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The purpose of this study was to evaluate the microleakage in Class V cavities restored with a new gingiva-shaded microhybrid composite resin and with a conventional microhybrid composite resin using three different dentin bonding systems (DBS). Class V cavities were prepared in sixty freshly extracted human teeth with the incisal margin in enamel and the apical margin in dentin/cementum. Restored specimens, after thermocycling, were placed in 2% methylene blue solution for 24 hours. Longitudinal sections were obtained and studied with a stereomicroscope for assessment of the microleakage according to degree of dye penetration (scale 0-3). Data were analyzed with Kruskal-Wallis test and with Mann-Whitney U-test. In this study there was no leakage in enamel: all the cavities showed no dye penetration at the incisal margins (located in enamel). None of the DBS used eliminated microleakage in apical margins (located in dentin or cementum): three-step total-etch and single-step self-etch were more effective in reducing microleakage in dentin margins when compared with two-step total-etch. This in vitro study concluded that microleakage in Class V cavities restored with the composite resins tested is similar.
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Annali di stomatologia
microleakage
Microleakage in class V gingiva-shaded composite resin restorations
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Microleakage in class V gingiva-shaded composite resin restorations
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                                                                                                   Original article


    Microleakage in class V gingiva-shaded
    composite resin restorations




                                                                                                  li
    Claudio Poggio, MD, DDS                                 Introduction
    Marco Chiesa, DDS                                       Cervical lesions are frequently found in daily practice.




                                                                                               na
    Alberto Dagna, DDS                                      Degenerative processes and gingival recession, as
    Marco Colombo, DDS, PhD                                 result of chronic periodontal inflammation or aggressive
    Andrea Scribante, DDS, PhD1                             periodontal therapy, expose root dentin predominantly
                                                            in older patients (1). The aetiology of cervical lesions
                                                            is multifactorial (2). Non-carious cervical lesions are




                                                                                            io
    University of Pavia, Italy                              characterized by the loss of dental hard tissue at
    Department of Operative Dentistry                       cementum-enamel junction as a result of abrasive
    1
      Department of Orthodontics                            or erosive effects (3); additionally cuspal flexure and




                                                                       az
                                                            tensile stresses in cervical region of the teeth are
                                                            hypothesized to cause disruption of the bonds among
    Corresponding author:                                   the hydroxyapatite crystals, leading to cracks and loss
    Prof. Claudio Poggio                                    of enamel and underlying dentin (4). Food acids and




                                                                     rn
    Insegnamento di Odontoiatria                            inappropriate tooth brushing procedures promote the
    Policlinico S. Matteo                                   development of saucer- or wedge-shaped lesions in
    P.le Golgi, 3                                           the cervical area of the teeth (1). In such patients, low
    27100 Pavia, Italy                                      dental care and non-effective preventive programs lead




                                                            te
    E-mail: claudio.poggio@unipv.it                         to rapid development of caries. The treatment regimen
                                                            depends on the individual cause of the cervical lesion (5).
                                                            Instructions for adequate oral hygiene, dietary advices,
                                                    In      occlusal adjustment and restoration of the defect are
    Summary                                                 recommended (6). Small non-carious cervical defects
                                                            with no hypersensitivity, especially in the posterior region,
    The purpose of this study was to evaluate the           may require only dietary consulting and oral hygiene
                                                  ni
    microleakage in Class V cavities restored with a new    instruction in order to avoid further progression (1,5).
    gingiva-shaded microhybrid composite resin and          Pain-associated or caries-affected Class V lesions need
    with a conventional microhybrid composite resin         to be restored. Particular attention is required in anterior
                                           io


    using three different dentin bonding systems (DBS).     teeth, both for small non-carious and for big carious
    Class V cavities were prepared in sixty freshly         lesions, where aesthetic reasons are perdominant. Glass
    extracted human teeth with the incisal margin in        ionomer cements, compomers and composite resins are
                                 iz



    enamel and the apical margin in dentin/cementum.        being mostly used to restore class V defects (1,3,6-8).
    Restored specimens, after thermocycling, were           Amalgam and gold restoration were used in the past but
    placed in 2% methylene blue solution for 24 hours.      today the increased demand for aesthetic decreased
                 Ed




