Q U I N T E S S E N C E I N T E R N AT I O N A L

Influence of resin composite insertion technique in preparations with a high C-factor

Sillas Duarte Jr, DDS, MS, PhD1/Welingtom Dinelli, DDS, MS, PhD2/ Maria Helena Carmona da Silva, DMD3
Objective: To evaluate the marginal microleakage in enamel and dentin/cementum walls in preparations with a high C-factor, using 3 resin composite insertion techniques. The null hypothesis was that there is no difference among the 3 resin composite insertion techniques. Method and Materials: Standardized Class 5 cavities were prepared in the lingual and buccal aspects of 30 caries-free, extracted third molars. The prepared teeth were randomly assigned to 3 groups: (1) oblique incremental placement technique, (2) horizontal incremental placement technique, and (3) bulk insertion (single increment). The preparations were restored with a 1-bottle adhesive (Single Bond, 3M ESPE) and microhybrid resin composite (Z100, 3M ESPE). Specimens were isolated with nail varnish except for a 2-mm-wide rim around the restoration and thermocycled (1,000 thermal cycles, 5C/55C; 30-second dwell time). The specimens were immersed in an aqueous solution of 50 wt% silver nitrate for 24 hours, followed by 8 hours in a photo-developing solution and evaluated for microleakage using an ordinal scale of 0 to 4. The microleakage scores obtained from occlusal and gingival walls were analyzed with Wilcoxon and Kruskal-Wallis nonparametric tests. Results: The null hypothesis was accepted. The horizontal incremental placement technique, the oblique incremental technique, and bulk insertion resulted in statistically similar enamel and dentin microleakage scores. Conclusion: Neither the incremental techniques nor the bulk placement technique were capable of eliminating the marginal microleakage in preparations with a high C-factor. (Quintessence Int 2007;38:829835)

Key words: adhesion, adhesive, C-factor, dentin, enamel, resin composite

A difficulty with adhesive restorative procedures is the impaired marginal seal, which allows access of bacteria, oral fluids, molecules, and ions at the preparation walls/ restorative material interface.14 The occur-

rence of microleakage can result in postoperative sensitivity, stained margins, secondary caries, and pulp pathology, which endanger the longevity of the restoration.57 The factors ascribed to marginal microleakage are the adhesive bond strengths to dental substrates3,810; residual stress created by resin composite shrinkage11,12; differences among enamel, dentin, and restorative material thermal expansion coefficients13; and failures during the restorative procedures, all of which are aggravating several clinical variables.7 In 1987, Feilzer et al postulated that the geometric configuration of the cavity plays an important role in the adaptation of resin composite restoration.14 Since then, several tech-

Associate Professor, Department of Comprehensive Care, Case School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio.

Formerly, Associate Professor, Department of Restorative Dentistry, So Paulo State University at Araraquara (UNESP), Araraquara, So Paulo, Brazil.

Private practice, Cuiab, Mata Grosso, Brazil.

Reprint requests: Dr Sillas Duarte Jr, Department of Comprehensive Care, Case School of Dental Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4905. E-mail: sillas.duarte@case.edu

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Ta b l e 1

Distribution of microleakage scores* verified at the enamel and dentin margins for the 3 experimental techniques (n = 20)
Enamel scores Dentin scores 4 0 1 2 3 4

Restorative technique

Oblique incremental (G1) Horizontal incremental (G2) Bulk increment (G3)

15 20 13

2 0 6

3 0 0

0 0 1

0 0 0

1 4 2

4 1 4

7 1 7

6 9 5

2 5 2

*See text and Fig 3 for explanation of scores.

