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 Table of Contents  
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 132-139

Clinical evaluation of three adhesive systems in class V carious lesions

Department of Restorative Dentistry, Faculty of Dentistry, Tanta University, Tanta, Egypt

Date of Submission25-Aug-2017
Date of Acceptance28-Nov-2017
Date of Web Publication10-Oct-2018

Correspondence Address:
Kholood E Morsy
Department of Restorative Dentistry, Faculty of Dentistry, Tanta University, Tanta
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tdj.tdj_44_17

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The purpose of this study was to evaluate the clinical performance of three types of adhesive systems (Futurabond universal adhesive in a self-etch mode, Tetric N-bond self-etch adhesive, and Single bond universal adhesive in a total etch mode) in class V carious lesions over 1 year.
Materials and methods
A total of 20 patients with three carious cervical lesions were participated in this study after obtaining informed consent. A total of 60 restorations were placed. The distributions of adhesive materials and the teeth locations were randomized. Cavities were prepared limited to just removal of carious lesions with incisal and gingival margins in enamel and beveling of incisal cavosurface margin. All adhesives were applied following manufacturer's directions. All cavities were restored with Grandio SO composite resin following manufacturer's directions. Finishing and polishing was performed using finishing burs and polishing discs. Each restoration was clinically evaluated at baseline (24 h), 6 months and 1 year for retention, margin integrity, margin discoloration, secondary caries, and postoperative sensitivity using modified United state public health service (USPHS) criteria.
The recall rate was 100% after 1 year. Also the retention rate for all restorations was 100% after 1 year. Using χ2-test, there was no statistically significant differences between the tested groups at all evaluation periods regarding marginal adaptation, marginal discoloration, and postoperative sensitivity (P > 0.05). None of restoration had secondary caries at any evaluation period.
Within the limitation of this short-term evaluation, there was no significant clinical difference between adhesives.
Clinical significances
All tested adhesive systems achieved excellent results after 1 year of clinical service.

Keywords: class V, clinical, nanocomposite resin, self-etch adhesive, universal adhesives

How to cite this article:
Morsy KE, Abdalla AI, Shalaby ME. Clinical evaluation of three adhesive systems in class V carious lesions. Tanta Dent J 2018;15:132-9

How to cite this URL:
Morsy KE, Abdalla AI, Shalaby ME. Clinical evaluation of three adhesive systems in class V carious lesions. Tanta Dent J [serial online] 2018 [cited 2019 May 26];15:132-9. Available from: http://www.tmj.eg.net/text.asp?2018/15/3/132/243076

  Introduction Top

New adhesive systems are continuously being introduced to the dentistry, unfortunately often without sufficient clinical validation [1]. Ideally, once an adhesive is tested in vitro, a clinical evaluation must follow immediately to assess the effectiveness of the tested adhesive [2]. Following the development of adhesive systems, they can be classified into two groups. The first group includes total etch adhesive systems. These etch-and-rinse systems require an initial phase of tissue conditioning with 37% phosphoric acid. This provides a porous and irregular surface which allows for the penetration of resin monomers to be polymerized, hence providing micromechanical retention through resin tags.

The second group includes self-etch adhesive systems. In these systems, acid monomers are combined with water, and hydrophilic solvents can condition the dental structure while simultaneously promoting the infiltration of resinous monomers, diminishing the risk of postoperative sensibility and reducing the chances of having demineralized dentin that has not being impregnated [3],[4]. Recently multimode one-bottle universal adhesives have been developed to make the clinical procedure more user friendly. These new adhesives can be used as self-etch or as etch-and-rinse adhesives.

Restoration of carious cervical lesions represents a major challenge for resin materials due to the different adhesive properties of the tooth structure, the biomechanical aspects of the cervical area and the difficulties in the access and isolation of the operative field [5]. Composite resins have been successfully used and were the common choice for class V lesions restoration. The polymerization shrinkage is the main cause of marginal discrepancies which are associated with; marginal discoloration, secondary caries, postoperative sensitivity, and microleakage [6],[7].

The ultimate success of a material is indicated by its longevity in the oral cavity. As the initial in-vitro screening of new materials does not always reveal their full limitations or possibilities, clinical testing of new systems remains the ultimate proof of effectiveness [8]. Therefore, the objective of this study was to determine the clinical effectiveness of three adhesive systems in class V carious lesions restored with a nanohybrid composite resin after 1 year follow-up period.

  Materials and Methods Top

In this study, class V carious lesions were restored using three different adhesive systems (Futurabond universal adhesive [Voco, Cuxhaven, Germany], Tetric N-bond self-etch adhesive [Ivoclar Vivadent, Schaan, Liechtenstein], and Single bond universal adhesive [3M-ESPE, California, USA]) and Grandio SO, a nanohybrid composite resin.

