Ó

Operative Dentistry, 2014, 39-1, E22-E30

Microleakage of Nanofilled Resin-

modified Glass-ionomer/Silorane-
or Methacrylate-based Composite
Sandwich Class II Restoration:
Effect of Simultaneous Bonding
F Shafiei  S Akbarian

Clinical Relevance
One bonding step with SE Bond or Silorane Adhesive with either nano-ionomer or the
respective composite could provide adequately sealed restorations in the deep interprox-
imal box with a simplified and time-saving open sandwich technique.

SUMMARY were prepared with cervical margins 1 mm

Objectives: Microleakage of composite restora- below the CEJ. The teeth were randomly
tions at the cervical margin placed apically to divided into six groups of 10 teeth each. In
the cementoenamel junction (CEJ) is still a the first three groups (groups 1-3), Clearfil SE
concern. This study evaluated the effect of Bond and Clearfil APX (Kuraray) were used for
simultaneous bonding application on cervical restoration in the total bonding technique
sealing of nano-ionomer/silorane- or methac- (group 1), conventional open sandwich tech-
rylate-based composite open sandwich Class II nique associated with a nano-ionomer (Ketac
restorations in the modified technique com- N100, 3M ESPE) (group 2), and modified open
pared with that of conventional bonding. sandwich technique with simultaneous bond-
ing application for both nano-ionomer and
Methods and Materials: In 60 sound maxillary
composite (group 3). In the second three
premolars, two standardized Class II cavities
groups (groups 4-6), Silorane Adhesive and
*Fereshteh Shafiei, DMD, MS, associate professor, Depart- Filtek Silorane composite (3M ESPE) were
ment of Operative Dentistry, School of Dentistry, Shiraz used in the same manner as in the first three
University of Medical Sciences, Shiraz, Iran groups, respectively.
Sahar Akbarian, DMD, MS, assistant professor, Department Results: The simultaneous bonding application
of Operative Dentistry, School of Dentistry, Shiraz Univer-
sity of Medical Sciences, Shiraz, Iran
in the modified sandwich restorations (with
SE Bond or Silorane Adhesive) resulted in a
*Corresponding author: Qasre Dasht St., Shiraz, Fars, Iran
significant reduction of the cervical micro-
7186783694
e-mail: [email protected] leakage compared with that of the convention-
al bonding (p,0.05). However, microleakage of
DOI: 10.2341/13-020-L
the modified technique was similar to that of
Shafiei & Akbarian: Microleakage of Modified Sandwich Restoration E23

