The internotionol Journal of Periodontics S Restorative Dentistry

537

The Dual Bonding Technique:

A Modified Method to improve
Adhesive Luting Procedures

Stefan J. Paul. DMD'

Peter Schrer, DMD, MS, PhD'*

indirect restorative prooedures usually require temporary restorations for

protection of the puip and for restoring the patients esthetic and functianai
needs. The use af temporary cements, either with or without eugenoi, however considerably decreases the adhesion of the bond on dentin if
according to the conventionai teohniquesuoh dentin bonding systems
are applied onoe ot the moment ot finoi cementation. With a duai application af the dentin bonding agents a considerable Increase in bond strength
values was discovered. This orticie presents o modified iuting procedure
caited the "dual bonding technique." (int J Periodont Rest Dent
1997:17:537-545.)

Research Assooiote. Department cf Advanced Prosthodontics,

Center for tne Heolth Sciences, University of California, Los Angeles:
and formerly Senior Lecfurer, University of Zurich Center for Dentai
and Orai Medicine. Zurich, Switzerland.
"'Professor and Chairman, Deportment of Fixed and Removable
Prosthodontics and Dentai Materiai Sciences, universify of Zurich,
Center tor Dentai and Orai Medicine, Zurich, Switzerland.
Reprint requests: Dr Stefan Paul, Deportmenf ot Advanced
Prosthodonfics, Center for the Healfh Sciences, University of
Caiifornia. Los Angeles. 10833 Le Conte Avenue, Los Angeles,
California 90024-1668. e-mail: spau139@idt.nef

Indirect restorations usualiy

require a provisional restorotion
that is iuted to the obutment
tooth with a temporary oement. Very discouraging and
sometimes very contusing results have been reported when
the shear bond strength of
dentin bonding agents was
meosured on dentin thot hod
been contominated with provisionai cements prior to the
bonding procedure,^ In some
cases the bond strength vaiues
were increosed, in other cases
they were deoreased. An
explanation for such varying
resuits was diffioult and led fo
disagreement.
An ottempt to improve the
cieaning of fhe dentinai surface after application of temporary cements was undertaken with the use of soaps,^
The results were again discouraging, probably becouse
cleaning the dentin with soap
resuited in the subsequent
inability of the dentin bonding
agents to wel the dentinai surface.

Volume 17, Number 6,1997

538

Fig Ja A 27-yeqr-old woman, presentIng no periodantai prqbiems, wanted

repiacement of her amalgam itings in
the mandibuiar ieft first ond second
molars.

Fig Ib A rubber dam is placed, the

amalgam is removed, secondary caries
is eiiminated, and a composite build-up
is piaoed with ART Bond and a selfcuring hybrid composite (Briiiiant MM).

Fig Ic The fnai preparation of the

iniay cavities is completed.

However, a considerable
increese in bond strength volues
at the moment of finol adhesive
luting was diseovered when the
dentin bonding agents were
applied twice,^ In a first step of
the "duoi bonding technique,"
the dentin bonding agent was
applied and cured right after
tooth preparation in adaptation
of the conventionai composite
filling method. After sealing the
dentinai surfoce, a provisionai
restoration using a temporory
cement was placed. At the time
of the compietion of the definitive restoration, the provisionai
restoration was removed, and
the dentinai surface was
cleaned with pumice. For the
second step of the duai bonding technique, the same dentin
bonding agent was applied
again, and the bonding resin
was cured oniy after seating the
definitive restoration with composite cement. With this technique a doubling of the bond

strength values was observed,

even though a provisional
cement containing eugenol
was used intermedidtely^
The first seaiing of the dentinai surface immediately after
preparation had no influence
on the quality of the impression
when polyether or hydrophobio
poly(vinyi siioxanes) were used,"
After a preliminary clinical
evaluation ot the duai bonding
technique (34 restorations), the
foiiowing clinical protocol was
proposed using ART Bond
(Coitne-Whoiedent), which
had performed as the best
commercioily availabie material in a previous study^