The materials, composition, manufactures, and application mode are shown in [Table 1].
Table 1: Composition and application mode of materials used in the study

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A total of 20 patients of both sexes with ages ranging between 20 and 45 years regularly visiting dental clinic of Faculty of Dentistry, Tanta University were participated in the study following detailed inclusion and exclusion criteria. Approval for this study was obtained from Faculty of Dentistry, Tanta University Research Ethics Committee. The purpose of the present study was explained to the patients and informed consents were taken from these patients to restore their teeth, according to the guidelines on human research published by the Research Ethics Committee at Faculty of Dentistry, Tanta University.

Inclusion criteria

(a) Presence of at least three carious cervical lesions in anterior region in either maxillary or mandibular arch with less than 2 mm depth, (b) normal occlusion, (c) accessible isolation, (d) availability for at least 12 months.

Exclusion criteria

(a) Patients with poor oral hygiene, (b) the presence of any para functional habit, (c) abnormal occlusion, (d) teeth mobility, (d) subjects with compromised medical history, (e) pulpitis, nonvital or endodontically treated teeth.

All the patients were given oral hygiene instructions before operative treatment and when needed they were referred to the Periodontology Department for Scaling and Polishing.

Each patient received three restorations representing the three tested adhesives and grouped as follow:

  1. Group I: Futurabond universal adhesive (one step)
  2. Group II: Tetric N-bond self-etch adhesive (one step)
  3. Group III: Single bond universal adhesive (etches and rinses two steps).

The distribution of the tested materials and teeth locations were randomized as showed in [Table 2].
Table 2: The distribution of the tested materials and teeth locations

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After anesthesia, cavities were prepared using #57 straight plain carbide fissure bur held in high speed contrangled hand piece with water cooling system and limited to just removal of carious lesions with incisal and gingival margins in enamel and beveling of incisal cavosurface margin. Operating field was isolated using rubber dam to prevent salivary contamination. The adhesive systems were applied following the manufacturer's instructions [Table 1].

All cavities were restored with Grandio SO, a nanohybrid resin composite shade A2 and cured with LED curing light (Bluephase N; Ivoclar Vivadent, Schaan, Liechtenstein) for 20 s. The power output of the light-curing unit was monitored periodically with a hand-held radiometer (Bluephase meter; Ivoclar Vivadent).

The restorations were finished with finishing diamond stones (Enhance finishing and polishing system; Dentsply Caulk, Milford, Newyork, USA) and polished with polishing kit and discs (Sof-Lex; 3M ESPE, Saint Paul, Minnesota, USA) under water cooling.

All restorations were evaluated clinically at baseline (24 h), 6 months and after 1 year using modified USPHS [Table 3], including retention rate, marginal adaptation, discoloration, secondary caries, and postoperative sensitivity. The patients were asked to record whether any sensitivity, pain, or discomfort (yes/no) occurred before and after the treatment to air from the dental unit.
Table 3: Modified USPHS criteria

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Also intraoral color digital photographs were taken at each evaluation visit as a permanent record for subsequent indirect evaluation and later reference.

Two calibrated investigators evaluated the restorations, an initial agreement of at least 85% between evaluators was considered significant. If disagreement occurred between the examiners, a third equally calibrated expert was asked for evaluation. The restorations were scored as follows: Alpha represented the ideal clinical situation, Bravo was clinically acceptable, and Charlie represented a clinically unacceptable situation.

The data was calculated, tabulated, and statistically analyzed using statistical package for the social sciences (SPSS; SPSS Inc., Chicago, Illinois, USA), version 23, computer program. Each tested criterion was analyzed separately regarding different follow-up periods and all groups were compared using χ2-test.

  Result Top

All patients were available at each evaluation period (recall rate 100%). All restorations were evaluated at baseline (24 h) and all criteria showed 100% Alpha rating except that of postoperative sensitivity.

The retention rates of all tested groups at different follow-up periods were 100% with no loss of any restoration as shown in [Figure 1].
Figure 1: Retention rate of all tested groups at different follow-up periods.

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Marginal adaptations shown in [Figure 2], all restorations showed alpha scores after 6 months while at 1 year, one Futurabond restoration (5%) showed Bravo score and two Tetric N-bond restorations (10%) received Bravo score. All Single bond restorations received Alpha ratings. Using χ2-test, there was no statistically significant difference between the three tested groups at 1 year where P value equal 2.105.
Figure 2: Marginal adaptation of all tested groups at different follow-up periods.