    Longitudinal sections were obtained and studied         their utilization. Composite resins combined with dentin
    with a stereomicroscope for assessment of the           bonding systems have already substituted glass ionomer
    microleakage according to degree of dye penetration     cements and compomers in Class V restorations because
    (scale 0-3). Data were analyzed with Kruskal-Wallis     of their excellent aesthetics, superior mechanical and
    test and with Mann-Whitney U-test.                      physical properties and higher bond strength to enamel
    In this study there was no leakage in enamel: all the   and dentin (1,9,10). The complex morphology of Class
 IC




    cavities showed no dye penetration at the incisal       V defects with margins partly in enamel as well as in
    margins (located in enamel). None of the DBS used       root dentin presents challenging task for the restorative
    eliminated microleakage in apical margins (located      material (1). Bond strength and sealing ability of adhesive
    in dentin or cementum): three-step total-etch and       systems to dentin is still inferior compared to enamel
C




    single-step self-etch were more effective in reducing   cavity segments (11). In Class V the polymerization of
    microleakage in dentin margins when compared with       composite resins competes with the bond strength of the
    two-step total-etch. This in vitro study concluded      adhesive systems and challenges marginal integrity and
    that microleakage in Class V cavities restored with     sealing ability especially in dentin segments. Marginal
©




    the composite resins tested is similar.                 gap formation leads to leakage, responsible for marginal
                                                            discoloration, secondary caries and partial or total loss
    Key words: gingiva-shaded composite resin, dentin       of the restoration (6,12). However, newly formulated
    bonding systems, microleakage.                          improved bonding systems provide a better adhesion
                                                            of the composite resin to dentin, although this is an
                                                            unresolved problem. The exposed and frequently worn
                                                            cervical areas of teeth often lack a pleasing appearance

    Annali di Stomatologia 2012; III (1): 19-23                                                                       19
     C. Poggio et al.



     when restored with conventional materials such as                                   After application of DBS (according to Manufacturers’
     glass ionomer cements or tooth coloured composite                                   instructions) cavities were restored with composite
     resins, especially when associated with aging and loss                              resin in three increments. Each increment of composite
     of gingiva. Today the interest is directed toward the                               resin was light-cured for 40 seconds with a curing light
     development of new restorative materials that permit                                in softstart-polymerization mode (Celalux 2 High-Power
     chair side gingival shade matching, in order to restore




                                                                                                                              li
                                                                                         LED curing-light, Voco GmbH, Cuxhaven, Germany).
     aesthetic and function of cervical areas exposed after                              The restorations were finished and polished with




                                                                                                                           na
     gingival recession (discoloured or hypersensitive necks                             finishing/polishing disks (Sof-Lex Pop-On, 3M ESPE,
     of teeth) and cervical V-shaped defects (13).                                       St. Paul, MN, USA) in decreasing granulation. All teeth
     The purpose of this in vitro study was to investigate the                           were coated with two layers of nail varnish up to 1 mm
     microleakage in Class V cavities restored with a new                                from the restorations margins, while the apical part was
     gingiva-shaded microhybrid composite resin (Amaris                                  sealed with wax. The restored teeth were then subjected




                                                                                                                        io
     Gingiva) and with a conventional microhybrid composite                              to artificial aging by thermocycling. All specimens were
     resin (Amaris) using three different dentin bonding                                 immersed alternately in water baths at 5 and 60°C for
     systems (three-step total-etch, two-step total-etch and                             1000 cycles, with at dwell time of 60 seconds in each bath




                                                                                                     az
     single-step self-etch). The null hypothesis of the study                            and a transfer time of 15 seconds. After thermocycling,
     was that there is no significant difference in microleakage                         the specimens were immersed in a 2% methylene blue
     scores among the various groups.                                                    dye solution and incubated at 37°C for 24 hours.




