Simplified adhesion of compomersin pédiatrie dentistry

Theodore P Croll, DDSVJoel Berg, DDS, MS^

A seif-etching adhesive agent for bonding poiyacid-modilied resin-based composite materials ("com-

pomers"] to enamei and dentin is now avaiiabie. The Prompt L-Pop system simpiifies and hastens dental

bonding procedures and has proved itself usefui in many adhesive dentistry appiications.This articie

desoribes the bonding system and shows clinical examples of its use in children and teenagers. The con-

cept wiil have further application in adhesive dentistry with introduction ot a new formuiation of Prompt, to

be used with traditional resin-based composite materials. (Quintessence int 2000:31:563-569)

Key words: adhesive dentistry, compomer, pédiatrie dentistry, poiyacid-modified resin-based composite

Resin-based composites are adhesively bonded toenamel and dentin using the traditionai acid-

etching technique. Polyacid-modified resin-based com-posite materials, also known as "compomers," arebonded to tooth surfaces in the same manner, A rou-tine honding technique using a 1-bottie type of bond-ing agent (primer and resin-bonding agent combined)involves the following steps:

1. Clean the tooth surface with prophylaxis paste orpumice.

2, Apply an acid-etching agent (typically 35% to 50%phosphoric acid gel or liquid) and agitate the fluidon the tooth surface.

'Private Practice, Pédiatrie Denlistry Doyieslown, Pennsyivania; CiinicalProtesscr. Department of Pedialric Dentistry. Uniuersity ol Pennsylvania,Schooi cf Dertai Medicine, Philadeiptiia, Pennsyivania; Ciinieal Professor,Cranicfacial Growtii and DeveiopmenI (Pedialric Dentistry), University ofTexas. Health Science Center al i-iouslon [Dental Branch), i-iouslon.Tesas: Adjunctive Associate Professer cf Pedialris Dentistry, University ofiov«. College oí Dentistry. Iowa City iowa.

^Formerly, Head of the Sciertilic Department, ESPE Dental. Seefeid,Germany; Currentiy Vice President. Clmical Allairs, Optiva Corporation,Bellevje, WA; Ciinical Associate Professor, Department of PédiatrieDeritislry. University of Pennsylvania, Schooi of Dental Medicine,Philadelphia, Penrsyivania; Adjunct Associate Professor, Department cfPedlatrrc Dentistry, University of Texas, Heailh Science Center at Houston(Déniai Branch), Houston, Texas,

fleprint requests: Dr Theodore P Croii, Georgetown Commons, Suite 2,708Shafly Retreat Road, Doyiestcwn. Pennsylvania 18901 Fa«: 215-794-3126.

Disclosurs. The senior author (TPC) is remunerated by dental manufacturers.including ESPE, lor certain consultation services regarding research andproduct deveiopmenl.

3. Wait 15 to 30 seconds for enamel etching; limit acidexposure of dentin to approximately 10 seconds,

4. Rinse the acid from the tooth surface with air-water spray lavage,

5. Use an air syringe (free of oil contamination) todry the enamel, leaving the dentin slightly damp.

6. Apply the liquid primer and resin bonding agent,7. Use an air syringe to blow off excess fluid,8. Polymerize the bonding agent with 10 to 20 sec-

onds' exposure to a visible light beam.9. Apply the compomer incrementally (less than 2

mm per layer).10. Polymerize each increment of compomer,11, Finish and polish the restoration.

A new bonding system has been introduced thatsimplifies bonding of compomers. Prompt L-Pop(ESPE) is a self-etching adhesive system that hondscompomer to tooth structure, eliminating several steps.It contains aqueous phosphoric ester solutions thatremove the smear layer, etch the enamel, and deminer-alize dentin in such a way that hybridization bondingoccurs in dentin while, simultaneously, micromcchani-cal bonding occurs in the enamei.

The exact chemicai nature of Prompt is proprietary.However, according the manufacturer,' the first bubblechamher of the dose package contains methacryiatedphosphates, initiators, and stabilizers. The second bub-ble chamber contains water, fluoride complex, and addi-tional stabilizers. The fluid volume ratio between thechambers is 4:1, When the contents of the chambers areblended by squeezing the bubbles, tbe water content inthe second bubble activates the acidity of the solution.

