Comparative Evaluation of Microleakage of Two Step Etch and Rinse, Two Step Self Etch and Universal Dentin Bonding

Mohammad Reza Soltani¹, Nasim Dadfar², Kiana Ghannadan³

¹Assistant Professor of Operative Dentistry, School of Dental, Ilam University of Medical of Sciences, Ilam, Iran

²General Dentist, Faculty of Dentistry, Ilam University of Medical Sciences, Ilam, Iran.

³Assistant Professor of Operative Dentistry, School of Dental, Qazvin University of Medical of Sciences, Qazvin, Iran.

*Corresponding Author E-mail: havasian1991@gmail.com

ABSTRACT:

Introduction: Dental composites have been extended as the selected material in most of recent restorations. However, the contraction caused by their polymerization remains the main issue. The stress made by this contraction could cause the divide of composite-tooth junction to be severed. Bacteria, liquids, molecules or ions could cross the gap made between the repair and the cavity wall which this process is called micro-leakage. Micro-leakage causes leakage, tenderness, secondary decay, damage to the pulp, marginal discoloration, which finally results in restoration failure. It can be said that the success of resin restoration material depends perfectly on the ability of the enamel and dentin bonds. This research aims to determine the best bonding to decline micro-leakage. Materials and Methods: In this research, 48 human premolar teeth were prepared without decay, restoration, fracture and wear. Each class V standard cavity was prepared on buccal and lingual surfaces. The shaved teeth were randomly divided into 4 groups including 12 ones. They were polished after restoration. All samples of the 4 groups were subjected to the heat cycling. Apex was sealed with adhesive wax and all parts of the tooth were covered with two layers of nail polish. The samples were incubated in 0.5% Fuchsin solution for 24 hours at room temperature. After that, they were washed under the faucet and the nail polish was removed from tooth surface. Teeth were divided into two mesio distal sections by a cutting machine. Samples were observed by stereo microscope. samples were evaluated based on the micro-leakage grading. Kruskal-Wallis, Mann-Whitney and Will Coxson tests were used to evaluate the results. Results: In each group, 48 cavities were examined. The results of this research showed that in none of enamel surface of bindings, micro-leakage was observed. In the dentine area, the least amount of micro-leakage was related to the Clearfil SE Bond. There was no statistically significant difference between the micro-leakage of Clearfil SE Bond and G Premio Bond by Self Etch method (P value> 0.05). Also, there was no significant difference between micro-leakage of G_Premio Bond by Self Etch and G_Premio Bond by Etch and Rinse method. The micro-leakage of Adper Single Bond 2 was significantly higher in the dentin rather than the other groups. Conclusions: In dentine level, the highest micro-leakage was related to Adper Single Bond 2 bonding and the least one was in Clearfil SE Bond and G Premio Bond by Self Etch method.

KEYWORDS: Microleakag, Two Step Etch and Rinse, Universal Dentin Bonding.

INTRODUCTION:

One of the main goals of restorative dentistry is to restore teeth and their function.¹ Dental composites that cause aesthetic and tooth-colored restorations have been developed as an optional material in many modern restorations.^2-4 However, the manifestation of shrinkage due to their polymerization continues to be a major problem.⁵ The stress from this shrinkage can cause debonding at the tooth-restoration interface⁶, especially if the restoration margins are in cementum or dentin, Bacteria, fluids, molecules, or ions can pass through this gap between the restoration materials and the cavity wall, a process called microleakage. Microleakage causes allergic reaction, secondary caries, pulp damage, and marginal discoloration, which ultimately leads to restoration failure.^7-11 There are a number of reasons for microleakage in composite restorations, including polymerization shrinkage, the difference between the thermal expansion coefficients of resin and tooth, and the lack of self-sealing mechanism of tooth surface, which is one of the biggest reasons for this process^.12-14 It can be said that the success of resin restorative materials depends entirely on the ability to bond to enamel and dentin. Before treatment, the enamel surface preparation is increased by the use of inorganic acids and chelators. For this purpose, phosphoric acid is the first choice, which first etch the enamel and then the dentin. However, the interaction of the etching agents with dentin is limited by the buffering effect of hydroxyapatite and other dentin components, which makes the bond strength of composite to dentin less than enamel^.1,15,16 Various solutions have been proposed to reduce the microleakage of bonded restorations, such as the use of incremental technique, the use of flowable composites, and the introduction of new generations of bonding agents. However, none of these strategies have been able to completely prevent microleakage.²

