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Table of Contents   
ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 763-769
Flowable resin and marginal gap on tooth third medial cavity involving enamel and radicular cementum: A SEM evaluation of two restoration techniques


1 Department of Oral Disease, University of Messina, Via Consolare Valeria 98100 Messina, IT, Italy
2 Department of Human Pathology, University of Messina, Via Consolare Valeria 98100 Messina, IT, Italy

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Date of Submission10-Jan-2011
Date of Decision05-Dec-2011
Date of Acceptance30-Apr-2012
Date of Web Publication3-May-2013
 

   Abstract 

Purpose: The aim of this study is to investigate the presence and the extent of a possible marginal gap after the interposition of a flowable composite between the composite restoration and the dental structures (enamel and cementum). This technique is also used to eliminate the infiltration in a zone of the cavity preparation that is frequently at a risk of secondary decay.
Materials and Methods: Fifteen human premolars extracted for orthodontic reasons were used for the study. A cavity with mesial and distal margin in enamel and cementum was realized in every tooth. The cavities were then restored with an adhesive system (ScotchBond 3MÔ) and composite (Filtek Supreme 3MÔ); and, a fine layer of flowable composite was applied in the distal margin of each cavity. Scanning electron microscopy (SEM) in secondary electron imaging (S.E.I.) modality was used for the study and identifying the marginal gaps in the composite restorations. Data was investigated on the mesial and distal margin of each cavity at the restoration-enamel interface, and at the restoration-cementum interface. The interfaces were divided in four groups: Group A (enamel/composite); Group B (enamel/flow/composite); Group C (cementum/composite); and, Group D (cementum/flow/composite).
Results: By the comparison of the gap's average width found in each group, it is evidenced that the average width of the gap increases when the interface moves from the coronal to the radicular end (Group A 0,1 ± 0,4 μm Vs Group C 12,3 ± 11,6 μm; Group B 0,2 ± 0,8 μm Vs Group D 2,8 ± 6,6 μm). Correlating the measurements of the marginal gap's average width among the Group A and Group B, no significant variations were obtained; and instead, on comparing Group C with Group D, the gap's average width decreases.
Conclusion: The interposition of a low elastic modulus composite between the adhesive layer and the composite resin allows an improvement of the cementum-restoration interface by the means of a lower shrinkage stress during polymerization.

Keywords: Cementum, flowable resins, shrinkage

How to cite this article:
Giudice G L, Cicciù M, Cervino G, Lizio A, Visco A M. Flowable resin and marginal gap on tooth third medial cavity involving enamel and radicular cementum: A SEM evaluation of two restoration techniques. Indian J Dent Res 2012;23:763-9

How to cite this URL:
Giudice G L, Cicciù M, Cervino G, Lizio A, Visco A M. Flowable resin and marginal gap on tooth third medial cavity involving enamel and radicular cementum: A SEM evaluation of two restoration techniques. Indian J Dent Res [serial online] 2012 [cited 2020 Dec 3];23:763-9. Available from: https://www.ijdr.in/text.asp?2012/23/6/763/111256
The polymerization shrinkage of composite resins certainly represents a drawback for the use of these materials in restorative dentistry. [1],[2] Scientific literature reports that the amount of this volumetric shrinkage is in the range of 3 to 7% of the starting mass. [3],[4],[5] Polymerization shrinkage can reduce the bond strength, thus not allowing a close contact between the restorative material and the tooth structure, and hence creating gaps at the composite-tooth interface with increased chances of failure of the restoration. [1],[6]

Dentinal sensibility and "microleakage" (The seepage of fluids, debris, and microorganisms and their toxic products along the interface between the restoration and the tooth margins', being harmful for the pulp and secondary decay formation) are both a direct consequence of the gap formation. [7],[8] In order to minimize the effects of polymerization shrinkage it is possible to use several techniques, materials and adhesive systems. [9],[10] Nevertheless, marginal failures and fractures between the adhesive layer and composites have also been seen with the newer adhesive systems with high bond strength values. [11]

