Microtensile Bond Strength to Enamel Affected by

Hypoplastic Amelogenesis Imperfecta

Batu Can Yamana / Fusun Ozerb / Cigdem Sozen Cabukustac / Meltem M. Erenc /
Fatma Korayd / Markus B. Blatze
Purpose: This study compared the microtensile bond strengths (+TBS) of two different self-etching (SE) and etchand-rinse (ER) adhesive systems to enamel affected by hypoplastic amelogenesis imperfecta (HPAI) and analyzed
the enamel etching patterns created by the two adhesive systems using scanning electron microscopy (SEM).
Materials and Methods: Sixteen extracted HPAI-affected molars were used for the bond strength tests and 2
molars were examined under SEM for etching patterns. The control groups consisted of 12 healthy third molars
for +TBS tests and two molars for SEM. Mesial and distal surfaces of the teeth were slightly ground flat. The adhesive systems and composite resin were applied to the flat enamel surfaces according to the manufacturers
instructions. The tooth slabs containing composite resin material on their mesial and distal surfaces were cut in
the mesio-distal direction with a slow-speed diamond saw. The slabs were cut again to obtain square, 1-mm-thick
sticks. Finally, each stick was divided into halves and placed in the +TBS tester. Bond strength tests were performed at a speed of 0.5 mm/min. Data were analyzed with two-way ANOVA and Tukeys tests.
Results: There was no significant difference between the bond strength values of ER and SE adhesives (p >
0.05). However, significant differences were found between HPAI and control groups (p < 0.05). HPAI-affected
enamel surfaces exhibited mild intra- and inter-prismatic enamel etching patterns after orthophosphoric acid application, while conditioning of HPAI-affected enamel with SE primer created a slightly rough and grooved surface.
Conclusion: SE and ER adhesive systems provide similar bond strengths to HPAI-affected enamel surfaces.
Keywords: Amelogenesis imperfecta, bond strength, microtensile, self-etch adhesive, etch-and-rinse adhesive.
J Adhes Dent 2014; 16: 714.
doi: 10.3290/j.jad.a30554

melogenesis imperfecta (AI) is a group of inherited

disorders affecting enamel formation and are characterized by clinical and genetic heterogeneity. 13 The
autosomal dominant forms of AI represent its most common form, representing approximately 85% of inherited
enamel diseases.5 The incidence of amelogenesis im-

Assistant Professor, Department of Operative Dentistry, Faculty of Dentistry,

Osmangazi University, Eskiehir, Turkey. Idea, performed experiments and
statistical analysis, wrote the manuscript.

Clinical Associate, Department of Preventive and Restorative Science, School

of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA. Designed the bond strength tests, interpreted the data, co-wrote manuscript.

PhD Student, Department of Operative Dentistry, Faculty of Dentistry, Istanbul University, Istanbul, Turkey. Contributed to application of bond strength
tests.

Professor, Department of Operative Dentistry, Faculty of Dentistry, Istanbul

University, Istanbul, Turkey. Co-supervised the study, proofread manuscript.

Professor, Department of Preventive and Restorative Science, School of

Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA. Supervised the study, contributed to discussion, proofread manuscript.

Correspondence: Dr. Batu Can Yaman, Department of Operative Dentistry, Faculty of Dentistry, Istanbul University, Istanbul, Turkey. Tel: +902124142020/30369, Fax: +90-2125250075. e-mail: batucan@istanbul.edu.tr
or batucanyaman@hotmail.com