Cervical areas are more challenging due to the difficulty in controlling moisture and the proximity of the lesion to the gingival margin, and isolation is not always possible for them, and bleeding usually occurs during preparation and restoration due to gum damage, and the amount of microleakage in this type of restoration is more. It has been observed that the greatest success of composites in class V restorations has been related to the bonding agent used.^12,17 Some studies have shown that there is no significant difference in the amount of microleakage of conventional composites and low-shrinkage ones in the long run, which can be said that the long-term clinical success of a composite restoration depends strongly on the efficiency of its bonding agents.¹⁸ Various bonding systems have been introduced in recent years, and after the introduction of the 4th generation of bonding agents and the achievement of acceptable results, major changes have been made in order to reduce the number of work steps and decrease technique sensitivity.¹⁹ Recent advances in self-etch adhesives are due to universal or multi-mode bonding agents, as they have the ability to be used on a variety of substrates such as enamel, dentin, metal and ceramic. These bonding agents can also be used as self-etch and total-etch^20-23, but according to the results of comparative studies, the effect of the bonding agents on the microleakage has been different in different studies and there is limited information on the bond strength resulted by the use of these bonding agents.^20,33,25 The aim of the present study was to evaluate the microleakage comparison when using 3 different bonding agents, which were: two-step etch-and-rinse, two-step self-etch, and universal bonding agents.

MATERIALS AND METHODS:

The present study was a quasi-experimental intervention study. 48 human premolar teeth without fractures, cracks, caries, restorations and abrasions that had been extracted due to orthodontic treatment or periodontal disease were prepared. While controlling the infection, the remaining soft tissue on the surface of the teeth was removed by a hand-held scaler, then the teeth were cleaned with Pamis toothpaste and carefully washed. And by magnifying 8 times, they were examined by a magnifying glass and under light to make sure they were healthy. On the buccal and lingual surface of each tooth, a standard U-shaped class V cavity with dimensions of 3 mm mesio-distal in width, 2mm occluso-gingival in length, and 1.5mm in depth was selected based on the ISO/TS-11605 test. Then, the specimens were randomly divided into four groups of 12. The groups were as follows:

A: Adper Single Bond 2

B: Clearfil SE Bond

C: G_Premio Bond…. Self-Etch

D: G_Premio Bond…. Etch and Rinse

In group A, after cavity preparation, enamel and dentin margins were etched with 37% phosphoric acid (Morva Etch, LOT: 101007169, Made in Iran) for 15 seconds. After 10 seconds of washing, the cavity was gently dried. Two layers of Adper-Single-Bond 2 were then placed on the walls, and the cavity was exposed to an air syringe for 5 seconds to allow the solvent to evaporate. The bonding agent was then cured for 10 seconds with a light-curing device (WOODPECKER S/N: L1700707H) with an intensity of 700mW/cm2. Finally, the composite (Amaris, VOCO, Germany, A2, 1731387) was placed in two layers on the cavity. Each layer was cured for 40 seconds. In Group B, after cavity preparation, the Clearfil SE Bond primer was placed on all the walls of the cavity for 20 seconds and then it was placed under an air syringe for 5 seconds. In the next step, the bonding agent was placed on the walls of the cavity and was cured for 10 seconds. The restoration phase was performed with a composite similar to group A. In Group C, after cavity preparation, the G Premio-Bond bonding agent waited on the enamel and dentin for 10 seconds, then the cavity was dried for 5 seconds with a strong air syringe and was cured for 10 seconds. The composite was then placed in the cavity similar to the previous groups. In group D, after cavity preparation, enamel and dentin were etched with 37% phosphoric acid for 10 to 15 seconds and were washed for 5 seconds. Then the cavity was gently dried and the bonding agent was placed on it and cured under the light of a light-curing device for 10 seconds. The composite restoration steps were similar to the previous ones. After the restoration with composite on buccal and lingual sides, the tooth was kept in water for 37 hours and after this period, the restoration surface was polished using Soflex polishing discs (3M ESPE, St. Paul, MN, USA) without using water. Specimens of 4 groups were alternately placed under 1000 thermal cycles at 5-55℃ in thermal baths with a dwell time of 30 seconds and a transfer time of 5 seconds.

Dyeing and Cutting the Specimens:

The specimens were immersed in a solution of 0.5% basic fuchsin (Merck, Germany) for 24 hours at room temperature, and after this period, they were washed under running water for 5 minutes, and the varnish on the surface of the teeth was removed with a scalpel blade. Then, for each restoration, the specimens were observed by a stereo microscope (PZO, Warsaw, Poland) with a magnification of 40 times and their microleakage rate was checked and a larger number on each side was reported.

Microleakage Rate Rating for Occlusal Margins:

0- Dye penetration was not seen in the distance between the restoration and the tooth.