Another risk factor is represented by the cervical margin located in the radicular cementum. Also, an adhesive's effectiveness is reduced in the radicular cementum, because of the latter's unique and different histologic characteristics as compared to the tooth enamel. It is essential to emphasize that the radicular cementum is a less mineralized tooth structure (65% inorganic content), and that it is characterized by a relevant organic component (23%), mainly represented by collagen, while enamel contains only 2% of collagen. Histological and structural differences make composite's adhesion to cementum weaker and less predictable as compared to enamel. In order to effectively hinder polymerization shrinkage, Davidson suggested the use of composites which could reduce the shrinkage stress to the cavity walls. [12] These materials follow the principle of gradual transaction of elastic modulus, presenting an intermediate value between the dentin and composite resins. [13] The marginal gap reduction is proportionally connected to shrinkage stress and elastic modulus; therefore, the higher the elastic modulus, the higher is the stress and the possibility of the development of a marginal gap. [14] These devices could be considered an ideal intermediate material due to their plasticity, although resins with a low elastic modulus present with high shrinkage. [13]

In fact, according to Kemp-Scholte and Davidson, [15] the interposition of a thin layer of a low viscosity resin, with a low elastic modulus, between the adhesive layer and the composite, can reduce (within the range of 20 to 50%) the negative effects of the polymerization shrinkage. The aim of this study is to evaluate the efficiency of a flowable composite's interposition between the restoration and the dental structures (enamel and cementum) in reducing marginal gap formation. The presence and the quantification of the gaps was evaluated by Scanning electron microscopy (SEM) observations.


   Materials and Methods Top


The study was performed on 15 bicuspids extracted from young patients for orthodontic reasons. Each tooth was stored in a physiologic saline solution (sodium chloride with a concentration of about 0,9%) for 1 month. Disinfection was achieved without using glutaraldehyde and sodium hypochlorite. A rectangular cavity with mesial and distal margins extending from the coronal medial third to 5 mm below the cementum-enamel junction (CEJ), therefore involving both enamel and radicular cementum, was prepared on the vestibular surface of each tooth [Figure 1]. The margin finish was beveled with a coarse flame diamond bur, and finished at low speed with a white arkansas stone point. This was then followed by etching with 37% orthophosphoric acid, for 15 seconds in the dentin and cementum, and for 30 seconds in the enamel. The surface was then rinsed leaving the cavity moist, and after 6 - 8 seconds, a priming-adhesive agent (Scotchbond TM 1XT, 3M TM Espe TM ) was applied and light-cured for 20 seconds.
Figure 1: Graphic representation of the cavity's preparation and of the restorative technique used in the study

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Before accomplishing the composite restoration, a thin layer of flowable composite (Filtek Flow TM , 3M TM Espe TM ) was applied on the cavity bottom and exclusively on the entire distal margin. All the cavities were restored using a nano-filled composite (Filtek Supreme TM , 3M TM Espe TM ) with an incremental technique. The adhesive system and the composite were used according to the manufacturer's instructions.

The mesial and distal margins of each cavity were observed at the restoration-enamel interface and at the restoration-cementum interface.

Consequently, the interfaces observed were divided in four groups:

  • Group A (Enamel/Composite);
  • Group B (Enamel/Flowable/Composite);
  • Group C (Cementum/Composite);
  • Group D (Cementum/Flowable/Composite).
The comparisons were made between the enamel and cementum margins of the restorations using the same technique (Group A vs. C and Group B vs. D). A further comparison was conducted between the margins of restorations, carried out with and without the interposition of the flowable composite in the same tooth structure (enamel or cementum) (Group A vs. B and Group C vs. D). The observations were conducted by SEM (JEOL Jsm-s6001 v) [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6] and [Figure 7]. The specimens were analysed under low magnification along the entire interface to locate any possible marginal gaps. The specimens were rotated during the observations to avoid recording of any artefacts due to the superimposition of the margins. Under higher magnification (1000X), the gaps bigger than 5 micron in width and 20 micron in length were considered as significant.
Figure 2: Group A (two specimens) -No evidence of discontinuity at the enamel/composite interface under 1000x magnification