                                                                                                   rn
                                                                                         Microleakage analysis
     Materials and methods                                                               The teeth were rinsed with distilled water, dried for 10
                                                                                         minutes, and sectioned longitudinally in a buccolingual
     Specimen preparation




                                                                                         te
                                                                                         direction with a low-speed water-cooled diamond
     Sixty caries-free vital human teeth freshly extracted                               cutter. All specimens were examined at 25´ in a
     for periodontic or orthodontic reasons were used in                                 stereomicroscope (Inspective 4Geek, Serravalle, RSM)
     this study. The teeth were cleaned with dental scalers,                             and standardized digital images were obtained. Two
     polished with pumice and stored in a 0.25% mixture of
                                                                                 In      observers scored each section blindly; consensus was
     sodium azide in Ringer solution until the date of use. In                           forced if disagreements occurred. An ordinal scale from 0
     each tooth two standardized Class V cavities (on buccal                             to 3 was used to score microleakage separately at incisal
     and on lingual surfaces) were prepared with a round-                                (enamel) and apical (dentin/cementum) margins of each
                                                                ni
     nosed no.245 carbide bur (Dentsply/Caulk, Milford, DE,                              section based on the following criteria, as described in
     USA) at high-speed with air/water spray, according to                               Osorio et al.(15) and in Moldes et al.(16): 0 = no leakage
     procedure described in Corona et al. (14): the cavities                             visible at tooth/restoration interface, 1 = dye penetration
                                                  io


     were prepared with the incisal margin located in enamel                             along the interface up to one-half of the cavity depth, 2 =
     and the apical margin located in dentin/cementum (3 mm                              dye penetration greater than one-half of the cavity depth,
     beyond the cementum-enamel junction); the dimensions                                3 = dye penetration to and along axial wall.
                                      iz



     of Class V cavities were similar, with mesiodistal width,
     incisal-apical measure and depth of 4 mm. The same                                  Statistical analysis
     trained operator prepared all the cavities. The teeth were                          The results of microleakage evaluation were submitted
                    Ed




     randomly assigned to six experimental groups (of 10                                 to statistical analysis using “Stata 7.0” computer
     specimens and 20 cavities each); Class V cavities were                              software (Stata Corp., Station College, TX). A Kruskal-
     filled with two composite resins and with three dentin                              Wallis test and a Mann-Whitney U-test were performed.
     bonding systems (DBS) as follows: group 1: Solobond                                 Significance was predetermined at p<0.05.
     Plus + Amaris Gingiva, group 2: Solobond Plus +
     Amaris, group 3: Solobond M + Amaris Gingiva, group 4:
 IC




     Solobond M + Amaris, group 5: Futurabond NR + Amaris                                Results
     Gingiva, group 6: Futurabond NR + Amaris.
     The same manufacturer (Voco GmbH, Cuxhaven,                                         Representative photographs revealing dye penetration
     Germany) prepared the composite resins and the DBS.                                 of sectioned specimens are shown in Figures 1-6.
C




     DBS tested are shown in Table 1.                                                    Microleakage scores values at incisal margins (in enamel)
                                                                                         are presented in Table 2 and microleakage scores values
                                                                                         at apical margins (in dentin/cementum) are presented in
                                                          etch for 20 sec with 37%
                                         two-step        orthophosphoric acid, rinse     Table 3. The results of the Kruskal-Wallis test indicated
©




