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Comparative evaluation of microleakage between bulk esthetic materials versus

resinmodified glass ionomer to restore Class II cavities in Primary Molars

Article  in  Journal of Indian Society of Pedodontics and Preventive Dentistry · July 2017

DOI: 10.4103/JISPPD.JISPPD_17_17

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1 Original Article 1
2 2
3 3
4
5 Comparative evaluation of microleakage between bulk 4
5
6
7 esthetic materials versus resin‑modified glass ionomer 6
7
8
9
to restore Class II cavities in primary molars 8
9
10 10
11 Vellore Kannan Gopinath 11
12 12
Department of Preventive and Restorative Dentistry, College of Dental Medicine, University of Sharjah, Sharjah, United Arab Emirates
13 13
14 14
15 ABSTRACT Address for correspondence: 15
16 Dr. Vellore Kannan Gopinath, 16
17 Aim: The aim of the study was to assess the Department of Preventive and Restorative Dentistry, College 17
18 microleakage of one high‑viscosity conventional of Dental Medicine, University of Sharjah, P. O. Box: 27272, 18
19 glass ionomer cement  (GIC) and a bulk‑fill Sharjah, United Arab Emirates. 19
composite resin, in comparison to a resin‑modified E‑mail: gopinathvk@yahoo.com
20 20
GIC in Class II restorations in primary molars.
21 21
Materials and Method: Standardized Class II slot
22 cavity preparations were prepared in exfoliating Access this article online 22
23 primary molars. Teeth were restored using one of Quick response code
23
Website:
24 the three materials tested (n = 10): SonicFill bulk‑fill www.jisppd.com 24
25 composite resin (SF), EQUIA Fil conventional DOI:
25
26 reinforced GIC (EQF), and Vitremer resin‑reinforced 10.4103/JISPPD.JISPPD_17_17
26
27 GIC (VT). The restorations were then subjected PMID:
27
28 to thermocycling procedure (×2000 5°C–55°C ******
28
29 10 s/min) and soaked in 1% neutralized fuchsin 29
30 solution (pH: 7.4) for 24 h at 37°C. Teeth were 30
sectioned longitudinally in a mesiodistal direction used for restoring decayed primary teeth with
31 conservative tooth preparations should function in 31
32 under continuous cooling into three slabs of 1 mm 32
mastication with adequate esthetics. The qualities of
33 thickness and studied under a stereomicroscope for 33
the material should demonstrate adequate strength,
dye penetration. Statistical Analysis: Data were adaptability, marginal integrity, and good color
34 34
evaluated by one‑way analysis of variance and the match.[1] Factors such as moisture tolerance, bulk fill,
35 35
Tukey’s multiple comparison test employing 95% and one‑step application are advantageous when
36 (α = 0.05). Results: EQF and SF showed significantly
36
treating young children. Restorative materials with
37 lower microleakage scores and percentage of 37
easier procedures and faster application steps that
38 dye penetration (%RL) when compared to VT reduce treatment time, especially in pediatric dentistry 38
39 resin‑reinforced GIC (P < 0.001). Conclusion: SF were used in this study. Due to ease of use and 39
40 and EQF produced the minimum microleakage acceptable esthetics, glass ionomer cement (GIC) and 40
41 when compared to VT in Class II restorations on composite resin restorative materials have been widely 41
42 primary molars. Fewer application procedures and advocated for restoring posterior primary teeth. The 42
43 reduction in treatment time in SF and EQF systems choice of restorative material must be based on the 43
44 proved advantageous in pediatric dentistry. This is an open access article distributed under the terms of the Creative 44
45 Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which 45
46 Keywords: Bulk‑fill composite, Class  II cavities, allows others to remix, tweak, and build upon the work non‑commercially, 46
glass ionomer cement, microleakage, primary molar, as long as the author is credited and the new creations are licensed under
47 resin‑reinforced glass ionomer cement 47
the identical terms.
48 48
49 For reprints contact: reprints@medknow.com 49
50 Introduction 50
51 How to cite this article: Gopinath VK. Comparative evaluation 51
of microleakage between bulk esthetic materials versus
52 In view of the anatomic and histological differences 52
resin‑modified glass ionomer to restore Class II cavities in primary
53 unique to primary teeth, the restorative material 53
molars. J Indian Soc Pedod Prev Dent 2017;XX:XX-XX.
54 selected should last the lifetime of the teeth. Materials 54

