Criteria for the Replacement of Restorations: Academy of Operative Dentistry European Section.

The replacement of a restoration is one of the most common procedures in dentistry. However, the criteria for such intervention, excluding catastrophic failure and persistent discomfort and pain, continue to be the subject of considerable debate. The decision-making process remains subjective on the part of the treating clinician, while the evidence base for refurbishment and repair rather than replacement for the management of defective and failing restorations continues to grow and strengthen. This article, prepared as an Academy of Operative Dentistry European Section consensus publication, reviews existing criteria for the replacement of restorations and encourages practitioners to shift, if not already doing so, to considering the replacement of a restoration as a last resort rather than as a prudent action to be taken if in any doubt about clinical acceptability. Further research in the area, spanning the risk assessment of defective and failing restorations and new diagnostic tools and processes, together with work to enhance the evidence base of restoration repair vs replacement, would be of immense value.

Recommendations for conducting controlled clinical studies of dental restorative materials.

About 35 years ago, Ryge provided a practical approach to evaluation of clinical performance of restorative materials. This systematic approach was soon universally accepted. While that methodology has served us well, a large number of scientific methodologies and more detailed questions have arisen that require more rigor. Current restorative materials have vastly improved clinical performance and any changes over time are not easily detected by the limited sensitivity of the Ryge criteria in short term clinical investigations. However, the clinical evaluation of restorations not only involves the restorative material per se but also different operative techniques. For instance, a composite resin may show good longevity data when applied in conventional cavities but not in modified operative approaches. Insensitivity, combined with the continually evolving and non-standard investigator modifications of the categories, scales, and reporting methods, has created a body of literature that is extremely difficult to meaningfully interpret. In many cases, the insensitivity of the original Ryge methods is misinterpreted as good clinical performance. While there are many good features of the original system, it is now time to move to a more contemporary one. The current review approaches this challenge in two ways: (1) a proposal for a modern clinical testing protocol for controlled clinical trials, and (2) an in-depth discussion of relevant clinical evaluation parameters, providing 84 references that are primarily related to issues or problems for clinical research trials. Together, these two parts offer a standard for the clinical testing of restorative materials/procedures and provide significant guidance for research teams in the design and conduct of contemporary clinical trials. Part 1 of the review considers the recruitment of subjects, restorations per subject, clinical events, validity versus bias, legal and regulatory aspects, rationales for clinical trial designs, guidelines for design, randomization, number of subjects, characteristics of participants, clinical assessment, standards and calibration, categories for assessment, criteria for evaluation, and supplemental documentation. Part 2 of the review considers categories of assessment for esthetic evaluation, functional assessment, biological responses to restorative materials, and statistical analysis of results. The overall review represents a considerable effort to include a range of clinical research interests over the past years. As part of the recognition of the importance of these suggestions, the review is being published simultaneously in identical form in both the "Journal of Adhesive Dentistry" and the "Clinical Oral Investigations." Additionally an extended abstract will be published in the "International Dental Journal" giving a link to the web full version. This should help to introduce these considerations more quickly to the scientific community.

[Inter-university cooperation in Flanders--an academic point of view on peer review]. / La Collaboration Interuniversitaire en Flandre - un point de vue académique sur les peer review.

Peer review as a possibility for discussion among practising dentists was introduced in Belgium in 1998 in the framework of a quality ensuring program. The 'Interuniversitary Cooperation', an initiative of Flemish universities active in teaching, research and patient treatment in dentistry has been involved in this program since its beginning to set up a dialogue between academia and dental practitioners and to gather information on scientific and educational matters. In this article the principles and organisation are described and thought is given to the attitude of the participants and future possibilities.

[The use of fluorides in dentistry in the year 2003]. / Het gebruik van fluoriden in de tandheelkunde anno 2003.

During the 20th century the entire Western world has been plagued by a tremendous increase of carious lesions in the dentition of children and adults. Near the end of that century a definite decrease in the number of carious lesions was noticed. That improvement in dental health is mainly attributed to an increased presence of fluorides in the oral cavity. Fluorides can be administrated systemically or locally. Recent findings clearly suggest that a local administration is the preferred option. Correctly applicated the local use of fluorides provides a favourable and positive effect during demineralization and remineralisation processes under carious attack. Although fluorides are not the only measure in caries prevention it is widely believed that they have largely contributed to an improvement of oral health, the relief of dental pain and the safeguarding of financial means during the last twenty five years.