1 - Dye penetration of 1/3 of the path of the gingival or occlusal wall

2 - Dye penetration between 1/3 to 2/3 of the path of the gingival or occlusal wall

3 - Dye penetration up to 2/3 along the occlusal/gingival wall that has not reached the axial wall

4 - Dye penetration between the restoration and the tooth that has reached the axial wall

Statistical Analysis:

In order to analyze the data, Kruskal-Wallis, Mann-Whitney and Wilcoxon tests and SPSS-version-24 software were used^24-26.

RESULTS:

As mentioned, there were 12 teeth in each group. Then 4 cavities were prepared for each tooth. Therefore, in the present study, 48 cavities were examined in each group. The results of the frequency distribution of microleakage rankings in the two enamel and dentin regions in the four studied groups showed that in the enamel region, the microleakage rate in all the four studied groups was zero, and in the dentin region it was shown that in group A, 12 cavities were ranked zero, 31 cavities were ranked 1, and 5 cavities were ranked 3, and in group B all the 48 cavities were ranked zero, and microleakage was not observed. The results for group C also showed that 45 cavities in this group were ranked zero and 3 cavities were ranked 1. In group D, 40 cavities were ranked zero and 8 cavities were ranked 1. The mean microleakage rank was significantly different between the studied groups in the dentin region (P<0.001) (Table 1). The microleakage of the dentin region in group A was significantly different from the three groups B, C, and D. There was no significant difference between the two groups B and C and between the two groups C and D in terms of microleakage (P> 0.05), and there was also a significant difference between the two groups B and D in terms of microleakage (P< 0.05) (Table 2). In group A, significantly, the amount of microleakage in 36 cavities in the dentin region was higher than in the enamel region, and in 12 cavities, the amount of microleakage of the enamel and dentin regions was equal (P< 0.05). In group B, the amount of microleakage of the dentin and enamel regions was equal in all the 48 cavities (P>0.05). In group C, the amount of microleakage in 3 cavities was higher in the dentin region than in the enamel region, and in 45 cavities, the amount of microleakage was equal (P> 0.05). In group D, in 8 cavities, the amount of microleakage in the dentin region was higher than in the enamel region, and in 40 cavities, the amount of microleakage of the two regions was equal, indicating that the microleakage in the dentin region was significantly higher than in the enamel region (P<0.05) (Table 3).

Table 1: The comparison of mean microleakage rank between the studied groups in enamel and dentin regions

Zone	Groups	Mean microleakage rank	X²	P-value
Enamel	A	96.5	0.000	1
	B	96.5
	C	96.5
	D	96.5
Dentin	A	145.57	96.763	P < 0.001
	B	73
	C	78.84
	D	88.58

A, Adper Single Bond 2;

B, Clearfil SE Bond; C, G Premio Bond Self Etch; D, G Premio Bond Etch and Rinse

Table 2. The comparison of mean microleakage rank between the studied groups in the dentin region

Zone	Groups	Mean microleakage rank	U	Z	P-value
Dentin	A	66.5	288	7.45	P < 0.001
	B	30.5
	A	65.16	352.5	6.782	P < 0.001
	C	31.84
	A	62.92	460	5.764	P < 0.001
	D	34.08
	B	47	1080	1.751	0.08
	C	50
	B	44.5	960	2.939	0.003
	D	52.5
	C	46	1032	1.594	0.111
	D	51

A, Adper Single Bond 2; B, Clearfil SE Bond; C, G_Premio Bond Self Etch; D, G_Premio Bond Etch and Rinse

Table 3. The comparison of the average rankings between dentin and enamel regions for each group

Groups	Rank	Number	Mean microleakage rank	Total Rank	Z	P-value
A	Enamel< dentin	0	0	0	5.687	P < 0.001
	Enamel < dentin	36	18.5	666
	Enamel = dentin	12	-	-
B	Enamel< dentin	0	0	0	0.000	1
	Enamel < dentin	0	0	0
	Enamel = dentin	48	-	-
C	Enamel< dentin	0	0	0	1.732	0.083
	Enamel < dentin	3	2	6
	Enamel = dentin	45	-	-
D	Enamel< dentin	0	0	0	2.828	0.005
	Enamel < dentin	8	4.5	36
	Enamel = dentin	40	-	-

A, Adper Single Bond 2; B, Clearfil SE Bond; C, G_Premio Bond Self Etch; D, G_Premio Bond Etch and Rinse

DISCUSSION:

The seal between a composite restoration and the tooth structure is provided by bonding agents, and since these materials alone do not have any antibacterial effect on oral pathogens, in the absence of adequate seal, the restoration fails due to the recurrence of caries; therefore, the creation of an effective seal between the composite and the tooth structure is an important factor in increasing the longevity of composite restorations. Previous studies on microleakage show that the bond to enamel margins shows less microleakage than the bond to non-enamel margins, so the most important factor influencing the clinical success of these restorations is the greater strength of the bond to the dentin compared to the bond to the enamel. As a result, recent advances in bonding systems have led to a stronger and more efficient bond between dentin and resin restorations.²⁷ In the present study, class V cavities were used to examine microleakage. According to Raskin et al., about 62.5% of microleakage evaluation studies used class V cavities, which with high C-factor, have the ability to evaluate both enamel and dentin margins simultaneously.^28-32 Class V cavities also had no macromechanical behavior, and the assessments were based solely on the impact of the bonding agent.³³ The cavity was also repaired with incremental technique. This technique compensates for the polymerization shrinkage. Torstenson and Oden used this technique to repair human molar teeth and found that it reduced the marginal seam by 25%.³⁴ In the present study, in the enamel region, none of the bonding agents showed microleakage. This result has also been obtained in the study of Sánchez-Ayala et al., and no microleakage was found between the bonding agents used in the enamel region, which is consistent with the present study.³⁵ In a study by Tuncer et al., the results of microleakage of Universal bonding agents in both SE and Etch modes on enamel were similar to those of Clearfil-SE and Adper-Single-bond control groups, which are consistent with the results of the present study. However, Single-bond-universal was used in this study, the composition of which is different from the bonding agent used in the present study.³⁶ In the study of Sai et al., although the strength of the bond to dentin of the G-premio in SE mode was lower than in Clearfil-SE-Bond, but the resulting bond did not change much during degradation processes within 1 year, and the results of this study showed that the durability of the dentin bond of the G-premio universal bonding agents in SE mode is sufficient for clinical use. Also, the microleakage results from the Clearfil SE bonding agent in the enamel area were higher than the two-step Adper-single-bond 2. This could be due to the weak acidic pH of the Clearfil SE bond, like other two-step self-etch bonding agents compared to the Adper-single-bond 2, which was an Etch and Rinse adhesive and the separate etching stage is performed by phosphoric acid, although this difference was not significant, and the results of that study did not correspond to the present study.³⁷ Also, in the Tuncer et al., study, the results of microleakage of the two-step etch-and-rinse adhesive, Adper-Single-Bond 2, in the enamel margin were similar to Clearfil SE. And in the dentin region, the microleakage in Adper-single-bond 2 bonding agent was higher than other bonding agents used in the study. These results are consistent with the present study.³⁶The Bolgül et al., study also found that the total-etch system showed a higher microleakage in the dentin region than the one-step and two-step self-etch systems, which is consistent with the results of the present study.³⁸ A study by Karaman et al., reported that the universal bonding agent used with the SE and E-and-R methods in both enamel and dentin regions showed a similar microleakage to the control group. Since, according to the manufacturer, the HEMA material is not used in the structure of the G-premio universal bonding agent, so the removal of this material from the structure of these bonding agents can be considered useful in forming nano-layering and thus improving bond strength and reducing microleakage. There have also been many reports of the HEMA potential in causing allergies, and the lack of this can be considered as another advantage of removing this compound from the structure of HEMA-Free bonding agents such as G-premio-bond.^38,39 In the Motevaselian et al. study, it was claimed that in enamel margins, Adper-Single-Bond 2 and Scotchbond-Universal bonding agents showed less microleakage by total-etch, but there was no significant difference, which is consistent with the results of the present study. But for reported dentin margins, the Clearfil-SE Bond and Scotchbond-Universal bonding agents with the SE method had the lowest microleakage. This difference was not significant, and the results in dentin margins did not match the present study, which is probably due to the different type of universal bonding agent used in the present study.⁴⁰ Also, a review study of Rosa et al. in 2015, which was conducted on the bond strength of several types of Universal-adhesives, recommended selective enamel etching for universal bonding agents with mild acidic strength when applied on enamel to improve bond strength. In the case of dentin, however, there was no difference between bond strength in SE and E and R among low-acidity universal bonding agents.⁴¹

CONCLUSION:

The results of the present study showed that in the dentin region, the highest microleakage was related to Adper Single-Bond 2 bonding agent and the lowest microleakage in this region was related to Clearfil-SE-Bond and G_Premio Bond by Self-etch method. Also, none of the studied bonding systems can completely prevent microleakage. Based on the results of microleakage in the present study, the use of two-step SE adhesives and universal adhesives with the SE method can be recommended to create a suitable bond in permanent teeth.

COMPETING INTERESTS:

The authors declare that they have no competing interests.

ACKNOWLEDGMENT:

I am grateful to the financial and spiritual support of the Ilam University of Medical Sciences.

SOURCE OF FUNDING:

This paper was developed using funds from the Ilam university of Medical sciences.

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Received on 23.04.2020 Modified on 13.08.2020

Research J. Pharm. and Tech. 2021; 14(6):3209-3214.

DOI: 10.52711/0974-360X.2021.00559