niques have been suggested to improve marginal adaptation of high C-factor preparations, including adhesive systems that potentially resist composite shrinkage,11,12,15,16 placement techniques for resin composites,1719 protocols for photopolymerization,20 and different cavity preparations.2123 Considering the resin composite placement method, some studies have shown that incremental techniques, especially the oblique technique, tend to improve marginal adaptation by resisting resin composite shrinkage stress.17,23 On the contrary, other reports demonstrated that bulk placement of composite induces less contraction stress,24 minimizing marginal microleakage.19 Hence, the objective of this study was to evaluate microleakage in enamel and dentin margins in high C-factor preparations when resin composite is placed according to 3 insertion techniques. The null hypothesis was that there is no difference in microleakage among the 3 insertion techniques.

buccal and lingual surfaces of each of 30 teeth, for a total of 60 cavities. The gingival cavosurface margin of the preparations was below the cementoenamel junction. The preparations were made with a no. 245 carbide bur (KG Sorensen) in a high-speed, standardized cavity preparation device under copious water coolant.25 After every 5 preparations, the bur was discarded and replaced with a new one. The final preparations had the following extensions: 3.0 mm occlusogingival, 3.0 mm mesiodistal, and 1.8 mm deep. The preparations were reevaluated under 10 magnification to ensure the absence of pulp exposure and enamel cracks at the cavosurface margin. The specimens were randomly and equally assigned to 3 experimental groups (n = 20) (Table 1). The preparations were etched with 35% phosphoric acid (Scotchbond Etchant, 3M Espe) for 15 seconds, rinsed with water for 15 seconds, and blot dried with a cotton pellet, leaving the dentin moist and shiny. An ethanol- and water-based, simplified adhesive system (Single Bond, 3M Espe) was applied in 2 consecutive coats to the entire preparation according to the manufacturers instructions, gently air dried to displace the solvent, and light cured for 20 seconds (XL 2500, 3M Espe). All the experimental groups were restored with a microhybrid resin composite (Z100, 3M Espe) shade A2. Each increment, for all experimental groups, was light cured for 40 seconds at a curing distance of 0.5 mm and light intensity of 550 mW/cm2, which was constantly monitored.

METHOD AND MATERIALS

Thirty caries-free human molars were selected after examination under stereomicroscope at 10 magnification to detect enamel cracks or fissures, which could cause errors during the microleakage test. The teeth were then stored in an aqueous solution of 0.5% chloramine at 4C. One standardized high C-factor Class 5 cavity (C-factor = 5) was prepared at both the

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2 1 a b 1 c

3 1 a b

2 1 c

3 2 1

Fig 1 Oblique insertion technique. (a) First increment contacting the gingival, axial, and distal walls (1). (b) Second oblique increment placed contact the occlusal, axial, and mesial walls, after the first increment has cured (2). (c) Third increment covering the other increments and sealing the cavosurface margin (3).

Fig 2 Horizontal layering technique. (a) First layer applied at the gingival one-third (1). (b) Second horizontal layer applied subsequently at the middle third (2). (c) Third horizontal increment placed at the occlusal onethird (3).

Group G1 was restored using the oblique layering technique in 3 increments.17 The first oblique increment was applied with a composite instrument (Almore) to contact the gingival, axial, and distal walls (Fig 1a). After the first increment was cured, the second oblique increment was inserted to contact the occlusal, axial, and mesial walls (Fig 1b). A third increment was applied to cover the other increments, sealing the cavosurface margin (Fig 1c). In Groups G1 and G2, the second and third increments were light-cured. Group G2 was restored with the horizontal layering technique. The preparations were divided into 3 equally spaced horizontal sections of 1.0-mm height, and the composite placed from the gingival toward the occlusal wall. The first layer was horizontally placed at the preparations gingival one-third and light cured as described above (Fig 2a). The second layer was subsequently applied at the preparations middle third (Fig 2b), and the last increment at the preparations occlusal one-third (Fig 2c). For group G3, the preparations were restored using resin composite bulk placement (single increment) and light cured for 40 seconds. The restored specimens were stored in distilled water at 37C for 24 hours. The restorations were then finished and polished with aluminum oxide disks (Sof-Lex Pop-On, 3M Espe). The teeth were coated with 2 layers of nail varnish, except for a 2.0-mm rim around the restoration, to allow the contact of the tracing agent with the margin of the restoration. The specimens were thermocy-

