria did not prevent the pen-
etration of acid or resin into the underlying
sclerotic dentine, the thickness of the hybrid layer
was greatly reduced in the presence of a thick
hypermineralised layer (Fig. 15A). In some areas,
the hybrid layer in sclerotic dentine is reduced to
the extent that it is almost nonexistent (Fig. 15B).
These thick hypermineralised layers serve as
obstacles to diffusion and prevent the penetration
of even phosphoric acid. Reduced hybrid layer
thickness may have no correlation with reduced
regional microtensile bond strength in natural
sclerotic dentine.40,42,57 However, the presence of
Figure 16 Demineralised TEM micrograph of the appli-
thin hybrid layers should clearly be differentiated
cation of Clearfil Liner Bond 2V to sound dentine (artificial
from the total absence of hybrid layer formation in
wedge-shaped lesion). To achieve effective bonding, a
the bonding substrate. Under such circumstances, self-etching primer must not only create a hybridised
the adhesive will be bonding directly to the smear layer (Hs), but also a hybrid layer in the underlying
diffusion barriers that impede acid-etching. The intact sound dentine (Ha). The dentinal tubule was sealed
resultant bond strength will depend on the strength by a hybridised smear plug (Hp). R: adhesive resin; D:
of the attachment of such obstacles to the sound dentine.
underlying sclerotic dentine. It is remarkable that
these morphological fluctuations are continuous
bond strength as along as a uniform deminerali-
and vary within a very small region of a lesion that is
covered by these micrographs. Such extreme sation front is created in sound intertubular
variations in hybrid layer morphology are probably dentine.89,98,104,105
responsible for the large standard deviations in There was concern, in normal dentine, that
microtensile bond strength measurements of bond- thick and rough smear layers may interfere with
ing to sclerotic dentine. It is likely that these diffusion of self-etching primers into the under-
segregated areas of deficient hybrid layer for- lying intact dentine. This may be due to the
mation act as weak links, or stress raisers, that physical presence of thick smear layers as a
contribute to the initiation of adhesive failures in diffusion barrier, or their ability to buffer the
bonded sclerotic dentine. acidic monomers, making the pH too high to
demineralise the underlying intertubular dentine.
Obstacles to bonding in sound dentin treated Recent studies showed that mildly aggressive self-
with a self-etching primer alone etching adhesives penetrated through smear
layers up to 3 4 mm thick and still retained
The use of two-step and single-step self-etch sufficient acidity to demineralise the underlying
adhesives represents an alternative means to intertubular dentine to a depth of 0.4 0.5 mm.106
acquire micromechanical retention in dentine. This suggests that either the buffering capacity of
They are attractive in that they may be used on the smear layer is weak, or the smear layer does
dry dentine and, after mixing, require only one not impose much of a physical barrier to the
primer application, which is subsequently air- primer compared with the underlying mineralised
dried rather than rinsed. The latest single-step dentine matrix. The looseness of the surface
self-etch adhesives further incorporates all portion of the smear layer and/or the presence
the resin monomers, photoinitiator and tertiary of diffusion channels between its constituents may
amine accelerator into a single bottle (iBond, facilitate diffusion of the self-etching primer
Heraeus Kulzer, Hanau, Germany) and eliminates through the smear layer.107 Disaggregation of the
an additional mixing step. Despite the physical smear layer into globular subunits108 further
appearance of thin hybrid layers and short, provides microchannels for diffusion of the self-
hybridised smear plugs in a two-step self-etch etch adhesives. These microchannels, in theory,
adhesive (Fig. 16), high initial bond strength has should be more permeable to resin monomers
been reported. This suggests that there is no than the interfibrillar spaces (ca. 20 nm) of
correlation between hybrid layer thickness and demineralised intertubular dentine.
Obstacles in bonding to self-etching primer