© 2017 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow 1
 Gopinath: Evaluation of microleakage in Class II cavity in primary molars
1 performance of the material under simulated and
2 clinical conditions.
3 diamonds (Busch, Engelskirchen, Germany) placed in
4 In spite of the improvements in adhesive restorative
materials, poor adaptation and microleakage remain
5 verified by a digital caliper (accuracy ± 0.25 mm). The
a major reason for failure in dental restoration.[2]
6 Restorative materials regularly used in posterior
7 primary teeth include composite resin, GICs, and
8 resin‑modified GICs  (RMGICs).[3] These materials
9 undergo dimensional changes when placed in the
10 prepared cavity as a result of placement techniques
11 and due to variations in the oral environment.[4]
Henceforth, the ability of the restorative material
12
to effectively sustain oral conditions depends on
13
the retentive ability of the material to seal the cavity
14 against the ingress of oral fluids and microorganism.[5]
15 Poor marginal sealing of the restoration results in the
16 passage of bacteria, fluids, and molecular penetration
17 between the cavity and restorative material interface.
18 Microleakage at the interface of the cavity wall and
19 restoration results in hypersensitivity of the restored
teeth, discoloration, recurrent caries, and pulpal injury
20
21 leading to the failure of restoration.[6] Microleakage of
posterior restorative materials at the margins of the
22 proximal box specifically at the gingival floor of Class II
23 restorations is a matter of concern to the clinician.[7]
24
25 It is vital that recently developed restorative materials
26 possess improved physical and mechanical properties,
as well as effectively seal the cavity restoration
27
margin, thereby accelerating the performance of
28
29 restorative materials under oral conditions. One
purpose of this study was to assess the microleakage
30
of one high‑viscosity conventional GIC and a bulk‑fill
31 composite resin, in comparison to a RMGIC in Class II
32 restorations in primary molars. The testing hypothesis
33 maintained that no statistically significant differences
34 are present between the materials tested.
35
36 Materials and Methods
37
38 In this study, one bulk‑fill composite resin, one
39 high‑viscosity bulk conventional GIC, and RMGIC
40 were evaluated. Names, codes, manufacturers,
41 mixing, and application procedures of the materials
tested are summarized in Table 1. Thirty exfoliating
42 primary second molars with intact marginal ridge
43 were collected for this experiment, with consent from
44 the patient’s parents, approved by the Ethical and
45 Research Committee of the University of Sharjah
46 protocol (141014). The teeth were stored in 0.5%
47 chloramine‑T at 4°C and used within 1 month. The
48 crowns of the teeth were thoroughly cleaned with
49 cleaning paste and a Prophy brush and rinsed with
copious amounts of tap water before cavity preparation.
50
51 One standardized occlusal slot Class II cavity
52 was prepared at the intact site of each tooth with
53 standardized dimensions of 3.0 mm facio‑lingually,
54 1.5 mesiodistally, and 3.0 mm occluso‑gingivally,
2 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume XX | Issue XX | Month 2017 |
using tungsten carbide burs (#329 Maillefer, 1
Ballaigues, Switzerland). It was then finished with fine 2
3
an air‑rotor handpiece driven by a parallelograph under 4
constant water cooling. The cavity dimensions were
5
bur was replaced after every three preparations. The 6
teeth were randomly divided into three experimental 7
groups (n = 10). Each group was assigned to one of the 8
three materials tested. Shade selected for all materials 9
was A3. A clear Mylar Matrix Strip (Patterson Dental 10
Supply, USA) was applied to the proximal surface 11
and kept firm in place with a metal paper clip applied 12
on the buccal and lingual surfaces of the specimen.
Materials were mixed as per the manufacturers’ 13
recommendations and immediately dispensed in 14
the cavities on a single layer. In all cases, material 15
extrusion began at the deepest part of the cavity and 16
care was exerted to avoid separation of the capsule 17
nozzle from the extruding material mass, to avoid 18
porosity. Contouring of the material was performed 19
immediately after packing with a smooth plastic
instrument. Light‑cured materials were polymerized
20
21
as per the manufacturers’ instructions with a
light‑emitting diode (LED) curing unit (Bluephase 22
G2, Ivoclar Vivadent, Schaan, Liechtenstein) emitting 23
1200 mW/cm2 light intensity as measured with a LED 24
curing radiometer (Bluephase Meter, Ivoclar Vivadent). 25
Once set (10 min after activation), the restorations 26
were finished with superfine diamond burs  (Busch, 27
Engelskirchen, Germany) under continuous water
spray and polished with the enhance polishing 28
29
system (De Trey Dentsply).
30
The apices of the teeth were sealed with RMGIC (Fuji 31
II LC, GC America Inc., Alsip, IL, USA). The restored 32
teeth were stored for 1 week in water at 37°C and then 33
thermal‑cycled (×2000 5°C–55°C 10 s/min). The entire 34
surface of each specimen was then covered with two 35
coats of varnish up to a 1 mm area from the restoration
margins. The teeth were soaked in 1% neutralized 36
fuchsin solution (pH: 7.4) for 24 h at 37°C. After the 37
immersion period, the teeth were rinsed with water; the 38
crowns were removed from the roots using a diamond 39
bur attached to a high‑speed handpiece, embedded 40
in epoxy resin, and longitudinally sectioned in a 41
microtome (Buehler IsoMet) in a mesiodistal direction
42
under continuous cooling into three slabs of 1 mm
thickness. Sections were polished with a sequence of
43
silicon carbide papers (320, 400, 800, and 1000), followed 44
by felt impregnated with 1 and 0.25 µm grit diamond 45
slurry used in an automatic polishing machine. Between 46
each granulation and at the end, the specimens were 47
cleaned and immersed in water in an ultrasonic bath. 48
Adaptation to the enamel walls and dye penetration 49
were assessed under a stereomicroscope (DM 4000B,
50
Leica) at ×60 magnification. The score criteria were:[8]
Score 0: perfect adaptation/no dye penetration; Score 1: 51
gaps and microleakage up in enamel not exceeding to 52
dentin walls depth from the margins toward the axial 53
wall; Score 2: dye penetration exceeding to dentinal 54
 Gopinath: Evaluation of microleakage in Class II cavity in primary molars

