1. Adhesives Sales Training Danny Forcucci – Marketing Manager, Clinical

2. When to Use a Dental Adhesive? By first applying a layer of adhesive to the tooth structure, modern resin-based restorative materials, such as composites and resin-based luting cements are able to adhere. Adhesive material is always used before placing a direct composite restoration, unless the doctor is using a self-adhesive composite. Adhesive material is always used before placing an indirect restoration with an adhesive luting-composite system (e.g. Variolink II, Variolink Veneer). Adhesive material is not necessary when using a self-adhesive resin cement, Glass- Ionomer, Resin-Modified-Glass-Ionomer, or any other conventional cement.

3. Direct vs. Indirect Restorations Indirect An adhesive may not be indicated for use with adhesive resin cements, when placing indirect restorations for these possible reasons: a)Film thickness -The thickness of the adhesive might prevent the restoration from not fully seating, especially if cured prior to seating the restoration. b)Incompatible chemistries -Formulation of adhesive may be incompatible with formulation of luting-composite (cement). c)Curability of restorative material -The adhesive might not contain the activators required to cure the cement. d)Pooling -The viscosity might cause the adhesive to “pool” in the corners which could prevent the restoration from fully seating. Direct Every adhesive is indicated for direct restorations.

4. Total Etch Technique Also known as “etch & rinse” the “total-etch” term refers to the procedure whereby both enamel and dentin are etched with phosphoric acid before bonding. This technique is typically used when bonding primarily to enamel (e.g. veneers, inlays, onlays.)

5. Total Etch Technique The (phosphoric) acid demineralizes the enamel to roughen or etch the surface. The adhesive can then penetrate the porosities and form an interlocking micromechanical bond for the highest bond strength. Before etching After etching Enamel Dentin The acid removes the smear layer, opening the dentin tubules, and demineralizes the intertubular dentin. The adhesive can then penetrate the open dentin tubules and form resin tags which results in the highest bond strength.

6. Total Etch Technique What is the “Smear Layer?” A thin layer with small crystalline characteristics composed mainly of saliva and bacteria. It appears on the surface of teeth that have undergone dental instrumentation procedures such as “prepping” with a dental bur. Not easily rinsed away, it must be removed by acid etching with phosphoric acid.

7. Total Etch Technique Source: Sturdevant's Art and Science of Operative Dentistry, 6 th Edition Acid-Etching + Rinsing Primer/Adhesive + Composite

8. Total Etch Technique When air drying the dentin before applying the adhesive, it is important not to over dry (desiccate) the dentin because this would collapse the collagen network and prevent the adhesive from infiltrating the dentinal tubules. Potential Hybrid Zone DRY - Collapsed Moist- Fluffy Critical aspects to bond to dentin

9. Self Etch Technique Reduced Risk of Post-Operative Sensitivity Dentinal tubules are not completely opened. The adhesive material etches and penetrates in one step, making the etching depth and depth of the adhesive’s penetration the same. More Technique Tolerant The concern about over drying the dentin discussed on the previous slide does not apply to the self etch technique because the doctor does not need to dry the surface before applying the adhesive. The “self-etch” term refers to the procedure whereby the tooth surface is not etched with phosphoric acid. Instead acidic resin, incorporated into the adhesive system itself, etches and primes the surface in one step. This technique is typically used when bonding primarily to dentin.

10. Selective Etch Technique Selective etching incorporates the advantages of Total Etch (highest bond to enamel) and Self Etch (reduced risk of post-operative sensitivity). However, bond strength can be compromised and post operative sensitivity could occur if the dentin is inadvertently etched with phosphoric acid. The “selective etch” term refers to the procedure whereby only the enamel edges of the preparation are “selectively” etched with phosphoric acid.

