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J Am Dent Assoc, Vol 137, No 2, 197-202.
© 2006 American Dental Association
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RESEARCH

Influence of cavity dimensions, insertion technique and adhesive system on microleakage of Class V restorations



Carmem Silvia Costa Pfeifer, DDS, Roberto Ruggiero Braga, DDS, MS, PhD and Paulo Eduardo Capel Cardoso, DDS, MS, PhD


   ABSTRACT
TOP
 ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. The authors evaluated the influence of cavity dimensions, insertion technique and adhesive system on microleakage of Class V composite restorations.

Methods. The authors prepared cylindrical cavities with enamel margins of 3-millimeter diameter by 1-mm depth or 6-mm diameter by 2-mm depth on the labial surface of bovine incisors. They defined experimental groups (n = 15) according to cavity size, insertion technique (bulk or incremental) and adhesive system applied (Single Bond, 3M ESPE, St. Paul, Minn., or Excite, Ivoclar Vivadent, Amherst, N.Y.). They restored preparations with Tetric Ceram (Ivoclar Vivadent). After 36 hours’ storage in distilled water at 37 C, specimens were submitted to microleakage using 50 percent silver nitrate as tracer. Teeth were sectioned twice and dye penetration on the axial wall was determined in millimeters.

Results. The authors analyzed the data using analysis of variance/Tukey test ({alpha} = .05). For large restorations, the use of Single Bond resulted in higher microleakage than Excite (1.56 ± standard deviation [SD] 0.26 mm and 0.63 ± SD 0.56 mm, respectively; P < .001), whereas for small restorations there was no statistical difference between adhesives (Excite: 0.47 ± SD 0.28 mm; Single Bond: 0.46 ± SD 0.28 mm).

Conclusion. The choice of adhesive system influenced microleakage only for large restorations. Incremental insertion of the composite did not affect dye penetration.

Clinical Implications. Microleakage of composite restorations cannot be predicted only on the basis of the restorations’ dimensions. In large restorations, it also depends on the choice of adhesive system, whereas in small restorations, the adhesive used does not seem to be an influential factor. Incremental insertion did not seem to reduce restorations’ microleakage.

Key Words: Microleakage; composite restorations; adhesive systems; insertion technique

Clinical and in vitro studies have demonstrated the difficulties of obtaining complete marginal sealing in composite restorations.1 Besides the obstacles posed by bonding to biological substrates, composite contraction stress has been described as one of the main causes of postoperative sensitivity, enamel cracking, margin discoloration and cusp deflection.2–4 In fact, previous studies have found a strong correlation between contraction stress values determined by mechanical testing and the damage inflicted to the bonded interface as assessed by microleakage tests.5,6

Researchers have studied the stresses developed during the polymerization of a composite bonded to the walls of a cavity preparation in terms of the material’s composition,7–9 degree of conversion10 and reaction kinetics.11 All of these influence the composite’s capacity to flow (that is, to undergo plastic deformation). At early stages of polymerization, viscous flow allows the material to accommodate the volume reduction associated with the formation of the polymer network and to delay stress buildup.12 The confinement conditions imposed on the material, usually expressed as the ratio between bonded and free surfaces of the specimen (a ratio known as "the cavity configuration factor," or C-factor), also affect its flow capacity; it is easier for the composite to yield to contraction forces by deforming its free surface, referred to as "macroscopic" flow, in comparison with "microscopic" (internal) flow (molecular rearrangement).5,13

A direct relationship between stress and confinement seems to hold true in cases in which stress values are measured in a rigid testing apparatus.12,13 Nevertheless, authors using more compliant experimental setups verified that stress values seem to be related directly to composite volume and inversely to confinement conditions.14,15 The idea that contraction stress values may be influenced by the volume of shrinking composite agrees with the findings of studies evaluating interfacial integrity of composite restorations in vitro.16,17 Other researchers, however, reported that microleakage and interfacial gaps were related to the choice of adhesive system and to confinement conditions of the prepared cavity.18 Though no correlation between bond strength and microleakage has been found,19,20 several investigators have reported lower bond strength values when composite was bonded to a prepared cavity rather than to a flat dentin surface,21,22 thus reinforcing the idea that the confinement of the composite may affect the integrity of the bonded interface. Incremental insertion techniques have been suggested as a way to improve composite curing in depth and minimize the effect of the confinement on contraction stress development.23 Stress would be reduced with such techniques because the confinement of each increment would be lower than that of the entire cavity. However, some authors have not found significant differences between bulk and incremental insertion in terms of magnitude and distribution of stress at the bonded interface.24,25

Several microleakage studies have associated the extent of interfacial damage with the efficacy of the adhesive system.26,27 With one-bottle adhesives, solvent type seems to influence monomer penetration into the demineralized dentin.28 Some authors believe that the presence of water in the adhesive composition may be advantageous, because it allows dentin rehydration in case the collagen network is over-dried.29 Other authors, however, have called attention to the fact that water in excess may cause incomplete solvent evaporation and affect the quality of the adhesive layer.30