1 Table 1: Names, codes, manufacturers, and application steps of tested adhesives 1

2 Material/lot number Code Manufacturer Application procedure
2
3 OptiBond FL OBFL Kerr Italia SrI, Salerno, Italy Cavity wall treatment 3
4 Lot no. 5077567 SF Kerr Corporation, Orange, CA, USA Etch enamel and dentin, with 37% phosphoric acid for 15 s, rinse 4
5 SonicFill (Sonic with water for 15 s, air‑dry for 3 s 5
activated)
6 Lot no. 4939377
Prime with light brushing motion for 15 s, air dry for 5 s, apply 6
adhesive for 15 s, air thin for 3 s
7 7
Light cure for 20 s
8 8
Material placement
9 Unidose capsule tip inserted into SonicFill handpiece
9
10 Dispensing rate/speed set at 5 in the handpiece and using foot
10
11 pedal activate handpiece outside mouth 11
12 Unidose tip placed at the deepest portion of the preparation and 12
13 activated to fill the entire cavity 13
14 Anatomy defined with a hand instrument 14
Light cure at regular mode for 40 s
15 15
Vitremer VT 3M ESPE Apply primer to enamel and dentin and scrub for 30 s, gently
16 Lot no. N451793 St. Paul, MN air‑blow and light cure for 20 s 16
17 Two powder scoops and liquid drop dispensed and mixed within 17
18 45 s 18
19 Back load material into delivery tips and syringe into prepared 19
cavity 20
20
Light cure at regular mode for 40 s
21 21
Finishing and application of finishing gloss which is light cured at
22 regular mode for 20 s 22
23 Equia Fil EQF GC Corporation Tokyo, Japan Apply GC conditioner for 10s and rinse and gently dry 23
24 Lot no. 1310181 Mix capsule for 10 s and working time 1 min 15 s from the start of 24
25 the mix 25
26 Dispensed into the cavity within 10 s 26
27 Final finishing after 2 min 30 s from the start of the mix 27
Restoration finished by applying Equia coat (Do not air blow)
28 28
Light cure for 20 s
29 29
30 30
31 walls of the gingival wall without reaching the axial 31
32 wall; Score 3: dye penetration reaching the axial wall. 32
33 Dye penetration at the tooth/restoration interface 33
at gingival margin of each slab was measured in
34 34
millimeters, and mean dye penetration of each tooth
35 was calculated from the average readings of the two
35
36 slabs. The extent of dye penetration was evaluated 36
37 by linear measurements (RL) and expressed in 37
38 percentage (%RL). The results of dye penetration 38
39 scores and measurements of the percentage of dye 39
40 penetration (%RL) were analyzed by one‑way analysis 40
41 of variance and Tukey’s multiple comparison test 41
42 employing 95% (α =  0.05) level of significance for 42
43 all comparisons. Both analyses were carried out by 43
44 SigmaPlot (version 12.3) software (Systat Software 44
Inc., San Jose, CA, USA).
45 Figure 1: Stereomicroscope image of Vitremer at ×60 45
46 46
47 Results 47
and EQF were compared, SF had the least microleakage
48 scores, whereas EQF scored slightly higher. However, 48
The microleakage scores and dye penetration
49 no significant difference was noted between SF and 49
percentages (%RL) indicated that
50 RMGIC  (Vitremer  [VT]) showed significantly EQF [Table  2]. Bulk‑fill composite resin  (SF) and 50
51 higher values when compared with bulk‑fill high‑viscosity bulk conventional GIC (EQF) showed 51
52 composite resin (SonicFill [SF]) and high‑viscosity the best results with the mean microleakage score 52
53 bulk conventional GIC (EQUIA Fil [EQF]) value of <1, whereas RMGIC (VT) showed a mean 53
54 [Figures 1‑3] (P < 0.001). It was observed that when SF score value of more than 2. 54

Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume XX | Issue XX | Month 2017 | 3
 Gopinath: Evaluation of microleakage in Class II cavity in primary molars

1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 Figure 2: Stereomicroscope image of EQUIA Fil at ×60 Figure 3: Stereomicroscope image of SonicFill at ×60
15
16 16
17 17
Table 2: The mean and standard deviation for dye and sculpting the restoration was reduced, which
18 proved advantageous when treating fidgety young 18
penetration scores and the percentage of dye of dye
19 children. 19
penetration (%RL)
20 20
Product Microleakage Score Percentage of dye
21 penetration (%RL) The microleakage of restorative materials necessitates 21
22 Mean SD Mean SD
further evaluation, as inadequate interfacial 22
23 SF 0.20a 0.42 9.26a 1.71
adaptation and low‑quality marginal seal causes 23
24 leakage, recurrent caries, and pulpal irritation.[13,14] 24
EQF 0.50a 0.71 11.58a 2.71
25 A high‑quality marginal seal aids the performance 25
VT 2.80b 0.42 68.88b 4.68
of restoration. The extent of dye penetration was
26 Same superscript letters show mean values with no statistically significant
evaluated by linear measurements usually performed 26
difference (P>0.05). SD=Standard deviation
27 by direct assessment of the outer restorative margins 27
28 using reflection optical microscopy,[15] confocal 28
29 Discussion microscopy,[16] and environmental scanning electron 29
30 microscopy.[17] Indirect assessment involves evaluation 30
31 The present study assessed microleakage of dental of the interfacial dye penetration or contract agents in 31
32 restorative materials in Class II cavities of primary microleakage studies.[5] 32
molars. RMGIC (Vitremer, 3M, St. Paul, USA)
33 33
were compared with high‑viscosity conventional The marginal seal of restorative materials to the cavity
34 GIC  (EQUIA Fil, GC, USA) and a bulk‑fill composite 34
walls depends on two variables.[18,19] The first refers
35 resin (SonicFill, Kerr, CA, USA). RMGIC (VT) has to material properties such as the type of adhesive, 35
36 been widely used to restore Class II cavities in polymerization shrinkage, viscoelasticity, and stiffness 36
37 primary molars with reasonable success.[9,10] Hence, a of material. The second refers to individual treatment 37
38 controlled study comparing newer materials such as conditions which include cavity size, geometry, 38
39 high‑viscosity conventional GIC  (EQF) and bulk‑fill restorative placement, and curing techniques. The 39
40 composite resin (SF) were included in this study. clinical implication of microleakage is related to 40
EQF is a new generation glass ionomer for one‑step discomfort in conjunction with occlusal forces, which 41
41
posterior restoration with easy handling and excellent may be attributed to fluid accumulation within the
42 esthetics. Resin coating (EQUIA coat) optimizes its gap and the subsequent fluid movement within the
42
43 physical properties. It is easy and convenient to place, tubules.[20] The results of the present study demonstrate 43
44 self‑adhesive with no bonding steps. The inclusion of significant differences in microleakage between 44
45 EQF in the experimental group was based on a clinical RMGIC (Vitremer, 3M, St. Paul, USA) when compared 45
46 trial which evaluated its performance with microfilled with high‑viscosity conventional GIC (EQUIA Fil, GC, 46
47 hybrid composite (GC Gradia Direct posterior) on USA) and a bulk‑fill composite resin  (SonicFill, Kerr, 47
48 Class II cavity revealing similar clinical success over CA, USA). Consequently, the hypothesis testing was 48
49 a period of 4 years.[11] Whereas SF in the experimental rejected. 49
group has been tested in vitro,[12] the inclusion of this
50 50
material in the present study was based on its bulk‑fill The rationale for the differences noted in the present
51 property and innovative material delivery system study between the systems tested could be attributed 51
52 utilizing KaVo handpiece that enabled sonic activation to the variance in materials tested and their handling 52
53 reducing the composite’s viscosity to fill the cavity characteristics. Cavity size and geometry cannot be 53
54 rapidly. Therefore, time spent on placement, packing, considered as a variable in the present study that used 54