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Use of the Prompt L-Pop system involves the fol-lowing steps:

1, Clean the tooth surface with prophylaxis paste orpumice,

2, Activate the L-Pop dose package. Using the smallbrush applicator, paint the self-etching fluid overdentin and enamel for 15 seconds,

3, Air dry the surface until the fluid is "tacky" (lightactivation is not required at this point).

4, Apply the compomer in increments of 2 mm orless,

5, Photopolymerize with a visible light beam,6, Finish and polish the restoration.

Techniques

The following techniques were selected to demon-strate the diverse uses of compomer material, bondedwith ProfTipt, in children and teens:

1, Restoration of primary teeth with caries lesions2, Application of a ligature wire splint for stabilizing

traumatically displaced teeth3, Bonded compomer "bandage" restoration of a trau-

matically fractured tooth, for interim repair4, Interim restoration of a tooth with décalcification

or a caries lesion adjacent to a bonded orthodonticbracket

5, Creation of a bonded inclined slope for single-toothanterior crossbite correction

These examples typify the types of applications aself-etching adhesive agent can have in adhesive den-tistry for children and teenagers. Other potential useswill be reviewed in the discussion section.

Case reports

Case 1

A 9-year-oid boy was referred for restoration of themaxillary left primary canine tooth. The tooth had alarge caries lesion covering a good portion of thelabial surface (Fig la).

After injection of local anesthetic, a retraction cordwas inserted to displace the free gingiva and control sul-cular fluid flow. Carious substance was debrided withlow-speed round burs, and the preparation includedsome mechanical "undercutting" near the margins,

A dose packet of Prompt L-Pop was activated byfirst squeezing the terminal bubble section, releasingfluid into the second compartment. The first section

was then bent on the second bubble section, and, withanother firm squeeze, the solutions were blended andexpelled into the third compartment, housing the tip ofthe small applicator. The self-etching primer was nowready to be applied to the dentin and enamel surfaces.

The Prompt solution was rubbed on the tooth sur-faces for 15 seconds [Fig lb) and then air dried (Figlc). Special care was taken so that the fluid did notsoak the free gingival margin. Prompt solution isacidic and should be handled with the same careused with phosphoric acid liquid or gels. Hytac com-pomer (ESPE) was syringed into place, sculpted, andphotopolymerized in 2 increments {Figs Id to If), Theretraction cord was removed, and the restoration wasfinished and polished with low-speed finishing bursand aluminum oxide disks. A 3-month postoperativeview is shown in Fig lg.

Case 2

A 9-year-oid sustained a traumatic blow to his perma-nent maxillary central incisors during sports (Fig 2a},Both incisors suffered coronal fractures involvingenamel and dentin, without exposure of the pulpspace. In addition, the fractured incisors were dis-placed paiataiiy and were moderately mobile.Radiographs ruled out radicular fractures. The planwas to splint the central incisors with a dead-soft dou-ble-strand ligature wire bonded with compomer mate-rial. Bonded compomer "bandage" repair of the frac-ture sites would follow.

After the labial surfaces of the central incisors werecarefully cleaned with an ICB Brush (Ultradent) andprophylaxis paste, the teeth were rinsed and dried.Self-etching Prompt solution was appiied to the labialsurface of each incisor with a 15-second rubbingaction (Fig 2a), The fluid was air dried, and a smallincrement of compomer material was placed on eachtooth but not yet exposed to the light beam, A twisteddouble strand of dead-soft orthodontic ligature wirewas compressed into the soft resin, which was thenlight cured (Figs 2b and 2c), Another small amount ofcompomer was applied and light-cured to cover andsecure the wire.

With no additional tooth preparation, the self-etch-ing solution was applied to the fracture sites andperipheral enamel and agitated with the applicator for15 seconds. After the primer was air dried, bondedcompomer interim bandage restorations were placedto repair the fractured teeth and restore an acceptableappearance. Long-term repair with traditional resin-based composite bonding would await dentoalveolarand pulpal healing. Tbe bonded splint and compomerbandage restorations, adhesively attached withPrompt, are shown in Fig 2d.