Four-year water degradation of total-etch adhesives bonded to dentin.

Resin-dentin bonds degrade over time. The objective of this study was to evaluate the influence of variables like hybridization effectiveness and diffusion/elution of interface components on degradation. Hypotheses tested were: (1) There is no difference in degradation over time between two- and three-step total-etch adhesives; and (2) a composite-enamel bond protects the adjacent composite-dentin bond against degradation. The micro-tensile bond strength (microTBS) to dentin of 2 three-step total-etch adhesives was compared with that of 2 two-step total-etch adhesives after 4 years of storage in water. Quantitative and qualitative failure analyses were conducted correlating Fe-SEM and TEM. Indirect exposure to water did not significantly reduce the microTBS of any adhesive, while direct exposure resulted in a significantly reduced microTBS of both two-step adhesives. It is concluded that resin bonded to enamel protected the resin-dentin bond against degradation, while direct exposure to water for 4 years affected bonds produced by two-step total-etch adhesives.

Improved filler-matrix coupling in resin composites.

Ineffective silane coupling between filler and matrix within dental composites is prone to accelerated in vivo degradation. In this study, we examined to what degree a procedure involving chemical decontamination of filler prior to silanization could improve the filler-matrix bonding, and thus the physico-mechanical properties, of composites. X-ray photoelectron spectroscopy revealed that filler-matrix coupling largely depended upon siloxane bridge (Si-O-Si) formation between the silica surface and the silane molecule, rather than on intermolecular bonding between adjacent silane molecules. Pre-silanization decontamination based upon boiling silica in 0.05-5% sodium peroxodisulfate, followed by ultrasonic rinsing in acetone, most effectively decontaminated filler. Consequently, it significantly improved the bonding of silane molecules to silanol groups at the silica surface. Experimental composites produced following pre-silanization decontamination of filler revealed a diametral tensile strength that was resistant to degradation by thermocycling.

Adhesion/decalcification mechanisms of acid interactions with human hard tissues.

In order to study adhesion/decalcification mechanisms of acid interactions with human hard tissues such as bones and teeth, the chemical interaction of five carboxylic acids (acetic, citric, lactic, maleic, and oxalic) and two inorganic acids (hydrochloric and nitric) with enamel and two synthetic hydroxyapatite (HAp) powders with, respectively, a high and a low crystallinity were analyzed using X-ray photoelectron spectroscopy (XPS), atomic absorption spectrophotometry (AAS), and spectrophotometry (S). X-ray diffraction revealed that the crystallinity of the highly crystallized HAp was considerably higher than that of enamel while the crystallinity of the poorly crystallized HAp was similar to that of dentin and bone. XPS of acid-treated enamel demonstrated for all carboxylic acids ionic bonding to calcium of HAp. AAS and S showed for both HAps that all carboxylic and inorganic acids except oxalic acid extracted Ca significantly more than P, leading to a Ca/P ratio close to that of synthetic HAp (2.16 w/w). Oxalic acid extracted hardly any Ca, but substantially more P, leading to a significantly smaller Ca/P ratio than that of HAp. AAS showed that the calcium salt of oxalic acid hardly could be dissolved, whereas the calcium salts of all the other acids were very soluble in their respective acid solution. These results confirm the adhesion/decalcification concept (AD-concept) previously advanced. Depending on the dissolution rate of the respective calcium salts, acids either adhere to or decalcify apatitic substrates. It is concluded that the AD-concept that originally dictated the interaction of carboxylic acids with human hard tissues can be extended to inorganic acids, such as hydrochloric and nitric acid. Furthermore, HAp crystallinity was found not to affect the adhesion/decalcification behavior of acids when interacting with apatitic substrates, so that the AD-concept can be applied to all human hard tissues with varying HAp crystallinity.

Microleakage of adhesive restorative materials.