Vol 16, No 1, 2014

Submitted for publication: 16.03.12; accepted for publication: 30.05.13

perfecta reportedly varies between approximately 1:700

and 1:16,000, depending on the population studied and
diagnostic criteria. Clinically, these developmental dental defects range from opacities to severe hypoplasia.20
The diverse clinical presentation of AI is thought to be
the result of specific genetic defects affecting the deposition, calcification, and maturation of enamel.23 Four major
types were recognized based on phenotype (hypoplastic, hypomaturation, hypocalcified, and hypomaturationhypoplastic) and then subdivided into 15 subtypes based
primarily on phenotype and, secondarily, by mode of inheritance.1
Enamel hypoplasia is an exclusive ectodermal disturbance, related to alterations in the organic enamel matrix
which can cause white flecks, narrow horizontal bands,
lines of pits, grooves, and discoloration of the teeth varying from yellow to dark brown.32 Hypoplastic enamel does
not develop to normal thickness. On radiographs, enamel
contrasts normally from dentin.37 Enamel hypocalcification is a defect in the mineralization process, and in this
form, the enamel is soft and friable.10 Hypomaturation
is an abnormal occurrence in the final stages of the mineralization process and differs from hypocalcification in
that the enamel is harder, with a mottled opaque white to
yellow-brown or red-brown color.11,27
7

Yaman et al

Restoration of AI-affected teeth is important not only

because of esthetic and functional needs, but also because of patients psychological improvement.16,21 According to the type of AI and the patients age, many
treatments have been proposed and various strategies
may be used to overcome the compromised esthetics and
function. A contemporary approach is the use of direct and
indirect resin composite restorations by maintaining the
maximum amount of dental hard tissues in young patients
with AI. The ability to achieve a strong and durable bond
between the restorative material and tooth structure is
of paramount importance for the clinical success of such
dental restorations.31
Various types of resin bonding systems have been
developed over the last decade. However, current resin
bonding systems can generally be divided into two main
categories in terms of simplified clinical applications.
Etch-and-rinse (ER) adhesive systems include aggressive
phosphoric-acid etching, while self-etching (SE) systems
combine etching and priming in one procedure. Both types
of resin bonding systems have the ability to produce high
bond strengths to enamel and dentin.11,25
However, there is a discussion among clinicians about
the preferred resin material for treatment of AI-affected
teeth. In some patients with AI, bonded restorations
have been successful to restore teeth to acceptable
form, function, and esthetics.12,33 In others, however,
adhesive restorations showed high failure rates associated with inadequate bonding between the restoration
and enamel.9,28,39 Chemical and morphological differences between sound and AI-altered enamel accounted
for these failures.10,24
The availability of AI-affected teeth for laboratory bondstrength testing is limited. In the dental literature, there
are only a few studies testing the bonding ability of resin
materials to AI-affected enamel.8,19,24 However, in these
studies, the phenotypes of AI-affected enamel are different from those of the present study. This in vitro study
compared the microtensile bond strengths of two different
types of adhesive bonding systems (SE and ER) to enamel
affected by HPAI. The enamel etching patterns of two
bonding systems were analyzed with a scanning electron
microscope (SEM).
The hypotheses tested were that:
1. The bond strength to HPAI-affected enamel exhibits
differences as compared with that to sound enamel.
2. Bond strengths to HPAI-affected enamel are different
between SE and ER adhesive systems.
3. There is a difference in etching patterns between SE
and ER adhesive systems on AI-affected enamel and
healthy enamel.

MATERIALS AND METHODS

Collection and Grouping of Experimental Teeth
The seven patients who were self-conscious about the
appearance of their teeth were referred to the Department of Operative Dentistry for treatment. Prior to treatment, a detailed medical, dental, and social history
8