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Case1

Fig la The primary canine looth has afacial caries iesion. Carious substancehas been cfebrided: the margins followtne shape ot the iesion.

Fig l b Biended fluid is rubbed onenamel and denlin for 15 seconds.

Fig 1c Prompt fiuiQ is dried with an airstream until taci<y.

Fig Id The tirst increment of compomeris applied and light cured for 30 seconds.

Fig l e The second incrementappiied, sculpted, and iight cured.

Fig 1f A finai iight beam exposure of 40seconds IS used to assure through-and-through curing

Fig Ig The finished restoration is shown3 months alter piacement.

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Case 2

Fig 2a The maxillary permanent oentral incisors are frac-tured and mobile after a traumatic blow. Prompt is applied tothe labial suriace.

Fig 2b A compomer and ligature wire splint is placed to sta-bilize the repcsitioned incisors.

Fig 2c The oompomer is phctopolymerized. Fig 2d The splint is secured, and oompomer "bandage"restorations are completed without a separate etching step.

Case 3

Fig 3a Deoalcitioation and a caries iesion have developed Fig 3b An interim ocmpomer restoration is bonded withadjacent to a bonded orthodontic bracket. Prompt.

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Case 4

Fig 4a The permanent central inoisorsare in crossbite in a 10-year-old patientwho IS not yet ready tor comprehensiveorthodontic treatment.

Fig 4b Inclined compomer slopes arebonded witti Prompt, so that themandibular incisors apply labial torce tothe lingual aspect ol the opposing maxil-lary teeth.

Fig 4c The crossbite has been cor-rected m several weeks by the compomerslopes The trimmed compomer will belefl in place tor 3 additional months toprevent relapse.

Case 3

A teenaged patient with poor oral hygiene developeddécalcification and a caries lesion adjacent to theorthodontic bracket on the mandibular right perma-nent canine (Fig 3a), Carious suhstance and decalci-fied enamel were removed with a small round burused at slow speed. Peripheral enamel was roughened,and a layer of compomer was bonded into place usingthe self-etching adhesive system (Fig 3b),

Case 4

A 10-year-old boy was referred by his orthodontist forcorrection of the crossbite affecting his maxillary cen-tral incisors (Fig 4a), The patient was not yet ready forcomprehensive orthodontic intervention, and it wasbelieved that dental tipping using honded compomerslopes could correct the erossbite relationship with noburden of cooperation on the patient.

Inclined slopes of compomer material were made,using acetate crown forms, and bonded in reverse (Fig4b). The slopes were designed so that the incisai edgeof the opposing incisors struck the lingual compomersurface of the extended maxillary incisor crowns. Theforces created by routine function were sufficient totip the maxillary teeth labially, creating an overbiterelationship.

Once the crossbite was corrected, the compomermaterial was left in place for 3 additionai months (Fig4c), Increments were then trimmed away periodicallyover another 3 months, to minimize the chancesof relapse.

Discussion

For a dentist who, for more than 25 years, has beenusing 3O''.'o to oOo/o phosphoric acid to etch tooth struc-ture prior to application of resin materials, it is diffi-cult to believe that a self-etching adhesive system cangive equivalent bonding results. However, review ofrecent clinical research reveals that much is alreadyknown about adhesive bonding of compomers withthe Prompt L-Pop system,̂ -^ Electron microscopicstudies have revealed that enamei surfaces treatedwith Prompt are etched in a pattern similar to thatresulting from use of phosphoric acid,- Results ofanother investigation have shown that the hybrid layerformed is virtually identical in thickness to that result-ing from etching with conventional systems,'

Li and Powers-" compared dentin bonding to com-pomer material with Prompt and conventional dentinbonding systems and found the adhesive bonds to beequivalent. In addition, they found that the bondbetween tooth and compomer material was signifi-cantiy better when Prompt was used than when bond-ing was achieved without phosphoric acid etching. Thisis particularly ititportant because eompotners wereoriginally marketed as not requiring enamel or dentinetching for adhesive bonding to tooth surfaces. Testingmarginal integrity of the Prompt-eompomer bond,using the scanning electron microscope, Blunk andRoulet^ found no visible marginal gap when Promptwas used in conjunction with Dyract AP {Dentsply),'