cled for 1,000 cycles at 5 1C and 55 1C with 30 seconds of dwell time. The specimens were immediately immersed in 50% silver nitrate solution for 24 hours, followed by 8 hours in photo-developing solution to allow the reduction of silver ions to metallic silver grains. The nail varnish was removed and the specimens sectioned through the center of the restoration with a precision, water-cooled, slow-speed diamond saw (Isomet 1000, Buehler). The sections were polished with silicon carbide papers (600-, 800-, and 1,200-grit) in a water-cooled polishing device. Then the restorations were analyzed with a stereomicroscope at 30 magnification and scored for the degree of dye penetration along the occlusal and gingival walls by 2 examiners: 0 = No marginal leakage (Fig 3a) 1 = Silver nitrate penetrates up to the dentinoenamel junction (DEJ) or correspondent length at the dentin wall (Fig 3b) 2 = Silver nitrate penetrates beyond the DEJ or correspondent length at the dentin wall, surpassing half the cavity depth (Fig 3c) 3 = Silver nitrate penetrates beyond half the cavity depth, without reaching the axial wall (Fig 3d) 4 = Silver nitrates penetrates along the axial wall (Fig 3e). The data were submitted to nonparametric Wilcoxon and Kruskal-Wallis statistical analysis (P < .05) to compare the difference among the resin composite placement techniques.

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Fig 3

Microleakage scores: (a) score 0; (b) score 1; (c) score 2; (d) score 3; (e) score 4.

RESULTS
Table 1 displays the microleakage scores according to the resin composite insertion techniques at enamel and dentin margins. The Kruskal-Wallis test for the comparison of placement techniques at enamel margins found no statistically significant difference among the experimental groups (2 = 3.933; P > .27), notwithstanding the behavior of group G2. For dentin margins, the KruskalWallis test also showed no statistically significant difference among the groups (2 = 2.301; P > .51). The null hypothesis was accepted. The horizontal incremental placement technique, oblique incremental technique, and the bulk insertion technique resulted in statistically similar enamel and dentin microleakage scores. None of the techniques for resin composite placement in high C-factor Class 5 preparations were able to eliminate marginal microleakage.

DISCUSSION
To ensure outstanding marginal adaptation of an adhesive restoration, some restorative aspects must be considered, such as preparation design,2629 resin composite shrinkage,24,30,31 and dental adhesive bonding strengths.26 Feilzer et al14 proposed a method by which the potential of adhesive failure can be theoretically foreseen. It is predicted by dividing the total of adhered surfaces by the total of free surfaces present in a cavity preparation.11,14 Because a Class 5 preparation has more adhered surfaces than free surfaces (C-factor = 5), the effects of resin composite shrinkage might be more noticeable.11,26 Restoring a box-shaped preparation with incremental placement of resin composite has been suggested based on the concept of reducing the volume of resin to be photopolymerized.11,14,15,17,19,23 Consequently, the number of free surfaces would increase, and theoreti-

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cally, the polymerization shrinkage stress on adhered surfaces would decrease.11,23 However, the shrinkage of each individual composite increment causes deformation of the cavity preparation, forcing a deflection of the preparation walls.18 Therefore, the preparation is volumetrically filled with a smaller amount of resin than that of the original cavity preparation volume.18 Any adhesive restoration is subjected to 2 phenomena: (1) The bonded interface resists shrinkage stress, and (2) the shrinkage stress surpasses the bond strengths.18 When the bonded interface resists the shrinkage stress, the residual stress of polymerization might lead to postoperative sensitivity due to deformation of the preparation.18 Conversely, if the composite shrinkage surpasses the bond strengths, the restoration may debond; a gap will be formed, with a high possibility of microleakage.32-34 Marginal microleakage can be defined as the penetration of fluids, bacteria, molecules, and ions at the tooth-restoration interface, probably due to the presence of gaps at the cavosurface margins of a restoration.2 The results of this study revealed that even when an incremental resin composite placement technique was used, the penetration of tracing agent was not eliminated (see Table 1). This occurrence proves that resin composite restoration is extremely technique sensitive and exposed to factors that are difficult to control clinically. Since the occlusal walls are located at enamel margins, more resistance of microleakage was expected than that at the gingival walls, as observed in this project.33 One factor that induces this outcome is that acidetching creates microporosities, allowing penetration of the adhesive system, thus forming a micromechanical bonding with the resin composite restoration.15,35 Nevertheless, all techniques for composite placement showed some level of marginal microleakage for enamel margins, except the horizontal technique (see Table 1). This method could be considered an acceptable technique for resin composite insertion at enamel margins since standardized layers of equivalent volume allow superior control of the polymerization shrinkage levels.24 However, at dentin