requested the repiocement of

her amaigem fiilings in the
mandibular left first and second
molars for esthetic reasons (Fig
la). After rubber dam piacement, amaigam removal, and
elimination of seoondory caries,
a composite build-up (Fig lb)
was placed to correct possible
internol surface defects. The following materials were used
strictiy according to manufacturers' instructions during ail steps
of the treatment described: (1)
ART Bond, which is a two-step
dentin bonding agent with selfetching primer: (2) Briilicnt MH
(Coltne-Whaledent), a seif-curing hybrid composite filiing
material; and (3) Porceiite U
(Kerr), o duai-cured composite
luting resin.

Clinical protocol for ttie dual

bonding fectinique
Cavity preparation
A 27-year-oid woman, presenting no periodontal problems.

The International Journai at Periodcntics S Restorative Dentistry

539

Fig 2a ART Bond primer A and B are

mixed 1:1 in o plastic dish.

Fig 2b A brush tip is used for 30 seconds for the first application of ART
Bond primer A and B on dentin and
enamel. Enamel is not etched at this
time with a 37% phosphoric acid gei.

Fig 2c Primed tooth surfaces ore oir

dried for 5 seconds.

Fig 2ci One drop at the uniied ART

Bonding resin is reieased.

Fig 2e Eirsf oppiicotion ofARJ

Bonding resin on dentin and enamel
using a brush tip for 30 seconds.

Fig 2f Bonding resin is air thihned with

gentie biasting from o dental syringe.

Part i of the duai bonding

technique
The dentin bonding agent is
first applied immediately after
finai preparafion in fhe following manner (Fig Ic):
1, Mix the ART Primer A and B
in o 1:1 ratio (Fig 2a).

Brush ART Primer A ond B

onto denfin and enamei for
30 seconds (Fig 2b), Do not
efch enamei af fhis time wifh
37% phosphoric acid gel fo
avoid a micromechanicai
inferiock befween enamel
and fhe subsequehfly added
bonding resin.
Air dry primed toofh surfaces
for 15 seconds (Fig 2c).

4. Release one drop of ART

Bonding resin (Fig 2d).
5. Brush one layer ot ART
Bonding resin onto the
primed tooth surfoces tor 30
seconds (Fig 2e).
. Air thin fhe bonding resin
with gentle blasting from
fhe denfci syringe (Fig 20.

Volume 17, Number 6,1997

540

fig 2g Brush tip in Fig 2e is used again

for a second brush-in without picking up
new bonding resin to recover eventuai
ix>nding voids after air thinning.

Fig 2h Preparation is iight cured for 60

seconds.

Fig 2i The first oppiiootian of the dentin

bonding agent (Port i of the duai bonding technique) is occompiisiied.

Fig 2j After removai of the ruPPer

dam. an impression is made with poiyether.

Fig 2k A pravisional is luted with

eugenat-oantaining Temp Bond.

7. Perform a second brush-in

of the Bonding resin using
fhe some brush fip without
picking up new bonding
resin fo recover possible
bonding voids after air fhinning (Fig 2g).
8. Light cure for 60 seconds (Fig
2h). Parf i of fhe dual bonding technique is accompiished (Fig 21).
9. Make the impression with
either polyether (eg, Permadyne, ESPE) or poiy(vinyi
siloxane) (eg. President.
Coifne-Whaiedent) (Fig 2j).
10. Lufe fhe provisional wifh
eugenol-confaining femporcry cement (Temp Bond.
Kerr) (Fig 2k).
Part ii of the duai bonding
technique
The second parf of the dual
bonding technique is performed af final cementotion
(Fig 3a). Following is fhe procedure for efchable ceramics
(eg. Empress, Dicor, or any feldspafhic ceramics):
1. Cieon fhe cavify check the
morginai fif and color
inatch, ond etch and silanate fhe internal surfoces of
the resforotions (Fig 3b).
2. Place rubber dam and
ciean cavity wifh pumice
(Fig 3c).
3. Etch enamel with 37% phosphoric acid gel for 30 seconds (Fig 3d).