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When the group was evaluated according to time, marginal adaptation did not decrease over time in Single bond restorations. Other groups showed difference between baseline and 1 year with one Futurabond restoration and two Tetric N-bond restorations showed bravo score. Furthermore, these differences were not statistically significant where P value equals 0.596 and 0.126, respectively [Table 4].
Table 4: Marginal adaptation of all tested groups at different follow-up periods

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Marginal discoloration, the data was illustrated in [Figure 3]. At 6 month one Futurabond U, one Tetric N-bond, and two Single bond restoration showed Bravo scores which is superficial and clinically acceptable. However, there was no statistically significant difference with P values of 0.786.
Figure 3: Marginal discoloration of all tested groups at different follow-up periods.

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At 1 year another one Futurabond U and one Tetric N-bond restoration showed Bravo rating. However, there was no statistically significant difference between all groups at 12 months (P = 1.000). Marginal staining was always seen at the gingival margin of the restorations.

When the group was evaluated according to time, marginal discoloration showed no change over time in Single bond restorations between 6 months to 1 year where P value equal 0.343. Other groups showed difference between 6 months and 1 year with another one Futurabond restoration and one Tetric N-bond restorations showed bravo Score. Furthermore, these differences were not statistically significant where P value equal 0.349. As recorded in [Table 5].
Table 5: Marginal discoloration of all tested groups at different follow-up periods

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The presence of secondary caries, the data was illustrated in [Figure 4]. As shown, there was no secondary caries at any evaluation periods.
Figure 4: Secondary caries of all tested groups at different follow-up periods.

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Postoperative sensitivity: as illustrated in [Figure 5], one Tetric N-bond and two Single bond restorations exhibited postoperative sensitivity which disappeared within few days.
Figure 5: Postoperative sensitivity of all tested groups at different follow-up periods.

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Using χ2-test; there was no statistically significant difference among tested recall periods where P value equal 0.362 and 0.126 for Tetric N-bond and Single bond restoration, respectively, while this complaint did not appear at any follow-up period in Futurabond restorations. The difference between the three tested groups was not statistically significant at baseline where P value equal 0.349 [Table 6].
Table 6: Postoperative sensitivity of all tested groups at different follow-up periods

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The data for all tested criteria were collected in [Table 7].
Table 7: The collected results of clinical evaluation of all tested groups at each follow-up period

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[Figure 6], [Figure 7], [Figure 8] showed representative photographs of some clinical cases of all tested materials over 1 year.
Figure 6: Grandio SO restorations with different adhesive systems at different evaluation periods.

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Figure 7: Grandio SO restorations with different adhesive systems at different evaluation periods.

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Figure 8: Grandio SO restorations with different adhesive systems at different evaluation periods.

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  Discussion Top

During the last two decades, a variety of adhesive systems has been continuously developed in order to produce good adhesion to dental substrates. These great advances in the adhesive dentistry have changed the basic concepts of cavity preparation into more conservative and minimally invasive ones. This new generation of bonding agent has been named universal adhesives.

These multimodal adhesives may be used in etch-and-rinse mode, self-etch mode, or selective-etch mode, depending on the clinician's preference. There are many studies analyzing the in-vitro behavior of materials while simulating the optimal oral environment. Laboratory tests, although easier, quicker, and more convenient, cannot replace clinical studies, nor can they predict the clinical performance of restorative materials in vivo.

Although many composites are in the market, it is difficult to select a composite with minimal microleakage. One study stated that it is not only the degree of conversion that acts upon the polymerization shrinkage, but also the composition and structure of the material [9]. Ibrahim et al. [10] stated that among nano filled composite resins, nanohybrid composites revealed less microleakage when compared to other composites due to their high filler content. In the present study grandio SO nanocomposite was used which has been reported to have distinct mechanical and physical properties.

Regarding retention rate, the bonding of Futurabond U was sufficient to provide adequate retention over 1 year. This is attributed to its chemical composition which contains highly functionalized SiO2 nanoparticles (Ø20 nm) which facilitate a cross-link of the resin components and enhance its film-building properties and reinforce the hybrid layer for long lasting high bond strength. In addition to its acidity (pH = 2.3) which considered a mild self-etch adhesive which interact with dentin superficially, dissolve the smear layer and penetrate it to form a more uniform and stable, resin-infiltrated hybrid layer [11].

The result of this study was similar to that of another clinical study examining the tested material for the same evaluation period which found that in self-etch mode, all tested criteria were given Alpha rating after 1 year without exception [12].