Considering that the role of the composite volume and confinement on marginal integrity of restorations remains a controversial matter, and considering the influence of the adhesive system on marginal sealing, we conducted a study to verify the hypothesis that marginal leakage is influenced by the dimensions of the Class V cavity preparation, the insertion technique and the adhesive system used.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Table 1Go lists the materials we tested. One investigator (C.P.) was responsible for specimen preparation. Using 240- and 600-grit silicon-carbide sandpaper, she flattened the labial surfaces of bovine incisors that had been stored in 0.5 percent chloramine solution at 7 C. She divided the teeth into two groups, according to the dimensions of the cavity. She prepared the cavities with custom-made cylindrical diamond burs (KG Sorensen, Barueri, São Paulo, Brazil) of 3-millimeter diameter x 1-mm depth or 6-mm diameter x 2-mm depth. Their abrasive coating was the same as that used in regular diamond burs for clinical use. Sixty teeth received 3 x 1-mm cavities (volume: 7.1 mm3), while the remaining 60 incisors received 6 x 2-mm cavities (volume: 56.5 mm3). The researcher prepared the cavities under air-water spray, placing them between the middle and cervical thirds of the surface, with all margins in enamel. In both cases, the C-factor was 2.3. She further divided the preparations into eight groups (n = 15), according to the adhesive system used (Excite or Single Bond) and composite placement technique (bulk or incremental). Figure 1Go is a diagram of the experimental design.


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  		TABLE 1 Materials used in the study.*

 

Figure 1
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  		Figure 1. Diagram of the experimental design. Excite is manufactured by Ivoclar Vivadent, Amherst, N.Y. Single Bond is manufactured by 3M ESPE, St. Paul, Minn.

 
The researcher initiated the restorative procedure by applying 37 percent phosphoric acid to the cavity walls for 15 seconds. After rinsing for the same interval, she removed the excess water with a gentle air spray. She applied adhesives according to manufacturers’ instructions and photoactivated them for 10 seconds at 600 milliwatts per square centimeter (Optilux 500, Kerr, Orange, Calif.). For teeth restored using the incremental technique, the researcher applied composite in two horizontal increments, each one photoactivated for 40 seconds. For specimens built using bulk insertion, she photoactivated the composite for 40 seconds.

After 24 hours’ storage in distilled water at 37 C, the investigator polished the restorations using 240-, 320-, 400- and 600-grit silicon carbide sandpaper. She applied two layers of nail polish to the teeth, except for 1 mm around restoration margins, and stored them again in distilled water at 37 C. Twelve hours after the nail polish was applied, the investigator immersed the specimens in a 50 percent silver nitrate solution for two hours in the dark, followed by a six-hour period in radiographic developing solution. After this period, the researcher sectioned specimens twice, perpendicularly, through the center of the restoration. Therefore, eight areas of the tooth/ restoration interface could be visualized (Figure 2Go). Depth of dye penetration on the axial walls of the restoration was determined by the researcher in millimeters under x20 magnification using a profilometer (Optimus 300, Werth Spezialfabrik Optischer Messgeräte, GmbH, Giessen, Germany). The researcher recorded the highest dye penetration found in each specimen. She and another of the authors (R.R.B.) analyzed the data by means of a three-way analysis of variance/Tukey test, with a global significance level of 5 percent.


Figure 2
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  		Figure 2. Schematic representation of the specimen. A. Composite restoration placed on the labial surface of the bovine incisor. Lines represent the location of the two perpendicular cuts. B. Sectioned specimen. C. Fragment of the specimen, showing dye penetration at the tooth/ restoration interface.

 

   RESULTS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Table 2Go (page 201) presents the microleakage averages and standard deviations. The second-order interaction was not statistically significant (P = .431). The same was observed for cavity dimension by insertion technique (P = .310) and adhesive system by insertion technique (P = .143). The cavity dimension by adhesive system interaction was statistically significant (P < .001), indicating that for the large restorations, dye penetration verified in restorations composed of Single Bond was statistically higher than that observed in cavities restored using Excite. For the small restorations, both adhesives allowed similar microleakage levels (Figure 3Go, page 201). Microleakage with Excite did not vary significantly, regardless of restoration size.


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  		TABLE 2 Average dye penetration.*

 

Figure 3
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  		Figure 3. Average dye penetration shown by the two cavity preparations, as a function of the adhesive system used (vertical lines represent ± 1 standard deviation). The horizontal line connects statistically similar values (P > .05). Excite is manufactured by Ivoclar Vivadent, Amherst, N.Y. Single Bond is manufactured by 3M ESPE, St. Paul, Minn.