was obtained and recorded. The intraoral examination

revealed that the teeth were of yellow-brown color and
the thickness of the enamel was reduced. The enamel
surface was smooth or smoothly irregular, and glossy.
Radiographically, a contrast between enamel and dentin
was observed. According to the criteria described by
Witkop,37 the cases were diagnosed as hypoplastic amelogenesis imperfecta (HPAI) type ID by two independent
operators who were calibrated with a number of individual parameters specific to the disorder.
Eighteen fully or partially erupted third molars scheduled for extraction were collected from the patients with
HPAI after obtaining the patients informed consent. Additionally, 14 caries- and restoration-free permanent,
healthy, freshly extracted human third molars were used
in the study for the control groups. All teeth were cleaned
and soft tissue remnants were removed; then the teeth
were stored in saline solution (0.9 % sodium chloride in
water) at 4C for one week. The roots of the teeth were
then removed with a slow-speed saw (Isomet, Buehler;
Lake Bluff, IL, USA) under water irrigation. Sixteen HPAIaffected enamel teeth were selected for +TBS testing
and the two remaining HPAI-affected molars were used
for SEM analysis. As controls, twelve healthy third molars
were used for the +TBS test and two were selected for
SEM analysis.
The mesial and distal enamel surfaces of the teeth
were slightly ground with 600-grit SiC abrasive paper for
10 s to obtain flat enamel surfaces, and then rinsed and
dried with an air syringe for a total of 10 s.
Experimental Design
The adhesive systems and composite resin restorations
were applied to mesial and distal enamel surfaces of
the teeth at random and according to the manufacturers instructions. Detailed material information is listed
in Table 1.
Groups 1 (ER Adhesive Control Group) and 2 (ER Adhesive HPAI Affected Enamel Group): Phosphoric acid 35%
(3M ESPE; St Paul, MN, USA) was applied to the ground
enamel surface for 30 s and then rinsed for 15 s with water. Two consecutive coats of ER adhesive (Adper Single
Bond 2, 3M ESPE) were immediately applied and gently
dried for 5 s each, avoiding excess of the adhesive agent.
Subsequently, the bonding surface was light cured for
10 s (LE Demetron II; Bioggio, Switzerland). Microhybrid
composite resin (Filtek Supreme XT, 3M ESPE; Seefeld,
Germany) was built up on the pretreated surface in two
incremental layers, and each layer was light cured for 20
s. The light output of the curing unit was 950 mW/cm2.
Groups 3 (SE Adhesive Control Group) and 4 (SE Adhesive HPAI Affected Enamel Group): The primer of the
bonding system (Clearfil SE Primer, Kuraray Medical;
Kurashiki, Japan) was applied to the enamel surface for
20 s and then dried with a light flow of air. Subsequently,
the bonding agent (Clearfil SE Bond, Kuraray Medical)
was applied and gently dried with air flow. The bonding
surface was then light cured for 10 s. The composite
resins were applied in the same manner as mentioned
above.
The Journal of Adhesive Dentistry

Yaman et al

Table 1

Composition and manufacturers of the materials used in the study

Materials and
Lot Numbers

Composition

Manufacturers

Adper Single Bond 2

Lot# N113791

Water, ethanol, bis-GMA, HEMA, UDMA, bisphenol-A glycerolate, polyalkenoic

acid copolymer, dimethacrylate, camphorquinone, 5-nm silica particles

3M ESPE; St Paul,
MN,USA

Clearfil SE Bond
Lot# 061538

Primer: MDP, HEMA, hydrophilic dimethacrylate,camphorquinone, diethanol,

toluidine, water
Bond: MDP, bis-GMA, hydrophobic dimethacrylate, camphorquinone,diethanol,
toluidine, silanated colloidal silica

Kuraray Medical;
Kurashiki, Japan

Filtek Supreme XT
Lot# 20070714

Matrix: bis-GMA, bis-PMA, TEG-DMA, UDMA

Filler: Silica nanofillers, zirconia/silica
nanocluster (0.61.4 m)