The favorable clinical performance of Tetric N-bond restorations was attributed to its composition which contains methacryloxydecyl dihydrogen phosphate (MDP) monomer which is speculated to have chemical interaction with hydroxyapatite crystals forming stable calcium–phosphate and calcium–carboxylate salts, respectively, along with only a limited surface-decalcification effect ('adhesion-decalcification concept'). This additional chemical interaction is also thought to particularly improve bond durability [13]. In addition, it can create so-called 'nanolayering' with hydroxyapatite, forming a stable adhesive layer and enhancing the durability of adhesion.

Similar to our results Burrow and Tyas [14] who tested HEMA free all-in-one adhesive in combination with the composite material Palfique Estelite for restoring non carious cervical lesion (NCCLs). At the end of their evaluation period, the retention rate was 100%.

The successful finding concerning single bond restorations resulted from its two-fold bonding mechanism. First, micromechanical interlocking created by phosphoric acid. Phosphoric acid application dissolves hydroxyapatite crystals within prismatic and interprismatic enamel. This increases microscopic roughness, surface area, and energy. The adhesive infiltrates the etch pits by capillary attraction [15]. Upon in-situ polymerization, microtags and macrotags are formed that are responsible for the durable micromechanical interlocking.

At dentin, phosphoric acid removes the smear layer, demineralizing dentin, thereby exposing a scaffold of collagen fibrils nearly depleted of hydroxyapatite [15]. The exposed collagen fibrils function as a micro retentive network for micromechanical interlocking of resin monomers that diffuse into it and in-situ polymerize, eventually forming a hybrid layer and resin tags.

Second, intense chemical interaction of the functional monomer, 10-MDP, present in Single bond universal with residual hydroxyapatite (remaining around the exposed collagen fibrils within the hybrid layer [16] and with enamel crystalline. Yoshida et al. [17], showed that an effective chemical interaction occurs between MDP and hydroxyapatite forming a stable nanolayer that could form a stronger phase at the adhesive interface.

The results of this study are similar to the results of Perdigao et al. [18], and Lawson et al. [19], who found 100% retention rate for single bond universal adhesive in total etch.

The major problem with class V composite resin restorations is microleakage especially along the cervical wall in these restorations [20], which defined as the penetration of bacteria, fluids, molecules, or ions into the spaces between the cavity walls and the restorative materials, resulting in sensitivity, recurrent caries, discoloration of the restoration margins, irritation of the pulp, and restoration failure. Therefore, measures should be adopted to prevent microleakage when an adhesive system is being developed for dental applications [21].

The results demonstrated that the tested adhesive systems showed good marginal integrity during the evaluated period, which is desirable, because restorations with deteriorating margins are more likely to fail than restorations with ideal margins [22]. Studies carried by Fron et al. [3], and by Barcellos et al. [23], are in agreement with the current results and showed good results of 1-self etch adhesive (SEAs) for marginal integrity. Simone et al. [24], stated that there is no statistically significant difference in microleakage when using total etch and self-etch technique.

Marginal discoloration may be caused by three factors, such as the presence of excess filling materials (positive marginal adaptation), a deficit of filling materials at the margin (negative marginal adaptation) and the formation of gaps [25]. It is thought that these mild discolorations are due to the retention of microscopic pigments derived from colored beverages and food at marginal defects which can be solved by polishing.

Secondary caries may arise, when remnants of infected dentine incompletely removed during cavity preparation or from oral microorganism which gain entry via leaky gap at the tooth-restoration interface [26]. Another factor which leads to secondary caries is that all composites shrink during curing period, and thus it is important to minimize the effect of composite shrinkage following the usage instructions of the materials [27].

Delbons et al. [28], reported no statistically significant differences with respect to all parameters including retention, marginal adaptation, and staining when the universal adhesive systems used in self-etch or in total etch technique.

Postoperative sensitivity has been attributed to several factors including operative trauma, dentin etching, desiccation, leakage, and bacterial penetration to the pulp [29]. The results of the current study showed that, three restorations had immediate postoperative sensitivity that improves with time with no statistically significant differences between the three groups at baseline.

This result agrees with Perdigão et al. [30], who found that the increased sensitivity at the beginning of the evaluation results from retraction of the gingiva and tooth root surface exposure, which occurs immediately after placing a restoration or after its finishing and polishing.

These successful findings might be related to the relatively short evaluation period, which is consistent with many studies in which there were no significant differences between the tested materials in early evaluation periods.

It should be noted that the time frame for this study was not of such duration to indicate the long-term suitability of the tested materials, but it may provide an indication for detecting material-related initial changes in color and surface topography regarding their future performance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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