PURPOSE: To compare the marginal sealing ability of two conventional and one polyacid-modified resin-based composite, and two conventional and three resin-modified glass-ionomers in conventional cylindrical box cavities following a silver-staining microleakage evaluation method. MATERIALS AND METHODS: In 80 freshly extracted and caries-free human third molars, three standardized cylindrical butt-joint cavities were prepared: the first cavity in coronal enamel, the second at the cemento-enamel junction (CEJ) and the third completely in root cementum. A control group of 10 additional teeth was chosen. After the cavities were restored randomly using the eight restorative materials tested, the specimens were first stored in distilled water at 37 degrees C for 7 days and then thermocycled (500 cycles). Thereafter, the specimens were centrifuged for 10 min in plastic bottles containing 50 wt% silver nitrate aqueous solution. The degree of microleakage was recorded at four different depths along the restoration margins using an optical stereomicroscope equipped with a measuring gauge. RESULTS: None of the tested systems prevented microleakage completely, but the extent of leakage decreased towards the bottom of the restorations. The resin-modified glass-ionomers performed better than the conventional resin-based composites and conventional glass-ionomers. CLINICAL SIGNIFICANCE: Distinct leakage patterns were recorded among all materials investigated. Complete marginal sealing could still not be reached with the new adhesive restorative materials.

Dynamic elastic modulus of 'packable' composites.

OBJECTIVE: A new type of so-called 'packable', 'condensable' or 'mouldable' composite has been developed and aims at replacing amalgam for posterior restorations. The purpose of the present investigation was to study the dynamic elastic modulus of 12 packable composites, and to follow the evolution of this property following prolonged water absorption. METHODS: Of each material ten rectangular samples (1.5x5x35 mm) were prepared. The elastic modulus (GPa) of each sample was determined with a non-destructive dynamic method using a Grindo-Sonic after 24 h of dry storage at room temperature, and after 24h, 1, 3 and 6 months of wet storage at 37 degrees C. All data were analyzed using two-way ANOVA, Bonferroni/Dunn's test for multiple comparisons and paired t-test with a significance level of p<0.05. In addition, inorganic filler volume percentages were derived from the phenomenological model introduced by Braem et al. [11]. RESULTS: The studied materials varied widely in terms of elastic modulus, ranging between composites classified as Compact-Filled Densified (elastic modulus of 23.4+/-2.4 GPa) and as Microfine (elastic modulus of 8.5+/-2.1 GPa). SIGNIFICANCE: The great diversity observed in the elastic modulus of this type of composites necessitates clear specifications with regard to 'first' the definition of marketing terms such as packable and so on, and 'second' the justified use in posterior teeth.

Do condensable composites help to achieve better proximal contacts?

OBJECTIVES: Obtaining acceptable contact areas with adjacent teeth is a significant challenge when placing direct resin composite in Class II preparations. It was the purpose of this laboratory study to evaluate the influence of the type of resin composite ('packable' vs conventional) and of the matrix system on the quality of the proximal contact area in Class II composite restorations. METHODS: A standardized DO cavity was prepared in 170 frasaco teeth. Two operators each filled 85 teeth in the same frasaco model using four resin composites [Solitaire (S), Surefil (Su), P60, Z100], three matrix systems [Automatrix (A), Palodent (P), Lucifix matrix (L)] and one hand instrument specially designed to achieve better proximal contacts [Belvedere Composite Contact Former (B)]. The teeth were subdivided into 17 groups (Z100/1-A, Z100/1-P, Z100/1-L, S-A, S-P, S-L, Z100/1-A-B, Z100/1-L-B, Su-A, Su-P, Su-L, P60-A, P60-P, P60-L, Z100/2-A, Z100/2-P, Z100/2-L). Each operator made five fillings of each group. The quality of the proximal contacts was assessed by measuring the maximum mesio-distal (M-D) diameter of the restored teeth using a digital micrometer and the tightness of the proximal contact area using standardized metal blades. All data were analyzed using two-way ANOVA and Bonferroni/Dunn's test for multiple comparisons with a significance level of P<0.05. RESULTS: Regarding the matrix system, a significant larger M-D diameter and a stronger proximal contact area was achieved with the Palodent matrix system. The use of the Belvedere Composite Contact Former together with Lucifix matrix and Automatrix contributed to significantly stronger proximal contact areas. Concerning the type of resin composite, no significant differences were noted for both evaluation criteria when Palodent was used. Using Automatrix or Lucifix matrix, the more condensable resin composite P60 scored slightly better than Surefil and Z100. There was no operator effect. Both operators underwent a learning process. The longer they worked with a specific material/technique, the better proximal contacts they achieved. SIGNIFICANCE: The best proximal contact areas in Class II composite restorations were obtained using a sectional matrix system. The 'packability' of the resin composite did not help to achieve better proximal contacts.