the total bonding (with SE Bond or Silorane restorations.19 When comparing abrasion resistance,
Adhesive) (p.0.05), both showing good mar- NI behaved as an intermediate material between
ginal seal. RMGI and nanocomposite.17 The two-part paste of
NI might facilitate its handling properties.16
INTRODUCTION On the other hand, new silorane-containing resin
Resin composites have been widely used as a direct monomers using a combination of siloxane and
restorative material. Despite significant advances in oxirane have been developed based on cationic ring
adhesive systems, they are not capable of totally opening polymerization, resulting in reduced poly-
eliminating marginal microleakage, in particular at merization shrinkage of the hydrophobic compos-
the gingival margin of deep Class II restorations.1-3 ite. 20,21 The combination of NI and silorane
The stresses induced by polymerization shrinkage, composite in an open sandwich restoration may be
temperature fluctuations, and mechanical load cy- a viable method to decrease the overall stresses
cling may disrupt the bond between dentin and resin within the whole restoration. The use of nano primer
composite, resulting in postoperative sensitivity, before NI and use of a silorane adhesive system
bacterial leakage, and secondary caries initiation.3- before silorane composite are essential steps to bond
5
Moreover, in a deep Class II cavity, effective curing these materials to tooth structure.16,21,22 These
of the first composite increment due to the distance separate and double-bonding applications lead to a
between the light-curing tip and this layer may be a time-consuming and complicated procedure. In ad-
problem if a metal matrix is used.1,2 dition, in the case of applying and light curing nano
primer, this would possibly interfere with silorane
Resin-modified glass-ionomer (RMGI) is a good
adhesive conditioning before silorane composite
dentin replacement in such deep cavities; this is
placement. Silorane composite should be used solely
referred to as an open sandwich restoration.6 This
with its dedicated adhesive.
technique allows the dentist to benefit from the
clinical advantages of RMGI materials, including tri- The results of a recent study revealed that
or dual-cure setting, fluoride release, low coefficient different self-etch adhesives can adequately bond
of thermal expansion, greater tolerance to moisture the NI to the dentin, possibly providing simple NI/
than resin composite, and reduced volume of resin methacrylate composite sandwich restorations with
used.7-9 Furthermore, the high elastic deformation one bonding step.23Again, the use of the same
or flow capacity of RMGI during the early stage of adhesive system (self-etch silorane adhesive) for NI
setting can act as a stress absorber. This property and silorane composite would reduce the clinical
leads to reduced stress transfer toward the bonding application steps and time. Therefore, the present
interface.10 Consequently, improved marginal seal study aimed to investigate the marginal sealing of
has been reported in several studies.1,6,9,11,12 In the NI/silorane-based or methacrylate-based composite
open sandwich technique, that is highly recommend- open sandwich technique with simultaneous bonding
ed for patients with a medium or high risk of caries, application compared with that of the conventional
RMGI is applied on the gingival floor of the proximal technique in deep Class II restorations.
box, extending out to the cavosurface margins. This
exposure of RMGI to the oral environment may lead METHODS AND MATERIALS
to surface deterioration because of the high solubility Sixty sound human maxillary premolars recently
of RMGI in the oral fluid.13,14 extracted for orthodontic treatments were collected,
In the closed sandwich technique, RMGI is fully cleaned, and disinfected in 0.5% chloramine solution
veneered by composite.13-15 However, in the latter for 2 weeks. The teeth were then stored in distilled
technique, correct placement of RMGI short of the water at 48C until use.
gingival cavosurface margin or removal of its excess Two standardized Class II box-only cavities were
from this inaccessible area of the cavity is difficult.15 prepared on the mesial and distal surfaces of each
Alternatively, a novel, highly packed, nanofilled tooth (3 mm wide, 5-6 mm high, and 1.5 mm deep)
RMGI, Nano-Ionomer (NI), can be used in an open with gingival margins placed approximately 1 mm
sandwich technique because of its improved me- below the cementoenamel junction (CEJ) using new
chanical strength,16 resistance to biomechanical straight fissure diamond burs (ISO 806 314, Hager &
degradation,17 and fluoride release comparable to Meisinger GmbH, Neuss, Germany) for every five
RMGI.18 Lower polymerization shrinkage and better preparations. All dimensions of the preparations
cervical sealing were reported in Class V NI were verified with a periodontal probe. The buccal
E24 Operative Dentistry

Table 1: Materials Used and Their Composition

Material Batch No. Manufacturer Composition
Silorane adhesive N213019 3M ESPE, St Primer: phosphorylated methacrylates, vitrebond copolymer, bis-GMA, HEMA, water,
N213052 Paul, MN, ethanol, silane-treated silica filler, initiators, stabilizers
USA Bond: hydrophobic dimethacrylate, phosphorylated methacrylates, TEGDMA, silane-
treated silica filler, initiators, stabilizers
Clearfil SE Bond 1039AA Kuraray Medical Primer: MDP, HEMA, hydrophilic dimethacrylate, photoinitiator, water
1550AA Inc, Okayama, Bond: 10-MDP, bis-GMA, HEMA, hydrophilic dimethacrylate, microfiller, photoinitiator
Japan
Ketac N100 Primer N251185 3M ESPE HEMA, water, Vitrebond copolymer, photoinitiator
Ketac N100 N271282 3M ESPE HEMA,vitrebond copolymer, water,TEGDMA, PEGDMA, bis-GMA,
fluoroaluminosilicate glass, silane-treated zirconia/ silica, photoinitiators
Silorane composite N384451 3M ESPE 3,4-epoxycyclohexylethylcyclo polymethylsiloxane;bis-3,4-epoxycyclohexylethyl –
phenylmethylsilane; silanized quartz; yttiumfluoride; camphorquinone
Clearfil AP-X 1080AB Kuraray Medical BisGMA, TEGDMA silanated glass filler, silanated silica filler, silanated colloidal silica,
Inc comphorquinone
Abbreviations: bis-GMA, bisphenol A diglycidyl ether dimethacryalate; HEMA, 2-hydroxy-ethyl-methacrylate; TEGDMA, triethylene glycol diemthacrylate; MDP, 10-
methacryloxydecyl dihydrogen phosphate; PEGDMA, polyethylene glycol dimethacrylate.