treated sclerotic dentine
The smear layers in sound, cut dentine do not

impose much of a restriction to the bonding of
contemporary self-etch adhesives because of their
loose organisation. Unless they are instrumented,
shiny sclerotic cervical lesions are free of smear
layers. In lieu of smear layers, other diffusion
barriers in shiny cervical sclerotic lesions include
the much denser surface hypermineralised layer, as
well as the more loosely arranged, partially miner-
alised bacterial clusters. Some of the hyperminer-
alised layers in sclerotic dentine are so thick that
they restrict the penetration of strong inorganic
acids such as phosphoric acid that usually etches
5 mm or beyond into sound dentine. Being less
acidic in nature, a mild self-etching primer such as
Clearfil Liner Bond 2V (Kuraray) etches only 0.5 mm
into sound dentine that are covered with smear
layers. As sclerotic dentine is highly variable in its
ultrastructure, different morphologic expressions
of the resin dentine interfaces can be anticipated
when a mild self-etching primer is applied to this
abnormal bonding substrate. This may be classified
into three categories, depending on the in terms of
its thickness and continuity of the surface hypermi-
neralised layer at different locations of the wedge-
shaped lesion.
Sclerotic dentine with a thin hypermineralised

layer (<0.5 mm thick)
Figure 17 (A) Demineralised TEM micrograph of the
Thin hypermineralised layers are usually located
gingival aspect of a wedge-shaped lesion that was treated
along the gingival and occlusal aspects of wedge-
with Clearfil Liner Bond 2V (A). Uneven etching was
shaped lesions. Fig. 17A represents a straightfor- evident. On the left, only a hybridised hypermineralised
ward situation in which a very thin hypermineralised layer (Hh) was produced, within which were plate-like
layer is present, without bacteria, along the occlusal crystallite remnants (pointers). On the right, a 500 nm
aspect of a natural wedge-shaped lesion. This layer thick layer of hybridised sclerotic dentine (Hd) was
may be recognised by the characteristic arrange- formed beneath. SD: sclerotic dentine. (B) The bonded
ment of the partially dissolved crystallite remnants. interface from the occlusal aspect of a sclerotic lesion
The difference in hybrid layer morphology that that contained a thin hypermineralised layer but heavy
results from uneven etching is readily apparent. On surface bacterial deposits. The hybridised complex
consisted of: (1) a hybridised intermicrobial matrix
the left side, the effect of the self-etching primer is
(Him); (2) a hybridised hypermineralised layer; and (3) a
restricted to the surface layer alone, producing a
hybridised layer of intact sclerotic dentine. (Hd). The
0.1 mm thick, hybridised hypermineralised layer. On latter was absent on the right side of the micrograph
the right, the primer etched beyond the surface (arrows). SD: sclerotic dentine.
layer to form an additional layer of hybridised
dentine that was about 0.5 mm thick.
A similar uneven etching effect may be seen in the underlying intact sclerotic dentine. Unlike the
thin hypermineralised layers that contain additional hypermineralised layer that consists of densely
surface bacterial attachments (Fig. 17B). This arranged crystallites, the intermicrobial matrix is
complicates etching by the fact that the self- more easily penetrable by the self-etching primer.
etching primer must first infiltrate through the The hybridised complex, thus consisted of three
matrix between the bacteria, and then through the components: the hybridised intermicrobial matrix,
hypermineralised layer in order to demineralise the hybridised hypermineralised layer and the layer
Sclerotic dentine with a thick, continuous