11. Light- / Self- / Dual-Cure Adhesives Light Cure The adhesive must be exposed to a curing light. Self Cure The adhesive must be left to polymerize on its own without a curing light. These adhesives do not contain any light-initiators and therefore are not affected by curing lights. Dual Cure The adhesive can be either light- or self-cured. These adhesives usually require a dual-cure activator, or must come in contact with a dual-cure resin material (e.g. cement).* *Note: Some adhesives, such as ExciTE F DSC, must be light cured unless it comes in contact with a dual-cure resin material (e.g. Variolink II base & catalyst mixture.)

12. Compatibility with Light- / Self- / Dual-Cure Materials Practically all adhesives are compatible with light cured restorative materials. Some adhesives (such as AdheSE One F and ExciTE F) are not compatible with self- / dual-cure restorative materials because they do not contain the initiators required for polymerization of the materials. Some adhesives (such as AdheSE) are compatible with dual-cure materials only when used with an additional dual-cure activator

13. Chemical Composition Adhesives typically contain these three components that serve the following functions: Solvent : Surface wetting, infiltration, evaporation leaving behind only resin Functional monomers: Chemical bonding to tooth structure Fillers: Viscosity properties AdvantagesDisadvantages Acetone Dries quickly Highly volatile Can not expand collapsed collagen Effective only on moist dentin Ethanol Dries well after application Tolerant of dentin moisture Some extra drying time required (compared to acetone) to evaporate solvent Water Expands collapsed collagen Tolerant of dentin moisture Adhesive layer must be adequately dried to remove the water Longest drying time Types of Solvents

14. Generations of Bonding Agents With each generation… Reduced # of components Reduced # of working steps Faster application procedures Gen. Type of SystemSteps IV Product

15. ExciTE ® F ExciTE F is a light-curing, fluoride releasing, single- component total-etch adhesive used in: direct restorations (composites) adhesive luting of indirect restorations (ceramics, lab processed composites) involving light-curing cements ExciTE F is available in the unique VivaPen, in bottles or in Soft-Touch Single-Dose vessels

16. ExciTE ® F DSC ExciTE F DSC – Dual-Cure Single-Component – is a dual-curing, fluoride releasing adhesive for enamel and dentin bonding, which is used in combination with the total-etch technique. ExciTE F DSC has been further designed for clinical cases where light cannot be used for curing and when chemically curing composites are employed.

17. AdheSE ® AdheSE is a self-etching, light-curing, two- component adhesive system for enamel and dentin bonding used in: direct restorations (composites, compomers) AdheSE DC Activator Enables the AdheSE system to be used in conjunction with self- or dual-curing composites or luting material

18. AdheSE ® One F AdheSE is a self-etching, light-curing, single-component, fluoride releasing adhesive system used in: direct restorations (composites, compomers)

19. Clinical Procedure Dr. A. Peschke, Liechtenstein Etch enamel and dentin with phosphoric acid then rinse and lightly air dry Apply one layer of ExciTE F to moist prep and agitate for at least 10 seconds Light-cure for 10 seconds Gently apply air to evaporate solvent Total Etch – ExciTE F Apply a layer of AdheSE One F and agitate for 20 seconds Light-cure for 10 seconds Disperse excess with a strong stream of air to evaporate solvent Self Etch – AdheSE One F

20. Solution-based Selling Doctor’s Concerns Relating to Adhesives: Post-operative sensitivity Bond strength/retention Product waste Practice productivity

21. Post-Operative Sensitivity The released fluoride in AdheSE One F and ExciTE F can support the sealing of the tubules by forming calcium fluoride, which may help prevent dentinal fluid movement and the post- operative sensitivities associated with it. Not properly sealing the dentin tubules causes pressure or ionic changes in the fluid flow that exists in the dentin tubules, which stimulates post operative sensitivity.

22. Post-Operative Sensitivity Incomplete coverage of the bonding surface could result in poor bond strength and possibly also cause post-operative sensitivity. Acetone is a highly volatile material. Therefore, adhesives that have an acetone-based solvent, such as BISCO All- Bond, are composed of approximately 30% resin material and 70% solvent. Acetone-based adhesives require multiple coats to ensure that the resin (active ingredients) are coated on the bonding surface for proper coverage.