and lingual walls of the preparations were approx- the primer was light cured for 10 seconds. The bond
imately parallel to each other and connected to the was applied and light cured for 10 seconds.
gingival wall with rounded line angles. All cavity  Group 5 (conventional sandwich, NI primer þNI/
preparations and restorations were performed by silorane adhesive þsilorane composite): The appli-
one operator. The materials used in this study are cation of NI primer and KN100 was the same as in
shown in Table 1. group 2. After light curing KN100, the remaining
The teeth were randomly divided into six groups of cavity walls were treated in the same manner as in
10 teeth each (20 boxes in each group). The same group 4.
 Group 6 (simultaneous silorane adhesive applica-
materials and techniques were applied in the mesial
and distal boxes of each tooth. tion þNI/silorane composite): The bonding steps
were done in the same manner as described in
The restoration of the prepared teeth was per- group 4. Then, KN100 was applied as performed in
formed as follows: group 2.
 Group 1 (total bonding SE): Primer of Clearfil SE After this step, a universal Tofflemire matrix
Bond (Kuraray Inc) was applied to the cavity for 20 retainer (Miltex Inc, York, PA, USA) with matrix
seconds and gently air dried for 5 seconds. The band was placed around the tooth. The matrix was
bond was then applied, thinned with a gentle air tightened and fixed by applying low-fusing com-
steam, and light cured for 10 seconds. pound so that formation of gingival overhang would
 Group 2 (conventional sandwich, NI primer þNI/ not be allowed in the restorations. In the first three
Clearfil SE Bond þmethacrylate composite): Nano- groups (groups 1-3), Clearfil APX composite-shade
ionomer primer was applied for 15 seconds, air A2 (Kuraray Inc) was used; Filtek silorane compos-
dried, and light cured for 10 seconds; then, the two ite-shade A2 (3M ESPE) was applied in the remain-
pastes were mixed and applied to the gingival floor ing three groups (groups 4-6), using an oblique
with approximately 2-mm thickness extending to incremental technique. Each layer was cured for 20
the periphery of the proximal box. After light seconds for Clearfil APX and 40 seconds for silorane
curing of NI, Ketac N100 (KN100, 3M ESPE), the composite, according to manufacturers’ instructions.
remaining cavity walls were treated in the same All curing steps were done using a light-curing unit
way as in group 1. (VIP Junior, Bisco, Schaumburg, IL, USA) at 650
 Group 3 (modified sandwich, simultaneous Clearfil mW/cm2 light intensity. The intensity was checked
SE Bond application þNI/methacrylate composite): after every two restorations.
The bonding procedures were the same as in group After matrix removal, the completed restorations
1. Then, KN100 was applied as described in group 2. were finished and polished with Opti-Disk (Kerr
 Group 4 (total bonding silorane): Primer of silorane Corporation, Orange, CA, USA).The restored teeth
adhesive (3M ESPE) was applied to the cavity for were stored in distilled water at 378C for 1 week to
20 seconds and gently air dried for 10 seconds, and allow for complete acid-base reaction in NI and then
Shafiei & Akbarian: Microleakage of Modified Sandwich Restoration E25

Table 2: Microleakage Score Frequency in the Six Study Groups

Group Microleakage Scores Mean* (SD) Median
0 1 2 3 4
1. Total bonding SE 13 4 0 3 0 0.65a (1.08) 0.0
2. Conventional sandwich SE 3 10 4 2 1 1.40b (1.04) 1.0
3. Modified sandwich SE 15 4 0 1 0 0.35a (0.74) 0.0
a
4. Total bonding silorane 18 1 1 0 0 0.30 (0.65) 0.0
5. Conventional sandwich silorane 4 6 9 1 0 1.35b (0.87) 1.50
6. Modified sandwich silorane 13 7 0 0 0 0.35a (0.49) 0.0
* Different superscript letters indicate statistically significant differences among groups.