Adhesion to and decalcification of hydroxyapatite by carboxylic acids.

Fundamental to the processes of decalcification of or adhesion to mineralized tissues is the molecular interaction of acids with hydroxyapatite. This study was undertaken to chemically analyze the interaction of 1 mono-, 2 di-, 1 tri-, and 2 polycarboxylic acids with hydroxyapatite in an attempt to elucidate the underlying mechanism. Maleic, citric, and lactic acid decalcified hydroxyapatite, in contrast to oxalic acid and the two polycarboxylic acids that were chemically bonded to hydroxyapatite. Solubility tests showed that the calcium salts of the former were very soluble, whereas those of the latter could hardly be dissolved in the respective acid solutions. Based on these data, an adhesion/decalcification concept was advanced that predicts that carboxylic acids, regardless of concentration/pH, either adhere to or decalcify hydroxyapatite, depending on the dissolution rate of the respective calcium salts in the acid solution. This contrasting behavior of organic acids most likely results from their differential structural conformations.

Effect of remaining dentin thickness and the use of conditioner on micro-tensile bond strength of a glass-ionomer adhesive.

OBJECTIVES: The purpose of this study is to investigate the effect of remaining dentin thickness and the use of a 20% polyalkenoic acid conditioner on the micro-tensile bond strength of a glass-ionomer adhesive to dentin. METHODS: Resin composite was bonded to flat dentin surfaces from 14 extracted human teeth using Fuji BOND LC (GC) with or without a polyalkenoic acid conditioner, then sectioned to thin slabs, trimmed into an hourglass shape with the area of the interface being approximately 1mm(2), and subjected to micro-tensile testing at a cross-head speed of 1mm/min. Micro-tensile bond strengths were determined at three depth levels with a remaining dentin thickness of more than 3mm, between 2 and 3mm, and less than 2mm. Failure modes of the broken interfaces were determined using field-emission scanning electron microscopy. RESULTS: The micro-tensile bond strength to dentin significantly improved when the remaining dentin thickness increased and the conditioner was used. When the conditioner was used (irrespective of remaining dentin thickness), failures mainly occurred adhesively at the interface between the adhesive and resin composite. When no conditioner was used, no adhesive failures between the adhesive and resin composite occurred, but failures occurred mainly adhesively between dentin and the adhesive, or mixed adhesive-cohesively. SIGNIFICANCE: The bonding effectiveness of the glass-ionomer adhesive tested was affected by the area of intertubular dentin available for micro-mechanical retention through hybrid-layer formation. Removal of the smear layer improved the bond strength of the adhesive to dentin.

An in vitro wear study of posterior denture tooth materials on human enamel.

This in vitro study evaluated the wear effects of five posterior denture tooth materials on human enamel. The tooth specimen was cusp shaped and enamel specimen was formed as a 10 C 10 C 5 mm plate. All material-enamel combinations were tested using a machine designed to produce sliding contact 20 C 104 times at 60 cycles min-1 and a 4-mm sliding distance per stroke in the bucco-lingual direction under a load of 1 kg. Wear analysis was measured as the total height loss of each combination. In addition, the surface roughness (Ra) of each worn specimen was also evaluated. The least total height loss occurred with poly (methyl methacrylate) (PMMA) enamel pair, and the greatest did with porcelain (Po)-enamel pair. The lowest compound Ra value was measured in high-strength resin (HR)-enamel pair, and the highest in Po-enamel pair. These findings suggest that the best combination is PMMA-enamel, and the poorest combination is Po-enamel.

Microtensile bond strength of eleven contemporary adhesives to dentin.