23. Post-Operative Sensitivity Ivoclar Vivadent adhesives are acetone-free, which enable them to contain more than 70% resin and less than 30% solvent…allowing for true one-coat applications. Furthermore, the unique chemistry of AdheSE One F and ExciTE F creates a visible glossy layer on the surface during application to assure uniform coverage and sealing of the dentin and enamel.

24. Bond Strength/Retention Many adhesives contain an acetone-based solvent. Acetone has a high level of evaporation. Removing the bottle cap for each use causes some evaporation of the solvent which could reduce bond strength. Habib, C.; Kugel G; Tufts University, Boston, USA, 2000 Ivoclar Vivadent adhesives are acetone-free, allowing the adhesive to be used for longer periods of time without affecting bonding results.

25. Product Waste Most single dose products have enough material for three applications. Therefore 2/3 of the material could be wasted. With a bottle, it’s difficult to dispense the exact amount of adhesive needed for a procedure. Therefore, it’s common to have significant waste with the bottle delivery form. There is virtually no waste when using the VivaPen because it dispenses only what is needed.

26. Productivity ExciTE F DSC comprises a special patented applicator, which is coated with the initiators required for the dual-curing action. When the applicator is dipped into the adhesive solution, the initiators mix with the adhesive and impart it with the dual-curing properties. Fast, easy application Applicator coated with initiator crystals under the electron microscope

27. Fresh Material Every Time Virtually no evaporation of solvent in VivaPen because the locking mechanism within the cannula prevents air from entering the pen. Fresh material from the first to last drop Fast Application The “application” time of the VivaPen is significantly less than bottle because the doctor simply “clicks & bonds” IFU on the Product The adhesive IFU is printed on the side of the VivaPen, making it very easy for the doctor to ensure that the proper instructions are followed for optimal performance Ergonomic Design The VivaPen features a unique, ergonomic design allowing the adhesive to be applied in a relaxed manner. The slim, pen-like shape and the angled brush cannula are modeled after the time-tested design of dental instruments. No Waste The VivaPen has virtually no waste because it dispenses only what is needed Selling Advantages of the VivaPen

28. ExciTE ® F FeatureBenefit 10 second scrubFast application Fluoride releaseReduce risk of post-op sensitivity by “plugging” the tubules with calcium fluoride Visible glossy surfaceHigh bond strength and reduced risk of post-op sensitivity by ensuring complete coverage Acetone-freeConsistently high bond strength first to last drop Stable at room temperatureNo need to store in refrigerator and bring down to room temperature before using High resin contentMultiple coats not required 3 delivery forms, including unique VivaPen Accommodated doctor’s preference Feature/Benefit Summary

29. ExciTE ® F DSC FeatureBenefit Innovative brush technology Fast application Ultra-low film thicknessEnsure accurate fit of indirect restorations Fluoride releaseReduce risk of post op sensitivity by “plugging” the tubules with calcium fluoride Pre-curing not requiredEnsure accurate fit of indirect restorations Acetone-freeConsistently high bond strength first to last drop Stable at room temperatureNo need to store in refrigerator and bring down to room temperature before using High resin contentMultiple coats not required Feature/Benefit Summary

30. AdheSE ® FeatureBenefit Color coordinated bottle with matching color and instructions on dispensing well Easy and accurate application Acetone-freeConsistently high bond strength first to last drop Stable at room temperature No need to store in refrigerator and bring down to room temperature before using High resin contentMultiple coats not required Feature/Benefit Summary

31. AdheSE ® One F FeatureBenefit Acetone-freeConsistently high bond strength first to last drop Stable at room temperature No need to store in refrigerator and bring down to room temperature before using High resin contentMultiple coats not required Fluoride releaseReduce risk of post op sensitivity by “plugging” the tubules with calcium fluoride Visible glossy surfaceHigh bond strength and reduced risk of post- op sensitivity by ensuring complete coverage Feature/Benefit Summary

32. Sales Tools ExciTE F brochure (633212) AdheSE One F brochure (627528) ExciTE F scientific documentation Adhesive Power Point presentation