margins, the horizontal placement technique presented the greatest variability of results (see Table 1). If all composite increments were perfectly standardized, the horizontal technique would possibly show less microleakage.32 However, perfectly standardized increments are unachievable clinically. Some authors advocate the bulk increment as a safe restorative technique because it fills the total volume of the preparation and creates less residual shrinkage stress than the incremental technique.24,30,31 On the other hand, since this concept is based on the elastic deformation of the restorative material flowing toward the free surfaces, residual stress should be expected.24 Incremental resin composite application alone is not enough to prevent or reduce the marginal microleakage. It would be interesting to include a flexible-material intermediary layer in an attempt to reduce the hardness and to compensate the polymerization shrinkage stress.15,33,34 However, it has been demonstrated that even with the application of an elastic intermediate material, microleakage is not eliminated.36 Another issue that can contribute to the rupture of resin composite restoration seal is the thermal expansion coefficient.13,32 This variable is responsible for 1% of contraction, where cold would represent an increase in the marginal microgap of about 5 m, while heat would not change it significantly.13 Because resin composite has an organic matrix, it is subject to water sorption.37 Water sorption by resin composites promotes a volumetric expansion of those materials, which partially compensates the polymerization shrinkage, reducing marginal crack width.3739 However, this phenomenon is usually seen several weeks after restoration placement, making it viable for microleakage to occur at preparation walls.40

CONCLUSIONS
The null hypothesis was accepted. None of the techniques for resin composite placement was able to eliminate marginal microleakage in enamel and dentin margins.

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There was no statistically significant difference among oblique incremental, horizontal incremental, and bulk placement of resin composite for preparations with a high C-factor. The control of marginal microleakage in preparations with a high C-factor presents a challenge regardless of the resin composite insertion technique.

12. Swift E Jr, Perdigo J, Heymann HO. Bonding to enamel and dentin: A brief history and state of the art. Quintessence Int 1995;26:95110. 13. Torstenson B, Brnnstrm M. Contraction gap under composite resin restorations: Effect of hygroscopic expansion and thermal stress. Oper Dent 1998;13: 2431. 14. Feilzer AJ, De Gee AJ, Davidson CL. Setting stress in composite resin in relation to configuration of the restoration. J Dent Res 1987;66:16361639. 15. Kemp-Scholte CM, Davidson CL. Complete marginal seal of class V restorations effected by increased flexibility. J Dent Res 1990;69:12401243. 16. Triolo PT, Swift EJ Jr, Barkmeier WW. Shear bond strengths of composite to dentin using six dental adhesive systems. Oper Dent 1995;20:4650. 17. Hansen EK. Effect of cavity depth and application technique on marginal adaptation of resins in dentin cavities. J Dent Res 1986;65:13191321. 18. Versluis A, Douglas WH, Cross M, Sakaguchi RL. Does an incremental filling technique reduce polymerization shrinkage stresses? J Dent Res 1996;75:

ACKNOWLEDGMENT
This research was supported by Fundao de Amparo Pesquisa do Estado de So Paulo (FAPESP). The authors would like to thank Mr Claudio Tita and Mr Mario Srgio Fatini for their help with thermocycling procedures.

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