3M ESPE; Seefeld,
Germany

Microtensile Bond Strength Testing

The tooth slabs with composite resin material on their
mesial and distal surfaces were cut in a mesio-distal
direction with a slow-speed saw (Isomet 1000 Buehler),
creating slabs 1 mm thick. Three sound slabs were selected from each tooth to equalize the number of tested
slabs. Subsequently, the slabs were cut again to obtain
square 1-mm-thick sticks. Each stick was divided into
halves. Therefore, each cut test stick represented one
of the test groups (Fig 1). Two or three sticks were obtained from one tooth surface for each adhesive group.
The sticks were fixed to the +TBS testing machine
(Bisco Microtensile Tester; Schaumburg, IL, USA) with
a cyanoacrylate adhesive (Zapit; Corona, CA, USA ) and
tested in tension at a crosshead speed of 0.5 mm/
min until fracture occurred. Since no more than 5% of
all tested specimens failed during tooth sectioning,
they were not included in the data analysis but shown
in Table 2. A diagrammatic representation of specimen
preparation is shown in Fig 1.

MESIAL

DISTAL

MESIAL

DISTAL

Table 2 The distribution of failed sticks during cutting and failure modes after microtensile bond testing
(%)
c

Group 1
(ER-Control)

60

25

10

Group 2
(ER-HPAI)

Group 3
(SE-Control)

72.5

15

12.5

Group 4
(SE-HPAI)

28.5

7.1

35.7

42.8

D
35.7

28.5

35.7

Failure modes: a: cohesive failure within the resin composite or resin adhesive; b: adhesive failure at resin/enamel interface; c: cohesive failure
within dentin; d: mixed failure with a and b; e: mixed failure with b and c;
f: prematurely failed sticks.

Vol 16, No 1, 2014

C
d
Fig 1 Diagrammatic representation of specimen preparation.
a) Cutting slabs from the tooth. b) Obtaining sticks from the
slabs. c) Long sticks ready to cut into two parts. d) Microtensile test sticks. D: dentin, C: composite resin, E: enamel.

Yaman et al

Table 4 Microtensile bond strengths of adhesive systems to the enamel affected by HPAI and control groups

Table 3 Two-way ANOVA of microtensile bond

strength (split-plot model)
Source of
variation

Df

Sum of
squares

Mean
square

Groups

Bond strengths (MPa)

(mean SD)

Interaction

17.01

17.01

0.6754

Group 1 (ER-Control)

41

31.59 7.78b

Adhesives

107.8

107.8

4.279

Group 2 (ER-HPAI)

45

19.63 8.16a

Enamel

2978

2978

118.2

Group 3 (SE-Control)

40

29.24 7.17b

Residual

80

2015

25.18

Group 4 (SE-HPAI)

47

18.21 5.72a

Same lowercase letters indicate no significant difference (p < 0.05)

within same column.

35

ER

30

SE

MPa

25
20
15
10
5
0
Sound

HPAI

failure within the resin composite and/or resin adhesive; (b) adhesive failure at the resin/enamel interface;
(c) cohesive failure within dentin; (d) mixed failure of (a)
and (b); and (e) mixed failure of (b) and (c). Each type of
failure mode was expressed as a percentage of the total
number of specimens in that group.
Statistical Analysis
Numerical (quantitative) data were presented as means
and standard deviation. Two-way ANOVA and Tukeys
multiple comparison tests were used to compare the
means of the two adhesives. The significance level was
set at p 0.05. Statistical analysis was performed with
GraphPad Prism4 (GraphPad Software; La Jolla, CA,
USA) for Windows.

Enamel
Fig 2 Bar graph showing means and standard deviations of
of the microtensile bond strength (two-way ANOVA).

Sample Preparations for Scanning Electron Microscopy

(SEM)
The two HPAI-affected teeth and two healthy sound third
molars were used for SEM analysis. The crowns of the
teeth were removed with a diamond-coated separating disk
under irrigation. The teeth were cut in a mesio-distal direction with a slow-speed saw. The buccal and lingual surfaces were slightly ground to obtain flat enamel surfaces
with 600-grit SiC abrasive paper for 10 s, then rinsed and
dried with an air/water syringe for a total of 10 s. Clearfil
SE Primer was applied for 20 s to the buccal surface of
HPAI-affected enamel. The lingual surface of the enamel
was etched with 35% orthophosphoric acid for 30 s. All
specimens were sputter coated with gold-palladium for 60
s. The surface morphology of etched HPAI-affected and
healthy enamel was examined with an SEM (JSM5600,
JEOL; Tokyo, Japan) at 750X and 1500X magnifications.
Failure Analysis
The mode of failure was determined at a magnification
of 20X with a stereomicroscope (SZ61, Olympus; Tokyo,
Japan). Failure modes were classified as: (a) cohesive
10