After using Prompt for more than 1 year, and hear-ing personal and published reports about bondingcompomers witb the self-etching bonding agent,'" the

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authors believe that this dose-packaged self-etchingmaterial has numerous practical applications for pédi-atrie restorative dentistry. Not only does the techniqueeliminate the need to rinse the etchant, to dry thetooth surface, and to light cure the honding agent sep-arately, but also there is no need tc replace cottonrolls or other isolation materials to maintain the oper-ative field. The authors have found this simplificationextremely useful in toddlers and preschoolers, forwhom rapid treatment and a smooth operating contin-uum are desirable.

According to the manufacturer,' the sequence ofevents outiining the effects and actions of Prompt areas foilows: With its low pH, the fluid initially etchesthe enamel in a way similar to phosphoric acid. Anetched pattern is created in the enamel surface formicromechanical bonding of the restorative material.Simultaneously, the outer portion of mineral in thedentin is etched away, as is the case with phosphoricacid etching of dentin. However, with Prompt, etchingand resin incorporation into the demineraiized enameland dentin surfaces occur simuitaneously.

Because the water rinsing step is eliminated in theself-etching system, moisture control is not a concern.The need for moisture control maiics traditional bond-ing systems more compiicated and time consuming.The wetness or dryness of the dentin is critical in tra-ditional adhesive systems; a dentin surface that isoverdried can coliapse the demineralized collagen andnot aliow primer-liquid resin saturation. On the otherhand, too much water saturates the area and pre-ciudes use of a hydrophobic monomer.

As the etching process progresses, the pH of thephosphoric acid esters within Prompt rises, halting thedemineralization reaction. In the suhsequent dryingprocess, monomers of the self-etching iluid, because oftheir high viscosity, can no longer be removed fromthe demineralized regions associated with the dentinaltubules. The precipitates produced during this processare incorporated within the matrix during exposure ofthe visible light beam.

The Prompt L-Pop system was designed to be usedwith all brands of compomers on the market.Although the initial formulation was developed to heused oniy with compomers, a new version, designedfor use with either compomers or traditional resin-based composites, has been developed. The new mate-rial has already heen used hy the senior author in thepreventive resin restoration technique"-'^ to applyresin-based composite as a reinforced sealant" and formost other routine adhesive dentistry procedures. Six-month clinical observations of dozens of thoserestorations and sealants have been favorable, Clinicaisuccesses with the new formulation are heing substan-tiated by equally favorable research reports. Investi-

gators have reported about bond strengtbs, marginalseal, ultrastructure of the interface, protection againstacid challenge, bonding orthodontic brackets, and theeffect of the packaging system on quality of the bond-ing solution."""

Conclusion

As time goes by, innovative clinicians will discoverand develop even more new uses for the self-etchingadhesive system. In addition, new and ongoing clinicalresearch will answer questions such as the long-termquality of the "Prompt hond," compared to that cre-ated with traditional acid-etching methods, and impli-cations of the fluoride content in the self-etchingprimer system. If the self-etching primer concept doesprove workable in the mouth over the long term, per-haps such a bonding system is the harbinger of a trulyself-etching and self-adhesive direct apphcation dentalrestorative material.

Relerences

1. Prompt-L-Pop Product Dossier Seefeld, Germany: ESPEDental, 1999.

2. Breschi L, Perdigao ), Mazzotti G, Nunes MF, Gobbi P.Ultramorphology and shear bond strengths of self-etchingadhesives on etiamel [abstract 2957]. ! Dent Res 1999;78(special issue) :475.

3. Vargas MA. Interfacial ultrastructure of a self-etchingprimer/adhesive [abstract 950], J Dent Res 1999;78(specialissue):224.