The International Journal of Periodontics & Restordtive Dentistry

541

Fig 3o (left) The final ail-ceramic inlays

(Empress) are completed.

Fig 3b (righf) The cavities are cieaned

with pumice and the nai all-ceramic
iniays are checked for marginal tit and
catar match. Next the inlays are
etched and siianized because Empress
IS an etchabie ceramic.

4. Rinse ond dry to ciieck for

bonding resin remnants on
the covity margins. Where
no opaque-white etching
pattern is visibie, repeot iost
two steps (Fig 3e).
5. Brush one ioyer of ART Primer
A and B (1:1 mix) onto dentin
and enamel for 30 seconds.
Air dry primed tooth surfaces
for 15 seconds.
6. Brush one layer of ART
Bonding resin onto the
primed tootii surfoces for 30
seconds. Air thin the bonding resin w'U a gentle biast
from fhe dentai syringe.
7. Brush in again with the same
brush tip without picking up
new bonding resin. Do not
iight cure fhe bonding resin
yet, or the film thickness of
the bonding resin couid
interfere with the marginai fit
of the definitive restorotion.
8. Seat the restorotion with
composite luting resin (duoicured Porcelite U, Kerr) and
remove excess resin,
9. Light cure the dentin bonding ogent and composite
luting resin for 180 seconds
(Figs 3f dnd 3g).

Fig 3c Prior to the final cementation.

a rubber dam is placed and the cavities are again thoroughly cleaned with
pumice, rinsed, and dried.

Fig 3d Only the enamel is etched with

37% phosphoric acid for 30 seconds.
(ART Band contains a seif-etching
primer Therefore, when using ART Bond.
acid etching the denfin as o separate
step is not needed)

Fig 3e The acid gel is removed, and

the teeth are rinsed with water spray
ana completely air dried to check for
banding resin remnants on the cavity
margins m enamel. Where no opaquewhite etching pattern is visible, repeot
Steps in Figs 3c and 3d

Fig 31 Dentin bonding agent is

applied a second time, as described in
the teat.

Fig 3g Finai dinicat resuit oner repiacement af two amalgam fiiiings with two
Empress inlays. The occlusion is checked
oniy after the nai cementation.

Voiume 17, Number 6,1997

542

Nonetchable ceramics iike

in-Ceram Aiumina, In-Cerom
Spineii, or Zirconia have a core
fhaf is usually less translucent
than thot of etchoble ceramics
(eg. Empress. Dicor. or any feldspothic ceramics). Therefore, fhe
outhors recommend a slightly
different procedure that uses
only the ART Primer (nof the
ART Bonding resin) ond self-curing Panavia TC (Kuraray) fcr the
second oppiication. The selfcuring cemenf omits ony probiems that might result from
improper curing of the luting
materiais because of insufficienf iight penetration,
1. Cieon cavity, check marginal fif and coior motch.
and only sandbiosf the internai surfaces of fhe restorafions, Silane is nof needed.
2. PiGce rubber dam and
clean cavity with pumice.
3. Etch enamel with 37% phosphoric acid gei for 30 seconds.
4. Rinse and dry to checi< for
bonding resin remnants on
fhe cavity margins. Where
no opaque-white etching
pati-ern is visibie, repeat iast
two steps,
5. Brush one iayer ART Primer A
ond B (1:1 mix) onto dentin
and enamei for 30 seconds.
Air dry primed tooth surfaces for 15 seconds. Do not
use ART Bonding resin.
Nonetchable ceramics may

The International Journal of Periadontics & Restorotive Dentistry

have a core thaf is too

opaque for the penetration
of the poiymerizing iight. As
o consequence, the ART
Bonding resin may not be
fully cured,
6. Seot restorotion with seltcuring composite iuting
resin (Panavia TC, Kuraray)
directly on surface that is
oniy primed,
7. Remove excess resin.
8. Appiy air biock (Oxygard)
onfo margins.