hypermineralised layer (>0.5 mm)
Thicker hypermineralised layers are found along the
occlusal aspects and sometimes within the deepest
part of wedge-shaped, sclerotic lesions. As the
etching effect of a self-etching primer is limited, it
cannot etch beyond the hypermineralised layer into
the underlying sclerotic dentine (Fig. 19A). At a
higher magnification, the crystallites within the
bonded hypermineralised layer are shorter and
more sparsely arranged, when compared with the
underlying unaffected hypermineralised layer
(Fig. 19B). This partially demineralised zone was
about 0.5 mm in depth. Porosities created for resin
infiltration within this zone are reminiscent of acid-
etched, aprismatic enamel. It has been shown that
bonding to the surface hypermineralised layer alone
resulted in relatively high bond strength.42 The
ultimate strength of the entire bonded assembly,
however, depends on the strength of the attach-
ment of the hypermineralised layer to the under-
lying sclerotic dentine.
Partial demineralisation of the surface hypermi-
neralised layer also occurs in the presence of
bacteria inclusions. In Fig. 19C, an unstained
undemineralised TEM micrograph, silhouettes of
the unstained bacteria could be seen above the
partially demineralised, hypermineralised layer.
The depth of demineralisation within this layer is
comparable to the action of this self-etching primer
on sound dentine, and was about 0.5 mm thick. It is
reasonable to assume that a layer of hybridised
dentine cannot be formed in the underlying dentine
Figure 18 (A) The hybridised complex of Clearfil Liner
Bond 2V to sclerotic dentine in this micrograph consisted
when the surface hypermineralised layer is thicker
of only the hybridised intermicrobial matrix (Hm) and than 0.5 mm. It appears that the self-etching primer
hybridised, partially dissolved, hypermineralised layer can easily diffuse through the intermicrobial
(Hh). Crystallite remnants, arranged in a parallel orien- matrix. When such a complex is subjected to tensile
tation, were observed within the latter. No hybridised stress, it remains to be seen whether bond failure
dentine was found within the underlying sclerotic dentine would occur between the resin infiltrated bacteria,
(SD). (B) This micrograph was taken from the same the partially infiltrated hypermineralised layer, or
section as Fig. 18A. An additional layer of hybridised between the base of the hypermineralised layer and
sclerotic dentine (Hd) could be observed. B: bacteria; A: the underlying dentine.
filled adhesive; SD: sclerotic dentine.
Sclerotic dentine with a thick, discontinuous
hypermineralised layer (>0.5 mm)
of hybridised dentine. In this micrograph, the layer
These thick hypermineralised layers are found along
of hybridised dentine was about 0.5 0.8 mm on the
the apex or deepest part of wedge-shaped lesions. As
left, but was completely absent on the right. This
previously described, they consist of thin, discon-
illustrates the kind of biological variation that may tinuous hypermineralised layers that are dispersed
be expected along the entire lesion surface. The among several different colonies of bacteria. These
features are not the rare, one of a kind phenom- hypermineralised layers are probably intercon-
enon that is observed only in one single lesion. nected to form a three-dimensional structure
Fig. 18A and B are high magnifications of similar (Fig. 20A). It is highly unlikely that a self-etching
features observed in another specimen. There were primer can etch through a discontinuous hypermi-
taken from the same 1 mm 1 mm section of the neralised layer that is 10 15 mm thick. At a higher
gingival aspect of a bonded sclerotic lesion. magnification, Fig. 20B shows the demineralisation
front represented by the scalloped electron-dense

edge of the partially demineralised intermicrobial
matrix. It is anticipated that bond failure occurs
within the porous regions of this thick layer that is
occupied by bacteria but not infiltrated with
adhesive resin.
Summary of obstacles in bonding to sound vs.

sclerotic dentine
Potential deterrents to resin-infiltration following

total-etching or self-etching in sound and sclerotic
dentine are summarised schematically in Fig. 21.27
The left side of the figure illustrates the response to
bonding with a self-etching primer adhesive system
alone, while the right side illustrates the response to
pre-etching sclerotic dentine with 40% phosphoric
acid prior to bonding with the same self-etching
primer (Clearfil Liner Bond 2V). The thickness of the
hybrid layer is fairly consistent both for self-etch and
wet-bonded, acid-etched sound dentine, but is much
thicker in the latter group. Conversely, application
of the same adhesive strategy to sclerotic dentine
results in substantial variation in the hybrid layer
morphology in both treatment techniques. Absence
of a hybrid layer in some parts of a lesion suggests
that both treatment protocols are ineffective in
completely overcoming the diffusion barriers in
sclerotic dentine. This situation is comparable to
the early generation dentine adhesives that were
directly applied to the smear layers in sound
dentine.78 Similar to the junction between the
partially infiltrated smear layer and the underlying
intact sound dentine,109 areas devoid of hybrid layer
formation are potential weak links that may be
responsible for the lower bond strengths observed
when boning to sclerotic dentine.
Although reduction in hybrid layer thickness
may not affect micromechanical retention, spora-
dic absence of the hybrid layer and resin tags
indicate that both treatment techniques are
(pointer) within the partially demineralised zone of the