       Solobond M        0949326
                                       total-etching   with water, apply DBS, gently     the presence of significant differences among the
                                                        dry and light cure for 20 sec
                                                       apply DBS for 20 sec, dry with
                                                                                         microleakage values of the various groups (P<0.05).
      Futurabond M       0940451
                                       single-step      air for 5-10 sec to evaporate    Post-hoc Mann-Whitney’s Test showed no significant
                                       self-etching     solvents and light cure for 20
                                                                      sec                difference in microleakage scores between gingival-
                                                                                         shaded (groups 1, 3, and 5) and conventional (groups
     Table
    Table 1 -1 - Dentin
             Dentin      bonding
                    bonding systemssystems   (DBS)
                                    (DBS) used         used
                                               in this study.   in this study.           2, 4, and 6) composite resins both for occlusal and
                                                                                         gingival margins (P>0.05). Moreover, when evaluating

     20                                                                                                        Annali di Stomatologia 2012; III (1): 19-23
    Microleakage in class V gingiva-shaded composite resin restorations



                                                  Figure 1.                       Figure 4.
                                                  Representative     ste-         Representative stereo-
                                                  reomicroscopic photo-           microscopic photograph
                                                  graph of group 1 (Solo-         of group 4 (Solobond M
                                                  bond Plus + Amaris              + Amaris) original mag-
                                                  Gingiva) original mag-          nification 25x.




                                                                                       li
                                                  nification 25x.




                                                                                    na
                                                                                 io
                                                                              az
                                                                            rn
                                                  Figure 2.                       Figure 5.
                                                  Representative stereo-          Representative     ste-




                                                                            te
                                                  microscopic photograph          reomicroscopic photo-
                                                  of group 2 (Solobond            graph of group 5 (Fu-
                                                  Plus+Amaris) original           turabond NR+Amaris
                                                  magnification 25x.              Gingiva) original mag-
                                                                   In
                                                                                  nification 25x.
                                                       ni
                                           io
                                 iz
                 Ed




                                                  Figure 3.                       Figure 6.
                                                  Representative     ste-         Representative    ste-
                                                  reomicroscopic pho-             reomicroscopic photo-
                                                  tograph of group 3              graph of group 6 (Fu-
 IC




                                                  (Solobond M+Amaris              turabond NR+Amaris)
                                                  Gingiva) original mag-          original magnification
                                                  nification 25x.                 25x.
C
©




    Annali di Stomatologia 2012; III (1): 19-23                                                       21
Table 1 - Dentin bonding systems (DBS) used in this study.


                 groups
              C. Poggio et al.Score 0 Score 1 Score 2 Score 3
                     1       18 (90%) 2 (10%) 0 (0%)        0 (0%)
                     2       19 (95%) 1 (5%)      0 (0%)    0 (0%)
                     3       17 (85%) 2 (10%) 1 (5%)        0 (0%)
                     4       17 (85%) 3 (15%) 0 (0%)        0 (0%)        the priming and the bonding steps (also defined total-
                 groups
                     5        Score
                             17     0 Score
                                (85%)        1 Score
                                       3 (15%)    0 (0%)2 Score
                                                            0 (0%)3       etch systems); two-step systems include self-priming
                    16       16 (90%)
                             18 (80%) 23 (10%)
                                         (15%) 01 (0%)
                                                    (5%)    0 (0%)        adhesives (that require a separate etching step) or self-
                    2        19 (95%) 1 (5%)     0 (0%)     0 (0%)        etching primers (that require a separate bonding step);
                    3        17 (85%) 2 (10%) 1 (5%)        0 (0%)        finally, the recently introduced single-step (self-etching)
                    4        17 (85%) 3 (15%)
Table 2 - Occlusal margin-microleakage           0 (0%) for each
                                         scores obtained    0 (0%)
                                                                 experimental group combine all bonding procedures in a single
                                                                          adhesives




                                                                                                                          li
                    5        17 (85%) 3 (15%) 0 (0%)        0 (0%)        application, consisting of a mixture of acid monomers
(n=20).             6        16 (80%) 3 (15%) 1 (5%)        0 (0%)