RESULTS
The results of two-way ANOVA revealed that there
were no interactions between adhesives and types of
enamel (p = 0.4136). Bond strength to sound vs HPAIaffected enamel was found to differ highly significantly
(p < 0.0001). The split-plot model and box plot of the
microtensile bond strength results are shown in Table 3
and Fig 2.
Mean +TBS results and standard deviations for study
groups are listed in Table 4 and Fig 3. Although the
mean bond strength value (MPa) of the HPAI-affected
enamel was higher with ER (19.63 8.16) than with
SE (18.21 5.72), there was no statistically significant
difference (p > 0.05). However, significant differences
were found between HPAI-affected enamel and control
group results (p < 0.05). The highest +TBS was obtained for group 1 (31.59 7.78), followed by group 3
(29.24 7.17). The lowest bond strength was observed
in group 4 (18.21 5.72). The failure mode distribution
(%) is shown in Table 2. The majorities of the fracture patterns were adhesive failure at the resin/enamel interface
and cohesive failure within the enamel for HPAI groups;
also in control groups, the most common fracture patterns
were adhesive failure at the resin/enamel interface and
mixed failure modes.
The Journal of Adhesive Dentistry

Yaman et al
35
30
25
MPa

20
15
10
5
0

Fig 3 +TBS results of the study

(Tukeys HSD test).

Fig 4 The SEM micrographs of enamel

surfaces. a) HPAI-affected enamel after
35% orthophosphoric acid application
for 30 s (750X magnification). b) HPAIaffected enamel after 35% orthophosphoric acid application for 30 s (1500X
magnification). c) Healthy, sound enamel
after 35% orthophosphoric acid application for 30 s (750X magnification). d)
Healthy, sound enamel after 35% orthophosphoric acid application for 30 s
(1500X magnification).

Group 1 (ER-Control) Group 2 (ER-HPAI) Group 3 (SE-Control)

SEM Findings
The morphological changes in the enamel surfaces
treated with the phosphoric acid etchant or self-etching
primer are shown in Figs 4 and 5.
The orthophosphoric acid applied to HPAI-affected
enamel surfaces created shallow parallel grooves demarcating the incremental growth of enamel and a very few
pits with diameters similar to the diameter of the prism
core (Fig 4a). On the other hand, phosphoric acid produced well-defined etching patterns on the sound enamel.
Different dissolutions of either the prism cores or boundaries could be seen across the entire enamel surface of
the teeth (Fig 4b).
Vol 16, No 1, 2014

Group 4 (SE-HPAI)

Unlike phosphoric acid-treated surfaces, both the

HPAI-affected and sound enamel etched with SE primer
showed a less distinctive pattern. Especially the primer
produced a very mild etching effect on HPAI-affected
enamel, with most of the surface remaining unetched.
The enamel also appeared slightly rough and grooved
(Fig 5a). In the case of the self-etching primer, the intact
healthy enamel surface was not excessively demineralized, although some surface porosity was observed on
the surface that was treated with the SE primer for 20 s,
as seen in Fig 5b.