PURPOSE: To evaluate the microtensile bond strength (microTBS) of eleven contemporary adhesives to dentin, including three one-step self-etch systems, four two-step self-etch systems, three two-step total-etch systems, and one three-step total-etch system. MATERIALS AND METHODS: Resin composite (Z100) was bonded to flat, mid-coronal dentin from 33 extracted human third molars using the adhesives strictly according to the respective manufacturer's instructions. After storage overnight in 37 degrees C water, the bonded specimens were sectioned into 3 to 6 slabs of approximately 1 mm thickness and 2.5 mm width. They were then trimmed into an hourglass shape resulting in an interface area of approximately 1 mm2, and subsequently subjected to microTBS testing with a crosshead speed of 1 mm/min. RESULTS: The microTBS varied from 30.0 MPa for the one-step self-etch adhesive Prompt L-Pop 2 (ESPE) to 63.1 MPa for the three-step total-etch adhesive OptiBond FL (Kerr), the latter being the only one that significantly differed from all other microTBS values. Although not significantly different, one-step self-etch adhesives tended to have lower microTBS than two-step self-etch and two-step total-etch adhesives. Specimen failures during sample preparation occurred with Prompt L-Pop 2 (4 pretesting failures out of 17 specimens) and NRC/Prime & Bond NT (7 pretesting failures out of 14 specimens). CONCLUSION: Adhesives with simplified application procedures, either following a total-etch or self-etch approach, produced lower bond strengths to dentin than a conventional three-step total-etch adhesive. Some concern exists regarding the consistency in bonding effectiveness to dentin of some self-etch adhesives.

Evidence of chemical bonding at biomaterial-hard tissue interfaces.

For many years, glass-polyalkenoate cements have been described as possessing the unique properties of self-adherence to human hard tissues, such as bones or teeth. However, direct experimental evidence to prove the existence of chemical bonding has not been advanced. X-ray Photoelectron Spectroscopy (XPS) was used to analyze the chemical interaction of a synthesized polyalkenoic acid with enamel and synthetic hydroxyapatite. For both enamel and hydroxyapatite, the peak representing the carboxyl groups of the polyalkenoic acid was detected to have significantly shifted to a lower binding energy. De-convolution of this shifted peak disclosed two components with a peak representing unreacted carboxyl groups and a peak suggesting chemical bonding to hydroxyapatite. On average, 67.5% of the carboxyl groups of the polyalkenoic acid were measured to have bonded to hydroxyapatite. XPS of hydroxyapatite also disclosed its surface to be enriched in calcium and decreased in phosphorus, indicating that phosphorus was extracted at a relatively higher rate than calcium. Analysis of these data supports the mechanism in which carboxylic groups replace phosphate ions (PO4(3-)) of the substrate and make ionic bonds with calcium ions of hydroxyapatite. It is concluded that an ultrathin layer of a polyalkenoic acid can be prepared on a hydroxyapatite-based substrate by careful removal of non-bonded molecules. With this specimen-processing method, XPS not only provided direct evidence of chemical bonding, but also enabled us to quantify the percentages of functional groups of the polyalkenoic acids that bonded to calcium of hydroxyapatite.

Porcelain veneers: a review of the literature.

OBJECTIVES: Porcelain veneers are steadily increasing in popularity among today's dental practitioners for conservative restoration of unaesthetic anterior teeth. As with any new procedure, in vitro and in vivo investigations are required to assess the ultimate clinical efficacy of these restorations. The current literature was therefore reviewed in search for the most important parameters determining the long-term success of porcelain veneers. DATA SOURCES: Laboratory studies focusing on parameters in prediction of the clinical efficacy of porcelain veneers such as the tooth preparation for porcelain veneers, the selection and type of the adhesive system, the quality of marginal adaptation, the resistance against microleakage, the periodontal response, and the aesthetic characteristics of the restorations have been reviewed. The clinical relevance of these parameters was then determined by reviewing the results of short and medium to long-term in vivo studies involving porcelain veneers performed during the last 10 years. CONCLUSIONS: The adhesive porcelain veneer complex has been proven to be a very strong complex in vitro and in vivo. An optimal bonded restoration was achieved especially if the preparation was located completely in enamel, if correct adhesive treatment procedures were carried out and if a suitable luting composite was selected. The maintenance of aesthetics of porcelain veneers in the medium to long term was excellent, patient satisfaction was high and porcelain veneers had no adverse effects on gingival health inpatients with an optimal oral hygiene. Major shortcomings of the porcelain veneer system were described as a relatively large marginal discrepancy, and an insufficient wear resistance of the luting composite. Although these shortcomings had no direct impact on the clinical success of porcelain veneers in the medium term, their influence on the overall clinical performance in the long term is still unknown and therefore needs further study.

Microscopy investigations. Techniques, results, limitations.