4. Li D, Powers JM, Bond strength of compomers with acidicprimers to human enamel [abstract 2719]. J Dent Res1999;78(special issue):445,

5. Blunek U, Roiilet J-F, Marginal adaptation of compomerClass V restorations in vitro. J Adhesive Dent 1999;1^143-151,

6. Issa MD, Watts DC. Shear strengths of a compomcr/com-positc adhesive to enamel/dentin [abstract 421], J Dent Res2QQ0;79(specialissue):196.

7. Manhart J, Glomb C, Stueckgen D, Neuerer P, Flessa HP,Hickel R. Clinical evaluation of a self-etching adhesive at 6months [abstract 1033]. J Dent Res 2000;79(specialissue) :273,

8. lrie M, Suzuki K, Richter R. Adhesive effect on the marginalseal of compomers [abstract 1692]. ] Dent Res 2000:79(special issue) :355,

9. Hicks I, Gareia-Godoy F, Flaitz C, Secondary root surlacecaries adjacent to compomer tnaterials: In vitro polarizedhght study [abstract 3744]. J Dent Res 2000;79(specialissue);611.

10, Manhart J, Hitkel R, Esthetic eompomer restorations inposterior teeth using a new all-in-one adhesive' Case pre-sentation, I Esthet Dent 1999;ll:250-258.

11. Simonsen RJ. Preventive resin restorations I QuintessenceInt 1978;9(l):69-76.

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12, Simonsen R|, Preventive resin restorafions, II. QuintessenceInt 197S;912¡:95-102.

13, Simonsen R|, Conservation of tooth structure in resforativedentistry. Quinfessence Int 1985;16:15-24

14 Croll TP, Sundfeld RH, Resin-based composite reinforcedsealant. I Dent Child 1999;66:233-237,

15. Denehy GE, Cobb DS, Bouschlicker MR, Vargas MA.Clinical evaluation of a self-etching primer/adhesive in pos-terior composites [abstract 340]. ) Dent Res 2000;79(specialissue); 186.

16. Latfa MA, Stanislav CM, Barkmeier U'W. Rond strength ofcomposite fo enamel using three adhesive conditioners[abstract 843]. | Dent Res 2000;79(special issue):249,

17. Peumans M, Vargas M, Van Meerbeek B, Inoue S,Snauwaert ], Lambrechts P, Vanherle G, Correlative AFM,FeSEM and TEM examination ot the resin-denfin interfaceproduced by an all-in-one adhesive [abstract 1000]. ) DentRes 2000;79(special issue):268,

18. Peutzfeld A, Richter R. Shear bond strength of self- andtotal-etching adhesives [abstract 184Ö], | Dent Res 2000;79(special issue|;374,

19. Sadek FT, Perdiagao ], Malimann A, Cardoso PEC, Micro-tensile bond strength of a new self-etching adhesive[abstract 1855|. JDenf Res2000;791special issue]:375.

20. Friedi K-H. Oberländer H. Schmalz G, Hiller KA, Bondstrength of composite resins using a new one-step adhesivesystem [abstract 3633]. J Dent Res 2000;79(specialissue|:598.

21. Rueggeberg FA, Forfson WM, Mettenburg D|, Orthodonticbracket retention strength u,sing a self-etching resin primer[abstract 1110]. | Dent Res 2000;79(special issue);282.

22. Sfengcr A, Reusch B, Winter E, Berti M, Influence of pack-aging system on evaporation of four differenf adhesives[abstract 3156], I Dent Res 2000;79(special issue]:53S.

Quintessencelnfernationai

ElectroformmjRestorative

New Dimensions inBiologically Based Prostheses

Jakob Win and Andreas Hoffmann

Tills clinical atlas describes tiie use of elec-troforming technology to achieve estheti-

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technology hasbroad potentialfor use wilhimplant-support-ed prostheses

429 pp; 751 illüs;ISBN0-a6715-376-e;USS189

1, Biological Dental Prosfhetics2, Development of Elecfroforming Technology3, Elecfroforming—Dental Laboratory Technolog4, Elecfroforming—Clinical Aspects5, Material and Technological Aspects6, Tips and Tricks for tbe Dental Technician

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