4 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume XX | Issue XX | Month 2017 |
 Gopinath: Evaluation of microleakage in Class II cavity in primary molars

1 an air‑rotor handpiece driven by a parallelograph Conclusion 1

2 and verified cavity dimensions with a digital 2
3 caliper  (accuracy  ±  0.25  mm). A  precise adaptation When compared to RMGIC  (VT), bulk‑fill composite 3
4 of the restorative material to the walls of the cavity resin (SF) and high‑viscosity bulk conventional 4
and proper marginal seal is considered mandatory GIC (EQF) utilized in this study produced significantly 5
5
for the longevity of restoration. However, the present less microleakage. In addition, fewer application
6 study detected the percentage of dye penetration
6
7 procedures and reduced treatment time in SF and 7
values (%RL), and dye penetration scores were highest EQF systems are especially advantageous in pediatric
8 in RMGI (Vitremer, 3M ESPE, USA) compared to 8
dentistry where younger patients get easily agitated.
9 conventional glass ionomer (EQUIA Fil, GC, Japan) and The combination of these benefits and other results 9
10 bulk‑fill composite  (SonicFill, Kerr, USA). Similarly, enumerated above may prove valuable to the dental 10
11 other in vitro studies showed that high‑viscosity glass profession. 11
12 ionomer has significantly less microleakage when 12
13 compared to nano‑filled RMGI.[21] 13
Acknowledgment
14 This project was supported by the College of Graduate 14
Although microleakage scores and the percentage Studies and Research, University of Sharjah, Sharjah,
15 of dye penetration values of high‑viscosity
15
16 UAE (grant no. 141014). 16
conventional GIC (EQUIA Fil, GC, USA) were
17 significantly lower than VT, they differed little from 17
18 bulk‑fill composite  (SonicFill, Kerr, USA). Therefore, Financial support and sponsorship 18
19 indicating that both materials have minimal This project was supported by the College of Graduate 19
microleakage. The findings were in correlation with Studies and Research, University of Sharjah, Sharjah,
20 20
another study that compared high‑viscosity glass UAE (grant no. 141014).
21 21
22 ionomer restorative materials (EQUIA Fil, GC, USA) 22
with resin composites (VOCO, Germany) that also Conflicts of interest
23 There are no conflicts of interest. 23
exhibited similar microleakage scores such as those
24 observed in our present study.[22] Since our trials of 24
25 25
26
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6 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume XX | Issue XX | Month 2017 |

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