This paper critically reviews current microscopy techniques that are used to image resin-dentin interfaces and more in particular to investigate the process of hybridization and resin-tag formation. A short description of the four most commonly used microscopy techniques with their necessary specimen-preparation methodology is provided along with a discussion of their possibilities, limitations and potential artifact formation. With this critical appraisal on microscopy techniques available to study adhesive interfaces, it is hoped to encourage the use of high-resolution analytical tools to further elucidate the mechanisms of bonding at the ultra-structural level. Besides ultra-morphologic characterization, more research should be devoted to study the chemical and physical properties of resin-dentin bonds. The final objective of such fundamental research should be to establish a more durable and reliable adhesive restorative technique.

Porcelain veneers bonded to tooth structure: an ultra-morphological FE-SEM examination of the adhesive interface.

OBJECTIVES: The porcelain veneer technique bonds a thin porcelain shell to a minimally prepared tooth surface (enamel and/or dentin) with a luting composite in combination with an adhesive system. When complete, two adhesive interfaces are formed--resin to etched porcelain and resin to tooth structure. The purpose of this laboratory investigation is to analyze the ultra-structure of these two adhesive interfaces in order to find an explanation for some clinical phenomena and/or shortcomings of bonded porcelain veneers. METHODS: The surfaces of four porcelain disks were treated successively by sandblasting, etching with hydrofluoric acid, ultrasonic cleaning, and silanizing. The effect of each step on the surface structure of the porcelain was evaluated by field-emission scanning electron microscopy (FE-SEM). In addition, the effect of acid etching the tooth surface of veneer preparations on seven extracted upper anterior teeth was similarly determined. Finally, pre-treated porcelain veneers were luted to veneer preparations on 12 extracted upper anterior teeth by means of a contemporary total-etch adhesive system and a photo-polymerizable luting composite. The tooth/luting composite and the luting composite/porcelain interface of the veneer complex were then evaluated ultra-morphologically by FE-SEM after the specimens had been etched with an argon-ion beam to enhance the surface relief. RESULTS: FE-SEM imaging of the tooth/luting composite/porcelain interface showed strong micro-mechanical interlocking of the luting composite in the micro-retentive pits both of the acid-etched tooth surface and in the etch pits of the acid-etched porcelain surface. From this ultra-morphological perspective, the etched porcelain surface is more retentive than the etched tooth surface. At the tooth surface, cervical aprismatic enamel and exposed dentin showed the least resin-receptive surface texture. However, in these areas, no separation of the interface was observed when a multi-step total-etch adhesive system was used. SIGNIFICANCE: The strong interlocking of the luting composite into the retentive etch pits of both the porcelain and tooth substrates contributes to strong adhesion of porcelain veneers with good retention. This study suggests that a modern multi-step total-etch adhesive system can produce adhesion even to the less retentive cervical enamel and exposed dentin. Further clinical research is necessary to evaluate the long-term retention of porcelain veneers and to correlate these in vitro observations with clinical performance.

Polymerization shrinkage and elasticity of flowable composites and filled adhesives.

OBJECTIVES: The magnitude and kinetics of polymerization shrinkage, together with elastic modulus, may be potential predictors of bond failure of adhesive restorations. This study examined these properties in visible-light-cured resins, in particular new flowable composites and filled adhesives. METHODS: Polymerization shrinkage values were obtained by digital video imaging before and after light-curing; shrinkage kinetics were obtained by the "deflecting disk" method and the elastic modulus by analysis of the fundamental period of vibration. RESULTS: Flowable composites generally showed higher shrinkage than traditional non-flowable composites, while more densely filled adhesives presented lower shrinkage than lightly filled or unfilled resins. The elastic moduli of flowable composites were in the low-medium range, whilst the hybrid composites showed the highest values and the microfilled the lowest. More densely filled adhesives were more rigid than lightly filled and unfilled adhesives. The kinetics behavior was material dependent, mainly characterized by the coefficient of near-linear contraction between 10 and 40% of the final shrinkage and the time to reach 75% of the final shrinkage. SIGNIFICANCE: The higher shrinkage of flowable composites over that of hybrids may indicate a potential for higher interfacial stresses. However, their lower rigidity may be a counteracting factor. The microfilled composite showed low shrinkage and low rigidity, a combination that may prove less damaging to the interface. As the kinetics parameters tended to be material specific, no specific class of materials should be seen as more stress inducing until studies determine the relative importance of each examined parameter. The performance of adhesive resins as stress buffers also remains unpredictable.