11

Yaman et al

DISCUSSION
There are several alternatives for the rehabilitation of
defective enamel in amelogenesis imperfecta (AI) patients. The ultimate treatment plan relates to the age
and socioeconomic status of the patient, type and severity of the disorder, and the intraoral situation at the
time of treatment planning.27
The mineral content of dental hard tissues is related
to their potential micromechanical interlocking with
bonding agents. The higher mineral content of enamel
is expected to generate a better mechanical interlocking
with the adhesive resin than is the case with dentin substrate.35 However, enamel affected by AI presents loss
of the normal architecture. Enamel prisms are incompletely formed, sometimes with the presence of abnormal amorphous material obscuring the rods. Genetic mutations may result in hypocalcification of enamel, as the
altered tissue shows incomplete biomineralization and
thus lower bond strength.2,6,30 El-Sayed et al6 reported
an approximately 40% mineral reduction in enamel affected by HPAI. However, hypoplastic defects result in
deficiencies in the amount of enamel usually characterized as thin enamel.6 One would expect that the differences in mineral content and structure of HPAI-affected
enamel may provide challenges to the bond of adhesive
resin system.
Bond strength studies on AI-affected human teeth are
rare due to the difficulty of collecting respective samples. Sixteen teeth with HPAI were obtained for bond
12

Fig 5 SEM micrographs of enamel surfaces. a) HPAI-affected enamel after

Clearfil SE Primer application for 20 s
(750X magnification). b) HPAI-affected
enamel after Clearfil SE Primer application for 20 s (1500X magnification). c)
Healthy, sound enamel after application
Clearfil SE Primer for 20 s (750X magnification). d) Healthy, sound enamel after
application Clearfil SE Primer for 20 s
(1500X magnification).

strength tests in this study. Because small flat enamel

areas on the specimens were obtained, the microtensile
bond strength test was selected as the preferred method
to evaluate bond strengths of ER and SE adhesives on
HPAI-affected enamel. Advantages of microtensile bond
strength tests include: (1) more adhesive and fewer cohesive failures; (2) higher interfacial bond strength values;
(3) ability to measure regional bond strengths; (4) means
and variances can be calculated for single teeth; (5) testing of bonds to irregular surfaces; (6) testing of very small
areas.17
The two adhesive systems used for comparison in this
study (Adper Single Bond 2 and Clearfil SE Bond) were
selected because of their proven long-term clinical performance.7,36
In the present study, however, the SE system showed
lower bond strength values (29.24 7.17) to healthy
enamel than did ER (31.59 7.78), but no statistically
significant difference was found between bond strength
values of the two adhesive system (p > 0.05), which
is in agreement with other studies which reported that
self-etching adhesives were as effective as etch-and-rinse
adhesives on healthy enamel surfaces.14,15,18
The penetration and diffusion of the bonding agent into
the demineralized enamel surface were very important for
the enamel adhesion.4 The bond strength to the phosphoric
acid-etched enamel was mainly attributable to the resins
ability to penetrate between the enamel crystallites and
rods.29 This ultrastructure might have contributed to the
high bond strength values obtained with the ER.
The Journal of Adhesive Dentistry