thermocycled for 1000 cycles at 58C to 558C with a (modified sandwich) (p=0.009 and p,0.001, respec-
30-second dwell time. tively). There was no significant difference between
The root apices were sealed with utility wax, and group 1 and group 3 (p.0.05), revealing similar low
all the surfaces, except for the restorations and an cervical microleakage in the two groups.
area 1 mm from the margins, were coated with two The results of comparing the second three groups
layers of nail varnish. The teeth were immersed in a (with silorane composite) were similar to those of
0.5% methylene blue dye solution for 24 hours. Upon methacrylate composite groups; group 5 showed a
removal from the dye, the teeth were rinsed, blotted significantly higher microleakage at the cervical
dry, and sectioned vertically through the center of margin than groups 4 and 6 (p=0.001 and p=0.009,
the restorations from the mesial to distal surface respectively). However, no significant difference was
with a water-cooled diamond saw (Leitz 1600, found between groups 4 and 6 (p.0.05).
Wetzlar, Germany)
Similar groups with methacrylate composite ver-
The sections were blindly examined for dye sus silorane composite (group 1 vs group 4, group 2
penetration by two independent evaluators using a vs group 5, and group 3 vs group 6) showed no
stereomicroscope (Carl Ziess Inc, Oberkochen, Ger- significant difference (p.0.05) (Table 2). Examples
many) at 203 magnification. The extent of the dye of the specimens exhibiting different dye penetration
penetration was analyzed according to a 0 to 4 scale scores are presented in Figure 1.
(0=no dye penetration, 1=dye penetration less than
½ of the gingival wall, 2=dye penetration along the DISCUSSION
gingival wall, 3=dye penetration along the gingival
Microleakage is one of the major problems affecting
wall and less than ½ of the axial wall, 4=dye
penetration along the gingival wall and axial wall). the longevity of resin composite restorations. The
The worst score from the two sections of each dye penetration method is the most common and
specimen was recorded. simplest technique for assessing microleakage along
adhesive interface.24 Although correlation between
The Kruskal-Wallis test was used to analyze the clinical evaluation and in vitro dye penetration
differences within the groups. Pairwise comparison testing may not be documented, the latter is still a
among different groups was done with Mann- popular and valuable test as a preclinical screening
Whitney U-test (a=0.05). to compare the sealing ability of different adhesive
materials and techniques.25,26
RESULTS
According to the results of the present study, the
Dye penentration scores in the six groups are best cervical marginal seal was obtained by total
presented in Table 2. None of the groups showed bonding with silorane composite, which revealed no
complete elimination of microleakage. According to significant difference with the total bonding associ-
the Kruskal-Wallis test, there was a significant ated to SE Bond. Both conventional sandwich
difference in microleakage score among the six techniques had significantly higher microleakage
groups (p,0.001). than that of the respective total bonding. This result
Among the first three groups (with methacrylate contradicts previous studies that reported that the
composite), group 2 (conventional sandwich) re- open sandwich technique resulted in similar or
vealed significantly higher cervical microleakage better marginal sealing than total bonding.1,6,9,11,12
than group 1 (SE total bonding) and group 3 This difference can be attributed to the different
E26 Operative Dentistry

Figure 1. Examples of the restorations exhibiting different dye penetration scores.(A): Total bonding restoration showing score 0; (B): Modified
sandwich restoration showing score 0; (C): Modified sandwich restoration showing score 1; (D): Conventional sandwich restoration showing score 2
with dye penetration at the interface; and (E): Conventional sandwich restoration showing score 3.
Shafiei & Akbarian: Microleakage of Modified Sandwich Restoration E27