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Figure 3: Group B (two specimens) -No evidence of discontinuity at the enamel/composite interface with the interposition of flowable resin under 1000x magnification

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Figure 4: Group C (two specimens) -Evidence of marginal gap at the cementum/composite interface under 1000x magnification

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Figure 5: Group C (two specimens)-No evidence of marginal gap at the cementum/composite interface under 1000x magnification

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Figure 6: Group D (two specimens) -Evidence of marginal gap at the cementum/composite interface with the interposition of flowable resin under 1000x magnification

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Figure 7: Group D (two specimens)-No evidence of marginal gap at the cementum/composite interface with the interposition of flowable resin under 1000x magnification

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In order to score the efficiency of the interposition of flowable composite, the gap was quantified by means of linear measurements executed with computerized analysis (Autocad), and for each interface, the maximum distance gauged in-between the substrates was taken into consideration. The absolute values, the means, the standard deviations of each group, the correlation coefficients and the significance tests recorded in the study are reported in [Table 1], [Table 2] and represented in [Graph 1] and [Graph 2].
Table 1: Marginal gap observed in each specimen in the study. Absolute values (μ m), averages and standard deviations. Group A (enamel/composite) Group B (enamel/ flowable/composite) Group C (cementum/composite) Group D (cementum/flowable/composite)

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Table 2: Statistic analysis of the correlations among the various groups in the study

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   Results Top


  • The analysis of data reveals the presence of a gap at the enamel-composite interface (Group A) in 6,6% of the specimens examined, and this finding remains constant even in the group were the flowable composite was used (Group B). In this last group, a slight increase of the gap has been exhibited, in both the mean and absolute value [Table 1].
  • Group C: In this group, the seal was provided only by the adhesive system, and the gap between the radicular cementum and composite was present in 80% of the observations. Whereas, using the flowable composite (Group D), the specimens with margins in cementum displayed a marginal gap only in 20% of the cases examined.
  • Comparing group C and group D, it is evident that the gap is present in 80% of specimens in group C, and that the gap formation is cut down to 20% in the group where the flowable composite was used on the margin located in cementum.
  • Carrying out the comparison of the gap's average width found in each group between the control cases (margins in enamel), and the corresponding groups with margin in cementum (Group A Vs. Group C; Group B Vs. Group D), it is evidenced that the average width of the gap increases as the interface extends from the coronal to the radicular end: from 0,1 ± 0,4 μm (Group A) to 12,3 ± 11,6 μm (Group C) and from 0,2 ± 0,8 μm (Group B) to 2,8 ± 6,6 μm (Group D). This increment is less emphasized in the groups where the flowable composite was used.
  • Further, upon correlating the measurements of the marginal gap's average width among the specimens with margins in enamel (Group A Vs. B), with or without the interposition of flowable composite, no significant variations were obtained (Group A 0.,1 ± 0,4 μm, Vs. B 0,2 ± 0,8 μm), while vice versa comparing the averages of the specimens with margins in radicular cementum, with or without the interposition of flowable composite, the gap's average width decreases (Group C 12,3 ± 11,6 μm Vs Group D 2,8 ± 6,6 μm).
  • The statistical analysis of the correlations among the various groups shows that the numeric differences at the level of significance of 1% reveal a high significance, while the values reveal no tendency to vary jointly [Table 2].