Discussion
On dentin. bond strength vaiues
up to approximately 30 MPo
have been reported; however,
a very recent evaluation of the
newest adhesive systems resuited in bond strength voiues
that seem more reolistic. They
were in the ronge of 10.9 fo 7.5
MPa^ after a single applicotion
of the dentin bonding agent
(DBA).
In an in vitro set-up that
integrated multiple ciinically
reievonf porameters. maximum
bend strength values were
found to be ot a similarly low
ievei (around 8 MPa),^"^ It is clinicaiiy questionable if such
bond strength vaiues oround
10 MPa are reolly high enough
fo resist the contraction forces
generated during the polymerizoticn of composite resins (up
to 17 MPo').

543

With the duoi bonding technique, bond strength vaiues can

be doubied (mean values
between 13 and 19 MPa) using
either ART Bond, Syntac, or the
exprimentai P-Bond, even
when a eugenol-containing
temporary cement is used for
the provisional restorations,'
Such bond strength vaiues
might be strong enough to resist
contraction forces during the
polymerization shrinkage of
composites (up to 17 MPa').
Four major questions arise
with the dual bonding technique described:

Why use ART Bond?

in a previous study^ an experimental dentin bonding agent

(P-Bond) ochieved the highest
bond strength values (approximately 19 MPa) after contamination of the dentin with
eugenol-containing temporary
cement (Temp Bond), Unfortunoteiy, this product is not yet
commercioily ovailabie, ART
Bond performed second best in
the same study^ In addition, ART
Bond is a so-oalled "two-step"
dentin bonding agent that does
not require a separate etching
step for the dentin because it
contains a self-etching primer
and saves vaiuable clinicai
time.

is it possibie to remove the

bonding resin from the enamei
margins after the ^rst appiication of the dentin bonding resin?
if enamel is not acid etched
during the first application of
the dentin bonding agent, no
etch pattern will be generated,
Enomei, as a pureiy inorganic
material, and unfilled bonding
resins, as pureiy organic substances, are incapable of a
chemical reaction between
each other. Because no etch
pattern is created on the
enamel surfaee, no micromechanicoi bond can deveiop
between the two materiais at
the first appiieation. Therefore,
removing the bonding resin
from the unetched enamel
margins prior to the second
opplicotion by rubbing with
pumice is possible.

Volume 17,Number 6,1997

544

Wt^y does ttie eugenalcantaining Temp Bond nat

interfere with the paiymerizatian of tiie resin ftiat is applied
after ttie removai of fhe
provisional cement?
Eugenoi is commoniy known to
be a potenfiai inhibitor of the
poiymerization of any resinous
material. However, an increase
in the shear bond strength values after serial applicafion of a
denfin bonding agent^ despite
fhe use of a eugenol-confaining
provisional cemenf is possible,
because after the first appiication of fhe denfin bonding
agenf the denfin will be seoied
against fhe penetration ot the
eugenoi molecules. When fhe
final resforations are ready for
cemenfationafter a period of
severai weeksthe eugenolcontaining temporary cement
(Temp Bond) can be removed
easily from fhe resin-sealed
dentinal surface fo such o
degree fhat any eugenoi remnanfs no longer disfurb fhe second poiymerizafion of fhe DBA,
whioh fhen is applied for a second time. This explains fhe
aimost doubied bond strength
vaiues.' in oddition, the temporory cement (Temp Bond) can
be removed much more easily
and quickiy trom fhe seoied
tooth surface prior to the finai
cemenfation, saving vaiuable
ciiniooi time.