surface hypermineralised layer (HM). The ample poros-
ities thus created within this layer for micromechanical
retention of the adhesive is comparable to that of acid-
etched aprismatic enamel. SD: sclerotic dentine.
C. Undemineralised TEM micrograph taken from the
Figure 19 (A) Undemineralised TEM micrograph taken gingival aspect of a Clearfil Liner 2V-treated sclerotic
from the gingival aspect of a Clearfil Liner 2-treated lesion. The self-etching primer diffused through the
sclerotic lesion. There was only partial demineralisation unstained bacteria layer (B) and partially demineralised
(pointer) of the hyperminerlised layer (HM), with the (pointer) and infiltrated the superficial portion of the
latter still attached to the underlying sclerotic dentine hypermineralised layer (HM). The basal portion of the
(SD). Dentinal tubules were heavily obliterated with hypermineralised layer appeared to be firmly integrated
sclerotic casts (arrow). A: filled adhesive. (B) A higher with the underlying sclerotic dentine (SD). A: filled
magnification of Fig. 19A, showing the crystallites adhesive.
Figure 21 A schematic representation of the potential

deterrents to resin-infiltration during total-etching or
self-etching in sound and sclerotic dentine. The left side
illustrates the responses to bonding with a self-etching
Figure 20 (A) Bonding of Clearfil Liner Bond 2V to a primer adhesive system alone, while the right side
thick, discontinuous layer of hypermineralised dentine illustrates the responses to pre-etching sclerotic dentine
(HM). The presence of a segregated piece of hyperminer- with 40% phosphoric acid prior to bonding with the same
alised tissue (arrow) suggested that the discontinuous self-etching primer adhesive (Clearfil Liner Bond 2V)
layers are probably interconnected three-dimensionally, (modified from Kwong et al., 2000,27 with permission).
with the porous regions occupied by different colonies of
bacteria. Dentinal tubules (pointer) within the sclerotic
dentine (SD) were patent and were arranged parallel to intratubular resin infiltration. Moreover, the for-
the surface. (B) A higher magnification of a similar lesion. mation of a smear layer that consists of acid-
The action of Clearfil Liner Bond 2V was limited to the resistant hypermineralised dentine chips and
superficial part of this porous layer. The demineralisation whitlockite crystals derived from the sclerotic
front was represented by the electron-dense, scalloped
casts also creates additional diffusion barriers for
junction of the partially demineralised intermicrobial
both total-etch and self-etch adhesives.
matrix (arrows). Other discontinuous layers of hypermi-
neralised tissues could be seen (pointers) that may be Sclerotic dentine located at the apex of wedge-
connected outside the plane of this section. shaped natural lesions is derived from deep
dentine. Consequently, resin tag formation should
play an important role in achieving strong immedi-
inadequate in overcoming diffusion barriers in ate bond strength in the sclerotic cervical lesion.
sclerotic dentine. Physical removal of the super- However, resin tag formation is sporadic regardless
ficial obstacle layers with a bur may improve of the conditioning methods. Absence of intratub-
intertubular retention. In highly sclerotic lesions ular infiltration may even be observed in some of
however, this may be offset by moving the the occlusal parts of natural lesions that were
bonding interface pulpward into an area where etched with phosphoric acid, where the thickness
bonding requires increasing contribution from of intertubular infiltration is comparable to that
present in sound dentine. Similar to the results of

Ferrari et al.110 and Prati et al.,41 lateral branches
of resin tags were rarely observed when bonded
sclerotic dentine were examined by TEM.42,57 This
is likely to be caused by the acid-resistant nature
of the mineral-dense sclerotic casts that occlude
the dentinal tubules. It has been suggested that
20% of the strength of an interfacial bond was
contributed by resin-infiltration derived from resin
tag formation and another 20% from hybridisation
of the intertubular dentine.111,112 Regional tensile
bond strength from cervical sclerotic root dentine
was found to be 20 45% lower than those obtained
from artificial lesions prepared in sound root
dentine.40,42 This reduction may be due to the
absence of resin tags and incomplete hybridisation
in sclerotic dentine.
Regional microtensile bond strength