                                                                                                                       na
                                                                                    that etch enamel and dentin as well as primers that
                                                                                    permits penetration of resin into the demineralized dentin
              Table 2 - Occlusal margin-microleakage scores obtained for each       (27). No DBS currently available achieved a perfect seal
Table 2 - Occlusal margin-microleakage
              experimental  group (n=20). scores obtained for each experimental group
                                                                                    in dentin/cementum (15,19,20,28,30-34). The causes of
                                                                                    microleakage are usually associated with the composite




                                                                                                                    io
(n=20).
                 groups Score 0 Score 1 Score 2 Score 3                             resin used, the occlusal load, the location of the prepared
                      1      13 (65%) 5 (25%) 2 (10%)               0 (0%)          margins and the polymerization shrinkage (23): DBS
                      2      12 (60%) 7 (35%) 1 (5%)                0 (0%)          have the aim to minimize those effects.




                                                                                             az
                      3       3 (15%) 9 (45%) 5 (25%) 3 (15%)                       The restoration of cavities with margins located in dentin/
                      4       2 (10%) 11 (55%) 6 (30%)              1 (5%)          cementum is an unresolved problem in operative dentistry;
                 groups
                      5      Score
                             14  (70%)0 Score
                                            4 (20%)1 Score
                                                        2 (10%)2 Score
                                                                    0 (0%)3         microleakage has clinical effects and causes failure of
                     16      12 (65%)
                            13   (60%) 5 (25%) 23 (10%)   (15%) 0 (0%)              resin restorations. The reason for this difference between




                                                                                           rn
                     2      12 (60%) 7 (35%) 1 (5%)                 0 (0%)          apical and incisal leakage scores is that bonding to
              Table 33- Gingival
                             3 (15%)       9 (45%) 5scores
                                 margin-microleakage      (25%)obtained
                                                                   3 (15%)
                                                                        for each    dentin/cementum is much more technique-sensitive and
Table 3 - Gingival   4       2 (10%)(n=20).11 scores
                   margin-microleakage
              experimental  group              (55%) obtained
                                                        6 (30%) for 1 (5%)experimental
                                                                    each            substrate-sensitive than bonding to enamel (25,30-34).
                     5      14 (70%) 4 (20%) 2 (10%)                0 (0%)




                                                                                 te
                     6 margin
group (n=20). occlusal      12 (60%)
                                   scores,5 no(25%)     3 (15%)
                                                 significant        0 (0%)were
                                                             differences
              showed among the three different adhesives tested                     Conclusion
              (p>0.05). On the other hand, when analyzing gingival
Table 3 - Gingival margin-microleakage
              margin   scores, groups 3 and   scores obtained
                                                  4 showed
                                                                       In
                                                                for each higher
                                                             significant  experimental
                                                                                    This study showed no differences between the
              frequency of microleakage scores of “1” (P<0.05) than                 microleakage in class V cavities restored with the
group (n=20). the other groups, that both showed higher frequency of
                                                13                                  composite resins tested: Amaris Gingiva (gingiva-shaded
              score “0”.                                                            microhybrid composite resin) and Amaris (conventional
                                                          ni
                                                                                 microhybrid composite resin). Within the limitations of
                                                                                 this study it may be concluded that microleakage among
              Discussion                                                         two composite resins tested is similar. The microleakage
                                         13
                                                 io


                                                                                 of all DBS tested in enamel is significantly reduced or
              The null hypothesis of the study was partially rejected.           null, but three-step total-etch and single-step self-etch
              The results of the present investigation showed no                 were more effective in reducing microleakage in dentin/
              significant differences in microleakage values among
                                        iz



                                                                                 cementum margins when compared with a two-step
              the gingiva-shaded microhybrid composite resin (Amaris             total-etch.
              Gingiva) and the conventional microhybrid composite
              resin (Amaris). The microleakage of the DBS tested in
                          Ed




              enamel is significantly reduced or null. The results of            References
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   IC




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©




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    Annali di Stomatologia 2012; III (1): 19-23                                                                                       23