   Discussion Top


Till date, there have been a limited number of studies investigating the efficiency of flowable composites. The flowable composites introduced in the clinical practice in 1996, are characterized by long chain monomers such as poly-trimethylhexanediamine (PTMDA) that, once the polymerization is complete, give a higher elasticity to the resin matrix with a Young's modulus of about 3-4 Gpa. [16] A further characteristic is the low viscosity due to lesser filler particles, which are similar in size to the hybrid composite's particles (0,7-0,8 μm in diameter); however, are reduced in percentage of weight (60-70% vs. 70- 80%), and decreased in volume (46-65% vs. 60-75%). [16],[17] However, as per this study, the long chain monomers and the low viscosity do not seem to significantly influence the possible marginal gap formation on the restored cavity. Clinically, a low viscosity leads to a higher flow ability, allowing the material, originally produced for a better manipulation, to be placed with a small diameter dispenser, and allowing a more accurate and homogeneous distribution of the resin. [18]

However, when Bayne et al. evaluated the wear resistance, toughness, compressive strength, tensile and flexural strength of these flowable resin composites', they found that the mechanical properties were lower than those of conventional composites, thus restricting the use of flowable materials in low occlusal-stress clinical applications. [17] Consequently, the obvious and main use of these materials is in small class III or Class V cavities, and as a liner in class II cavities' interproximal boxes. Here, they help reduce adaptation problems, and internal void formation. This is of particular help, as these areas are difficult to access and free material flow is hard to achieve in these areas. [16],[17] The author's choice of performing the study on medial cavities on the extracted teeth, involving both the enamel radicular cementum had an important purpose. It is because of this choice that the effect of different types of tooth surfaces (whether enamel/radicular cementum) on the gap formation, could be studied. Further, it is clearly affirmed in the study that these materials may reduce the long-term adaption problems and the results of the investigation point out how the adhesion without gap formation may be related to the different characteristic of the treated cavity surfaces (enamel/radicular cementum). [16],[19]

Furthermore, the application of flowable composite resins could reduce the shrinkage stress on the composite-tooth interface thanks to the creation of an intermediate flexible layer, carrying out a better internal adaptation of the material, thus lessening the marginal defects. [16],[19],[20],[21] The low elastic modulus of flowable composites' permits a stress-absorbing action that limits or delays failures due to occlusal cyclic loads. However, it is still possible to produce a premature deformation of the conventional composite layers, which have a higher elastic modulus, placed upon the flowable material. Thus, they must be used only in thin layers as a bonding resin. [16] Moreover, studies on restorations carried out using these materials have exhibited discordant results regarding micro leakage. [22],[23],[24],[25],[26] In any case, the short-term clinical monitoring, the lack of available experimental information and the discordant data coming from the scientific literature should determine an attitude of extreme caution in the clinical use of these materials. [16],[18] Moreover, the data results suggest that the class of the defects should be strongly pointed out by the clinicians before selecting the materials for the restorations, in order to obtain a long term clinical success. [19],[22]


   Conclusion Top


During the last few years, the demand for restoration cervical defects, such as cervical erosion and root caries, has increased significantly. The longevity of these restorations is a fundamental goal for the clinicians and also important for the patients. The results of this study may allow the practitioners to choose a better material for treating the tooth defects. The microscopic observations carried out in the group where the cavity margin was located in cementum and the conventional technique (bonding + composite and no flowable resin) was used, show a marginal gap in 80% of the specimens; and, in some cases the gap is of a remarkable width. The technique that we used was shown as efficient on enamel, where the gap was detected only in 20% of specimens. The interposition of flowable composite between the adhesive layer and the composite, when the cavity margin is located in the cementum, revealed to be useful in reducing both, the gap's percentage incidence and the average width. On the other hand, no advantage has been recorded using the flowable composite when the margins are placed in enamel.

As per the results of this study, the restoration of a cavity with one or more margins located in the radicular cementum, with composite resin, cannot guarantee an ideal marginal seal in the cementum. However, the interposition of a composite with low elastic modulus between the adhesive layer and the composite resin allows for an improvement of the cementum-restoration interface, probably by the means of a lower shrinkage stress during polymerization. Consequently, the optimization of the composite restoration outcomes should consider the utilization of various materials with a common resin matrix, and having diversified chemical-physical properties, which would help to compensate for the gap formation due to polymerization shrinkage. Within the limitations of this study, our findings suggest that the flowable composite application may decrease the presence of marginal gaps in the critical restored areas of a tooth, and may guarantee an effective restoration with good longevity.