evaluation
Microtensile bond strength measurements compar-

ing resin bonds to the occlusal, gingival and the
apex or deepest part of natural lesions and
artificially wedge-shaped defects created in sound
cervical dentine were reported by Kwong et al.42
using the microtensile bond test.113 Lesions were
restored with Protect Liner (Kuraray) and Clearfil
AP-X resin composite (Kuraray) following treatment
with Clearfil Liner Bond 2V, with or without
phosphoric acid pre-conditioning of the lesions. Figure 22 Schematic representation of the protocol
Using the nontrimming technique developed by employed for regional microtensile bond strength
Shono et al.114 beams with a mean area of evaluation.
0.46 ^ 0.03 mm 2 were prepared and stressed
to failure. The use of a nontrimming technique
(Fig. 22) facilitated preparation of a series of slabs, substrate (i.e. sound dentine vs. sclerotic dentine)
thus allowing more than one beam to be harvested was found to have a significant influence on bond
from each lesion.113 strength p , 0:05: Multiple comparison tests
The mean tensile bond strengths of bonds showed that there was no difference in self-etching
produced by the self-etching primer alone to natural or total-etching sclerotic dentine except for the
lesions (48.7 MPa) were 26% lower (Fig. 23) than gingival aspect of the lesions, in which higher bond
those from artificial lesions (65.8 MPa) when all of strengths were obtained for total-etching (Fig. 23).
the bonds were pooled, and the result was statisti- These results are comparable to those of
cally significant p , 0:001: Similarly pooled data on Yoshiyama et al.40 in that lower bond strengths
bonds made using the self-etching primer with were found in natural sclerotic lesions, and to the
adjunctive phosphoric acid pre-conditioning to work of Phrukkanon et al.115 showing that bonding
natural lesions (53.1 MPa) were 24% lower p , of a self-etching primer to sound dentine is
0:005 than those produced from artificial lesions independent of the tubular orientation. The orien-
(69.8 MPa). Pooled data, however, showed no tation of dentinal tubules in the occlusal or upper
significant difference among the bonds made by wall of wedge-shaped lesions is approximately
self-etching or total-etching to either sound dentine parallel to the surface, while their orientation in
p 0:415 or sclerotic dentine p 0:314: Of the the gingival wall is perpendicular to the prepared
three factors (substrate, conditioning method and surface.116,117 Many believed that resin tag for-
location) tested, only the difference in the type of mation would be more prominent in surfaces where
reduced bond strength in sclerotic dentine is not

related to any single factor. Similar to other
biological variations, it is possible that each factor
contributes to a variable degree in different lesions.
The summation of all these factors, however, leads
to an overall reduction in bond strength.
The presence of a partially mineralised bacterial
zone in sclerotic lesions is analogous to the
presence of a smear layer on sound, abraded
dentine. This zone is porous, allowing easy pen-
etration of acids and primers to form a zone of
hybridised intermicrobial matrix. The presence of a
hybridised intermicrobial matrix may not affect
bonding, at least in the short term, providing that
the self-etching primer can effectively etch through
this layer into the underlying bonding substrate.
This is analogous to the hybridised smear layers in
sound dentine. It remains to be seen whether the
eventual degradation of the bacteria in this layer
would lead to decrease in bond strength with time.
The large standard deviation in bond strength
Figure 23 Regional microtensile bond strengths in self- results in natural sclerotic lesions may simply
etching and total-etching sound (light shade bars) or
reflect the large biological variation in the thick-
sclerotic (dark bars) dentine. Groups with the same letter
above the bars were not statistically significant p ,
ness of such a layer.
0:05: Number of teeth from which slabs were made in The presence of a hybridised hypermineralised
each group 10. layer together with an underlying zone of hybri-
dised dentine does not necessarily result in low
bond strength. This is comparable to the infiltration
the tubules are oriented perpendicular to the of a self-etching primer through smear layer-
surface rather than parallel. However, measure- covered sound dentine. Provided that the acids
ment of microtensile bond strengths of self-etching can penetrate the overlying diffusion barriers to
primers and total-etch adhesives to these walls in engage the underlying substrate with even a very
wedge-shaped cavities prepared in normal dentine thin hybrid layer, strong initial bonds may still be
revealed significantly higher bond strengths to achieved. However, erratic bonds may be expected
dentine in which the bonded surfaces were oriented when the hypermineralised layer in sclerotic dentin
parallel to the tubules (i.e. occlusal walls).116,117 is too thick for acids to etch through. Resin
Double-etching of dentin by phosphoric acid attachment to the partially demineralised surface
followed by a self-etching primer adhesive has of this layer is still strong and may be comparable
been shown to increase bond strengths to enamel with bonding to unground, aprismatic enamel.121
but to lower bond strengths in dentine,118 that may However, since a layer of hybridised dentine is not
be caused by incomplete infiltration of the adhesive produced, the strength of the bond will be highly
into the phosphoric acid-etched dentine.119 Using dependent upon the strength of the hyperminer-
Clearfil Liner Bond 2, Ogata et al.120 found that alised layer to the intact sclerotic dentine.
multiple applications of the primer to wedge- The fact that higher bond strength was observed
shaped lesions increased bond strength due to the along the gingival site of total-etched natural
weak acidity of the primer. Although this has not lesions (Fig. 23) merits further discussion. This
been tested in sclerotic dentine, the same result suggests that the inability of the adhesive to form
would be expected. That is, multiple applications resin tags in tubule lumina that are blocked by
of weakly acidic agents using constant agitation, mineral deposits is an important parameter that
should improve bonding. leads to the reduction in bond strength. If the above
TEM examination of the failed bonds exhibited by hypothesis is correct, then grinding of the surface
bonds created in sclerotic dentine revealed a wide hypermineralised layer of these cervical wedge-
variation in the mode of failure that included all of shaped defects prior to bonding122 should not result
the different structural components that are pre- in an increase in bond strength, since the underlying
sent within the resin sclerotic dentine interfaces.42 sclerotic dentine still contains dentinal tubules that
The complexity of failure modes indicates that are blocked by whitlockite crystallites. Application
of stronger phosphoric acid to these defects could that absorb water. Recent studies showed that both
have resulted in partial dissolution of the sclerotic hydrophilic resins131,132 and collagen fibrils within
casts and/or complete removal of the surrounding the hybrid layer133 136 degrade upon long term
peritubular dentine, allowing resin infiltration into water storage.137
the dentinal tubules. This may result in higher bond
strength along the gingival site of phosphoric acid-
etched, sclerotic dentine.
Conclusions
The structural complexity of noncarious sclerotic