The internofional Journal af Periadantics & Restarative Dentistry

Why is tfie risk of postoperative

sensitivity aimosf reduced to
zero?
Air thinning the banded footh
surtoces after the appiication of
the bonding resin prior to
cemenfation is porf of fhe recommendafions ot aimosf every
manufacturer's bonding insfructions fo minimize the risi< of an
exaggerafed film fhickness of
fhe bonding agehf.^'' On the
other hand, air-fhinning fhe
bonded dehtinal surfaces wifh
o "gentle" air-blast runs the risk
of dentinoi tubules not covered
with bonding resin,' Such
uncovered tubules are voids
which, in vivo, might be refilled
wifh dentinoi liquid offer fhe
anesfhesia is gone. Perhaps
such liquid-fiiled spaces are one
cause of postoperative sensitivity because every time pressure
is opplied on such an adhesive
denfin inferface during biting,
fhe iiquid in these voids might
be compressed and cause a
pressure change within the iiquid-fiiled tubuiar system fhof is
connecfed fo fhis space. The
aspiration of odonfoblasfic cell
bodies into the opening of the
fubuies mighf then cause pain.
For fhis reason, using the brush
twice when applying the bonding resin is recommended (see
Figs 2e fo 2g),This parficuiar procedure should close dentinal
tubules, prevent void iumina,
and controi film thickness.

545

Conclusion
The dual bonding fechnigue
pracfioally doubied the in vlfro
bond sfrengfh values of several
dentin bonding ogents.^ A preliminary clinical evaluafion
showed the following advantages of fhis technique for
adhesive luting procedures of
all-ceromic resforotions;
1. The bond sfrengfh to denfin
is capable ot resisting shrinkage forces during polymerization of composites.
2. There is a reduction of postoperotive sensitivity.
3. The use of eugenoi-containing temporary cements provides better retention of the
provisional when combined
wifh dentin bonding agents.
Removal ot eugenoi remnants prior to finai cemenfotion is more easiiy aohieved
through quick conventional
cavity cieaning.
4. Minimal odditionai ciinicai
working time is necessory.

Acknowledgments
The outhors wouid like to thonk the following fechnicions for performing
fhe very skillfui ail-ceramio resforofions: Nioolo Pietrobon, CDT: Arnoid
Wohiwend. CDT: Waiter Gebhord, CDT,
Friedrich Schuppisser, CDT; and Anyoung
Ngyen, CDT

References
1. Poui SJ, Schrer P Effecf of provisionol oemenfs on the sheor bond
strength ot various dentin bonding
dgents. J Ordi Rehabii 1997:248-14.
2. Bdchmann M, Paul SJ, Lthy H.
Schrer P Effect of cieoning dentin
Viiith soop ond pumice on sheor
bond strength of dentin bonding
agents. J Orai Rehabii 1997:24:
433-438.
3. Bertschinger C, Poul SJ, Lthy H,
Schrer P Duoi oppiioation of denfin
bonding ogents: Effect on bond
strength. Am J Dent 1996:9:115-119.
4. Zeilweger U. Der Einfluss der
Sduersfott-lnhibitionsschicht von
Dentin-ddhosiven ouf die Polymerisation verschiedener Abdruckmdteriaiien. Med Diss Zurich, 1997:
1-47.
5 Chrisfensen G. Clinicdi Reseorch
Associotes Newsietter, Moy 1996:20'
1-3.
6 Paul SJ, Schrer P intropuipai pressure ond thermoi cyciing: Effect on
sheor bond strength of eleven
modern dentin bonding agents. J
Esthet Denf 1993:4:179-185
7, Feilzer AJ, DeGee AJ, Dovidson CL
Increosed wail-fo-woil curing controcfion in thin bonded resin loyers
J Denf Res 1989:08:48-50
8 Pashiey EL. Oomer RAW. Simpson
MD, Horner JA, Pashiey DH,
Caughman WF Dentin permeobiiity:
Sealing the dentin in crown preparotions, Oper Dent 1992:17:13-20.
9, Peter A, Paul SJ. Lthy H, Schrer P
Fiim thici<ness of vorious dentin
bonding agents. J Orol Rehobii
1997:24:568-573.
10. Grimm A, Poul SJ, Schdrer P.
Dggelin M, Mafhys D, Guggenheim
R, Cryo-preporotion combined with
low-temperdture scanning eiecfron
microscopy (LTSEM) to evoiuote fhe
dentin adhesive interface. Acta
Med Dent Heiv 1997:2:60-75.

Voiume 17. Number 6, 1997