 
   References Top

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8.Pashley DH. Clinical consideration of microleakage. J Endod 1990;16:70-7.  Back to cited text no. 8
    
9.Komatsu M, Finger W. Dentin bonding agents: Correlation of early body strength with marginal gaps. Dent Mater 1996;2:257-62.  Back to cited text no. 9
    
10.Retief DH, Mandras RS, Russel CM. Shear bond strength required to prevent microleakage at the dentin restoration interface. Am J Dent 1994;7:43-6.  Back to cited text no. 10
    
11.Prati C, Chersoni S, Cretti L, Mongiorgi R. Marginal morphology of class V composite restorations. Am J Dent 1997;10:231-6.  Back to cited text no. 11
    
12.Davidson CL, Kemp-Scholte CM. Short-coming of composite resin in class V restorations. J Esthet Restor Dent 1989;1:1-4.  Back to cited text no. 12
    
13.Davidson CL, Degee AJ, Feilzer A. The competition between the composite-dentin bond strength and the polymerization contraction stress. J Dent Res 1984;63:1396-403.  Back to cited text no. 13
    
14.Cho E, Chikawa H, Kishikawa R, Inai N, Otsuki M, Foxton RM, et al. Influence of elasticity on gap formation in a lining technique with flowable composite. Dent Mater J 2006;25:538-44.  Back to cited text no. 14
    
15.Kemp-Scholte CM, Davidson CL. Marginal integrity related to bond strength and strain capacity of composite resin restorative systems. J Prosthet Dent 1990;64:658-64.  Back to cited text no. 15
    
16.Chuang SF, Liu JK, Chao CC, Liao FP, Chen YH. Effects of flowable composite lining and operator experience on microleakage and internal voids in class II composite restorations. J Prosthet Dent 2001;85:177-83.  Back to cited text no. 16
    
17.Bayne SC, Thompson JY, Swift EJ Jr, Stamatiades P, Wilkerson M. A characterization of first-generation flowable composites. J Am Dent Assoc 1998;129:567-77.  Back to cited text no. 17
    
18.Labella R, Lambrechts P, Van Meerbeek B, Vanherle G. Polymerization shrinkage and elasticity of flowable composites and filled adhesives Dent Mater 1999;15:128-37.  Back to cited text no. 18
    
19.Unterbrink G, Liebenberg W. Flowable resin composites as filled adhesives: Literature review and clinical recommendations. Quintessence Int 1999;30:249-579.  Back to cited text no. 19
    
20.Haak R, Wicht MJ, Noack MJ. Marginal and internal adaptation of extended class I restorations lined with flowable composites. J Dent 2003;31:231-9.  Back to cited text no. 20
    
21.Van Meeerbeck B. Vargas M, Inoue S, Yoschida Y, Peumans M, Lambrechts P. Adesives and cementums to promote presevation dentistry. J Dent Res 1996;75:871-8.  Back to cited text no. 21
    
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24.Ziskind D, Adell I, Teperovich E, Peretz B. The effect of an intermediate layer of flowable composite resin on microleakage in packable composite restorations. Int J Paediatr Dent 2005;15:349-54.  Back to cited text no. 24
    
25.Tredwin CJ, Stokes A, Moles DR. Influence of flowable liner and margin location on microleakage of conventional and packable class II resin composites. Oper Dent 2005;30:32-8.  Back to cited text no. 25
    
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Correspondence Address:
M Cicciù
Department of Oral Disease, University of Messina, Via Consolare Valeria 98100 Messina, IT
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.111256

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]

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[Pubmed] | [DOI]
21 Valutazione dei sistemi di ingrandimento in odontoiatria conservativa e restaurativa. Studio in vitro
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[Pubmed] | [DOI]
22 Effects of Fiber-reinforced Composite Bases on Microleakage of Composite Restorations in Proximal Locations
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[Pubmed] | [DOI]
23 Effects of Fiber-reinforced Composite Bases on Microleakage of Composite Restorations in Proximal Locations
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[Pubmed] | [DOI]



 

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