Restoring the class v sclerotic lesion cervical dentine is remarkable. The common pre-
sence of adherent bacteria on such surfaces and
Maintaining the marginal integrity and retention of their incorporation into the bonded restorations is
Class V resin composite restorations without the use disconcerting. This raises issues such as whether
of additional retention has always been a challenge these bacteria are dormant, and whether their
for clinicians. One major factor, already analysed is confinement by adhesives will create any long term
the difficulty in bonding to sclerotic dentine. liability. These questions have also recently been
Removing the hypermineralised surface layers by raised in reports that bacteria are present in resin-
grinding or by using stronger acids (Fig. 23) are bonded caries-affected dentine.127,128 The pre-
possible strategies to improve micromechanical sence of bacteria on these surfaces justifies the
retention in sclerotic dentine. While it is possible use of 2% chlorhexidine disinfectant treatment or
to produce hybrid layers in sclerotic dentine with the use of antibacterial adhesives to disinfect the
thin diffusion barriers, these hybrid layers become substrate prior to bonding.
erratic or even nonexistent in the presence of thick Microtensile bond strengths of self-etching
barriers. As clinicians have no way of discerning primers to sclerotic dentine were comparable
these differences at a clinical level, removal of the with those made to phosphoric acid-etched
surface layer of sclerotic dentin prior to bonding sclerotic dentine, although they were lower
should be adopted.42,122 Although such a rec- than those attained with sound dentine. These
ommendation may not result in an increase in bond strengths are probably high enough to
bond strength to sclerotic dentin, it does remove retain class V restorations even under heavy
one potential source of inconsistency that leads to loads, if is bonding is performed with etching of
bond failure. Based on the results of a two-year the enamel to create additional micromechanical
clinical trial, it has been suggested that micro- retention. Although there are clinical studies that
mechanical retention by acid etching of the enamel showed encouraging results with the use of
margin is still indispensable for the clinical success dentine adhesives on noncarious cervical
of cervical Class V composite restorations.123 Such a lesions,138 140 the failure rates of some specific
concept, however, was recently challenged by two adhesives have been reported to be high in other
Japanese studies, in which the authors maintained studies. For example, the retention rate for One-
that sclerotic dentine, being a part of the bodys Step, a total-etch single-bottle adhesive, in
natural defence mechanism, should be preserved as noncarious cervical lesions involving sclerotic
much as possible and that acid-etching should be dentine was only half of that of nonsclerotic
avoided to promote the marginal integrity of resin dentine.141 The retention rate of the same
composites that are bonded to these lesions.45,124 adhesive in noncarious cervical lesions was
While one may remove bacteria overgrowths reduced from the original 100% at 6 months to
from the surface hypermineralised layer, it is not 75% after three years.142 There are also other
possible to remove bacteria entirely from dentinal clinical studies that reported more favourable
tubules. This is analogous to the application of retention rates when glass-ionomer based
fissure sealants to stained enamel fissures,125,126 or restorative materials were compared with den-
the bonding of resins to the inner layer of carious tine adhesives/resin composites in restoring these
dentine.127,128 The use of bactericidal solutions lesions.143 145 Unfortunately, there are no TEM
(i.e. chlorhexidine) or adhesive resins with anti- studies that examine the bonding of glass-
bacterial activity129,130 would be helpful. However, ionomer cements and resin-modified glass-iono-
the longevity of bonds that contain dead, degrad- mer cements to sclerotic dentine. Admittedly,
able bacteria should be further investigated. This is TEM work on these types of restorative materials
particularly applicable to adhesives that contain an that are susceptible to dehydration is difficult to
increasing amount of hydrophilic resin monomers perform. However, this should be done to
complete our understanding of this alternative 17. Rees JS. The effect of variation in occlusal loading on the
type of chemical/micromechanical interaction70 development of abfraction lesions: a finite element study.
Journal of Oral Rehabilitation 2002;29:188193.
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therapeutical aspects of cervical lesions. Minerva Stomato-
logica 2003;52:6974.
Acknowledgements 19. Kuroe T, Itoh H, Caputo AA, Konuma M. Biomechanics of
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Quintessence International 2000;1:267274.
This work was supported by grant DE014911 from 20. Palamara D, Palamara JE, Tyas MJ, Messer HH. Strain
the NIDCR, USA, and by grant patterns in cervical enamel of teeth subjected to occlusal
20003755/90800/08004/400/01, Faculty of Dentis- loading. Dental Materials 2000;16:412419.
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Resin Bonding To Sclerotic Dentin