Yaman et al

In this study, the bond strength of the adhesives to the

AI-affected enamel was significantly lower than that of the
healthy enamel; thus, the first hypothesis was accepted.
The enamel of the normal teeth is a highly mineralized
tissue containing large crystals organized in a prismatic
structure. HPAI-affected enamel has morphological and
micromorphological differences from the sound healthy
enamel. These different results might be explained by
the presence of mineralization as well as morphological changes detected at the crystallite level in the HPAIaffected teeth.38
Even though the bond strength values were slightly
higher with the ER adhesive system, there was no statistically significant difference between ER and SE adhesives
in HPAI-affected enamel groups. Therefore, the second
hypothesis of our study was rejected. The slightly higher
bond strength values for the ER adhesive system can be
explained by more microretentive tooth surface obtained
on HPAI-affected enamel with phosphoric acid than with
the primer of SE adhesive.3
In a study by Faria-E-Silva et al,8 hypocalcified amelogenesis imperfecta (HCAI) enamel bond strengths were
14.2 MPa with the ER Adper Single Bond 2 adhesive system and, therefore, lower than the values observed in this
study. These differences can be attributed to the different
micromorphological alteration of the enamel related to the
severity of HCAI and different types of bond strength testing methods. Microshear and microtensile test methods
usually yield different bond strength values, with microtensile bond strength values up to two times greater than
corresponding microshear values.22,26
The primers of SE adhesive systems combine acidic
monomers with a priming agent, which allows these monomers to penetrate to the same depth in which demineralization occurs. This must be considered an advantage,
as microporosities created by the etching are completely
penetrated by the adhesive and provide micromechanical
interlocking with enamel.12 Interestingly, no other study
that compared etching patterns of ER and SE adhesive
systems could be found in the dental literature for HPAI.
In this study, the mildly acidic primer of a SE adhesive
system was used to etch HPAI-affected enamel surfaces.
SEM images revealed only slight etching patterns and
shallow grooves on the enamel surfaces (Fig 5). Independent of the different appearance in the SEM images, bond
strength values achieved with the SE adhesive were not
different from the ones obtained with the ER adhesive and
orthophosphoric acid. This can be attributed to the ground
enamel surface and the chemical bonding performance of
the SE adhesive system.34
In the SEM micrographs, orthophosphoric acid was
more effective in creating a desirable etching pattern both
of HPAI-affected enamel and sound enamel surfaces than
the primer of the SE adhesive system (Fig 4). In the current study, 35% orthophosphoric acid was applied for 30
s to HPAI-affected enamel and sound enamel. Shallow
parallel grooves as demarcation lines resulting from the
rhythmic and appositional enamel production were seen in
both enamel types after acid application. A typical etching
pattern was created along the grooves in healthy enamel.
Vol 16, No 1, 2014

However, on the HPAI enamel no typical etching pattern

was noticed. Only a few pits with diameters similar to the
diameter of the prism core were detected. The remarkable finding was that the surface of etched HPAI-enamel
appeared to be covered with a fibrous structure. In a study
by Seow and Amaratunge,28 orthophosphoric-acid etching
of smooth HPAI-affected enamel also showed a generally
uniform fibrillar surface, without any of the classical features of etched enamel. In that study, the authors also
used orthophosphoric acid for 30 s for SEM observations.
Due to the different enamel etching patterns between
ER and SE adhesive systems, our third hypothesis was
accepted.
With regard to the mode of fracture in HPAI-affected
enamel groups, the most common failure modes were
adhesive failure at the resin/enamel interface and mixed
failures with partly cohesive failures within the dentin and
resin adhesive. A possible explanation for the partly cohesive failure is the loss of normal architecture and thickness of enamel due to HPAI. The bonded enamel tissues
might have chipped away more easily from the dentinoenamel junction than is the case in normal enamel, leaving dentin surfaces exposed.
Direct composite resin restorations are the preferred
clinical choice to restore function and esthetics in patients
suffering from AI. The findings of this study suggest that
the clinical performance of composite resin restorations
bonded to HPAI-affected enamel may not be influenced by
the bonding agent selection when the choice is between
SE and ER adhesives. It must be noted, however, that the
enamel structure of AI-affected teeth differs among the
various types of AI. Since these variations may influence
the bonding ability of current adhesive resin materials,
generalizations of our findings are difficult. Further studies are necessary to investigate and determine the best
bonding protocols for different types of AI-affected enamel
before clinical recommendations can be given.

CONCLUSIONS
Within the limitations of this study, the following conclusions were drawn:
1. The micromorphological changes and irregularities
detected on the HPAI-affected enamel surface influenced bond strength values of both SE and ER adhesive systems.
2. SE and ER adhesive systems provided similar bond
strengths to HPAI-affected enamel surfaces.

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Clinical relevance: Self-etching and etch-and-rinse

adhesive systems provide reliable bonding to enamel
affected by hypoplastic amelogenesis imperfecta.

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