 

   DISCUSSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Influence of cavity dimensions. In our study, we observed microleakage in composite restorations with different volumes and similar confinement conditions. It is interesting to notice that depending on the adhesive system considered, the results would lead to different assumptions. For one of the adhesives (Excite), we observed no difference in microleakage between large and small restorations. If that had been the only adhesive we tested in the study, we could conclude that restorations with the same C-factor would develop similar stress levels regardless of their volume, in agreement with findings of stress tests using highly rigid setups.13 However, for the other adhesive tested (Single Bond), the results suggest that stress developed in large restorations was higher than in small ones. Considering the relatively low elastic modulus of the dentin,31 it is reasonable to assume that stress development would be influenced by the volume of shrinking composite, analogous to what has been verified in mechanical testing using less rigid settings.14,15 Therefore, it is possible that in small restorations, stresses with relatively low magnitude resulted in similar dye penetration for both adhesive systems. In large restorations, however, the bonding involving Excite and the dental substrate demonstrated better resistance to stresses of higher magnitude than the bonding involving Single Bond.

Studies evaluating the influence of volume and confinement on marginal adaptation of composite restorations have yielded controversial results. Some authors observed that gap formation was related directly to the volume of the restoration.16,17 On the other hand, a 2003 study verified that, for a constant composite volume, there is a direct relationship between confinement and microleakage.32 Other authors using cylindrical cavities with similar depth and different diameters showed a tendency of higher interfacial gap incidence with higher C-factors.18 In restorations with similar depth and different diameters, volume and C-factor are inversely related. Their findings, therefore, disagree with those of our study if we consider the use of Single Bond. However, in cavities with similar depths, it is possible that other factors—such as a higher flow from the free surface of restorations with larger diameter (a lower C-factor)—could explain such discrepancies.

Influence of the adhesive system. The experimental design used in our study does not allow us to affirm that the higher microleakage observed with the use of Single Bond in large restorations was solely due to higher contraction stresses. Another concurrent factor that must be considered is the variation in bond strength at different depths. It has been demonstrated that bond strength tends to be higher in superficial than in deep dentin.33 Toward the pulp, dentinal tubuli density increases, along with water content, and intertubular dentin decreases.34 Consequently, the area available for hybridization is reduced. Average enamel thickness of the prepared cavities was 0.6 ± 0.29 mm. This means that for the small restorations, a great part of the adhesion to the axial walls took place in enamel. In this situation, the adhesive systems tested showed similar behavior, which can be explained by a more reliable adhesion to that substrate.35 In large restorations, approximately two-thirds of the adhesion was on dentin. In that situation, the use of an adhesive containing water and ethanol (Single Bond) led to significantly higher microleakage than the system based only on ethanol (Excite). Some studies have shown that water-free adhesives perform better on deep dentin,36,37 perhaps because of a smaller risk of incomplete solvent evaporation.38,39 It is possible that residual moisture in deeper cavities may be the cause of the poorer performance of the adhesive containing water, allowing a more extensive debonding at the axial walls regardless of possible higher stresses developed by a larger volume of shrinking composite. Finally, we must point out that the adhesive system containing only ethanol (Excite) presented a higher overall dispersion of the results when applied to large cavities. This phenomenon was observed by other authors as well,40 suggesting that this system has a higher sensitivity to moisture conditions of the substrate, even though it seemed to resist contraction stresses better than did Single Bond.

Influence of the insertion technique. The incremental technique we used in this study did not influence the results, which agrees with studies using finite element analysis,24 photoelasticity,25 interfacial gaps measurements41 and microleakage.42 It is possible that reduction in C-factor for each increment (1.7, compared with 2.3 for the entire cavity) was not enough to be reflected in lower stress values.24,43 Another hypothesis that could explain the lack of statistical differences between insertion techniques would be that in the incremental technique, polymerization would be more uniform and efficient through the composite’s entire thickness. We could speculate that the more homogeneous polymerization of both increments, in spite of their low C-factor and volume compared with the entire cavity, would reduce the possibility of composite flow. Conversely, for cavities restored in bulk, a gradient of conversion due to light attenuation through the composite would allow the composite to flow from the bottom of the restoration, partially relieving the stress developed at the margins.44,45


   CONCLUSIONS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The results of our study suggest that, considering similar confinement conditions, microleakage of composite restorations depends on the interaction between the dimensions of the cavity preparation and the adhesive system used. Therefore, the chance of success of a composite restoration should not be predicted only on the basis of its volume. Insertion of the composite in two horizontal increments did not influence microleakage values. However, the results of this in vitro study should be considered carefully, as other composite/adhesive combinations, cavity geometries and dimensions must be evaluated.


   FOOTNOTES
 

Dr. Costa Pfeifer is a graduate student, University of São Paulo, School of Dentistry, Department of Dental Materials, Brazil.


Dr. Braga is an associate professor, University of São Paulo, School of Dentistry, Department of Dental Materials, Av. Prof. Lineu Prestes, 2227, São Paulo, SP 05508-900, Brazil, e-mail "rrbraga{at}usp.br". Address reprint requests to Dr. Braga.


Dr. Cardoso is an assistant professor, University of São Paulo, School of Dentistry, Department of Dental Materials, Brazil.


DISCLOSURE. The authors would like to thank KG Sorensen, Barueri, São Paulo, Brazil, for supplying the diamond burs used in this study. This study was supported by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Brasilia, Brazil, and Núcleo de Apoio à Pesquisa em Materiais Dentários (Dental Materials Research Group), São Paulo, Brazil.


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 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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