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Resin Bonding To Sclerotic Dentin

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Journal of Dentistry (2004) 32, 173196

Resin bonding to cervical sclerotic dentin: A review

Received 10 July 2003; accepted 15 October 2003

Introduction that our current knowledge on the variability of

layer is devoid of collagen fibrils,37 the ultrastruc-

Figure 4 (A) Undemineralised TEM micrograph of a

Mineralised bacteria could vaguely be discerned

The presence of colonising bacteria on the

Hypermineralisation implies that the density of the

Figure 6 (A) Crystallites (pointer) with the hyperminer-

the application of an electric field.54 Dentine is only

demineralisation by a self-etching primer (Clearfil crystallites without additional ZAF correction.

tricalcium phosphate.58 The additional presence of

Status of the collagen fibrils within

An intriguing question that has remained unan-

Sclerotic dentine is an abnormal bonding sub-

crystallite formation, this may enable larger

Bonding adhesive resins to sclerotic

on sound dentine may likewise be applicable to

Obstacles in bonding to acid-etched,

Adhesive strategies that rely mostly on microme-

Problems in bonding to sclerotic dentine

Irrespective of the use of a total-etch or a self-etch

Obstacles in bonding to acid-etched

Unlike sound dentine, application of the same

These eccentric hybrid layers in abnormal dentin

Figure 14 (A) Undemineralised section taken from the

demineralised, stained TEM micrographs taken

Obstacles in bonding to self-etching primer

The smear layers in sound, cut dentine do not

Sclerotic dentine with a thin hypermineralised

Sclerotic dentine with a thick, continuous

front represented by the scalloped electron-dense

Summary of obstacles in bonding to sound vs.

Potential deterrents to resin-infiltration following

(pointer) within the partially demineralised zone of the

Figure 21 A schematic representation of the potential

present in sound dentine. Similar to the results of

Regional microtensile bond strength

Microtensile bond strength measurements compar-

reduced bond strength in sclerotic dentine is not

The structural complexity of noncarious sclerotic

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