adhesive/composites and RMGI used in these stud- posite and one-step self-etch adhesive/methacrylate
ies. In particular, no study has compared the composite.38
marginal quality of bonded silorane composite with The findings of the present study indicate that the
sandwich restoration or the use of NI in sandwich two modified sandwich techniques using the same
technique versus total bonding. adhesive (SE Bond or silorane adhesive) associated
So far, only Fahmy and Farrag27 have recently with NI substantially improved the marginal sealing
evaluated microleakage in Class II primary molar of the restorations compared with the respective
cavities restored with NI/silorane or methacrylate conventional sandwich approach so that the modi-
nanofilled composite (open and closed sandwich) and fied methods exhibited no significant difference from
total bonding. They found superior marginal sealing the total bonding ones.
with total bonding compared with two sandwich A number of studies have recently demonstrated
techniques. This result is in agreement with our that the use of different self-etch adhesives could
findings. Also, Beznos2 concluded that RMGI could
improve the bond strength or marginal sealing of
not prevent extensive leakage at the cervical margin
RMGI.39-43 The acidic conditioners commonly used
of open sandwich restorations.
with RMGI partially demineralize the smear layer
Previously, some authors speculated that the and superficial dentin, facilitating the penetration of
excellent sealing ability of silorane composite might the 2-hydroxy-ethyl-methacrylate (HEMA) incorpo-
be related to comparatively low volumetric shrink- rated in the RMGI into the exposed collagen
age and shrinkage stress in this novel resin.22,28-30 network.39 The self-etching primer may act in a
Slower polymerization reaction with the higher similar manner, and copolymerization poly-HEMA
potential for stress relief by viscous flow of the and hydrophilic monomers of the self-etching adhe-
molecules was reported to be responsible for this sive may occur.40 On the other hand, RMGI can bond
lower shrinkage stress rate and the resultant very well to the resin layer formed on the surface of
reduced stress.20,31,32 Moreover, the bonding effi- self-etch adhesives via unsaturated carbon-carbon
ciency of the associated silorane adhesive system is covalent bonds upon copolymerization, providing
an important factor.22,30 The self-etching primer of similar results to bonding of resin composites.41
this two-step adhesive has been recently claimed to
KN100 in association with a light-cured primer
create chemical bonding to the remaining hydroxy-
was used in the conventional sandwich groups. This
apatite crystals around collagens.21 The tight inter-
self-etch primer (pH=3) may create a resin covering
face at enamel and dentin was obtained via nano-
on the primed dentin resembling those of mild self-
interaction of this ultra-mild self-etch primer
etch adhesives.42 Nevertheless, the low acidity of the
(pH=2.7). The separately applied and cured bond
primer may not allow the primer to totally dissolve
layer may contribute to maintaining the sealed
the smear layer.16,42
interface.21 On the other hand, somewhat higher
but insignificant microleakage was obtained by total According to scanning electron microscopy (SEM)
bonding with SE Bond/methacrylate compared with evaluations of two recent studies,16,23 NI interacted
silorane adhesive/silorane composite. Again, it is very superficially with the dentin without deminer-
well demonstrated that functional monomer (10- alization or hybrid layer formation. The primary
methacryloxydecyl dihydrogen phosphate [MDP]) in bonding mechanism of NI was found to be micro-
self-etch primer might be capable of bonding to the mechanical infiltration only into the surface rough-
hydroxyapatite crystals.33 This chemical bonding ness. The secondary one may be a typical
might lead to better resistance to hydrolytic degra- polyalkenoic acid copolymer chemical bonding to
dation and improved sealing reported by some dentin.
authors.15,34,35 Therefore, it was expected that two self-etch
Methacrylate composite used with SE Bond was adhesives used with NI in the modified technique
applied in an incremental oblique layering tech- could improve the cervical sealing of the restora-
nique. This method has been advocated to reduce tions. It was recently reported that carboxylic groups
overall contraction residual stress at the adhesive of acidic monomers and Vitrebond copolymer in some
interface,28,36 resulting in reduced microleakage by self-etch adhesives increased the bond strength of NI
modifying C-factor and decreasing the composite to the dentin.23 SE Bond has acidic monomer (MDP)
bulk cured in each increment.22,37 A recent clinical in its primer composition. The ultra-mild self-etch
trial found no significant difference between mar- primer of silorane adhesive contained Vitrebond
ginal adaptation of silorane adhesive/silorane com- copolymer.21 This copolymer is also a key component
E28 Operative Dentistry

of NI. These functional monomers contribute to adhesive application for both the NI and methacry-
establishing chemical bonding to the dentin and late- or silorane-based composite. This simplified
improving the marginal sealing of the modified combination would provide the benefits of two
sandwich restoration examined in this study. The materials in a single restoration performed in a
SEM evaluation of these adhesive interfaces is reduced application time.
required to detect the real interaction with the
dentin. Acknowledgements
Although KN100 is a methacrylate-based RMGI, it The authors thank the vice-chancellery of Shiraz University of
seems to be compatible with silorane adhesive. The Medical Sciences for supporting the research (Grant 91-5275);
bond of this adhesive creates a hydrophobic methac- Dr M. Vossoughi, from the Dental Research Development
Center, for statistical analysis; Dr N. Shokrpour for improving
rylate-based (with phosphate group) layer placed on the use of English in the manuscript; and Miss Z Hajjari and
the cured primer surface, providing bonding to Mrs H Ebrahimi, librarian of School of Dentistry, Shiraz
methacrylate resins.44,45 In the same manner, this University of Medical Sciences, for helping to provide the
related articles.
resin layer could act between KN100 and silorane
composite, and its phosphate group may react with Conflict of Interest
the overlying silorane composite.45 The compatibility
The authors of this manuscript certify that they have no
between methacrylate-based composite and silorane proprietary, financial, or other personal interest of any nature
adhesive was recently indicated.44,46 or kind in any product, service, and/or company that is
presented in this article.
One possible drawback of the open sandwich
technique is the creation of additional interfaces (Accepted 16 April 2013)
exposed to oral environment in a restoration. In the
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