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Original Article
Address for correspondence: Dr.Mouhamed Sarr, Department of Conservative Dentistry and Endodontics, Cheikh Anta Diop University, BP 17256, DakarLibert, Sngal.
Email:mouhamed.sarr@ucad.edu.sn
ABSTRACT Purpose: To evaluate the bonding effectiveness to dentin of eight dualcure composite cements after
6month water storage. Materials and Methods: This study is a followup of a recent study that investigated
the 1week bonding effectiveness of feldspathic ceramic blocks luted to dentin using the same composite
cements and experimental protocol. The microtensile bond strength(TBS) of different composite
cements, including two etchandrinse cements(Calibra, Dentsply; Variolink II, IvoclarVivadent), two
selfetch cements (Panavia F2.0, Kuraray; Clearfil Esthetic Cement, Kuraray), and four selfadhesive
cements(Unicem, 3M ESPE; Maxcem, Kerr; Monocem, Shofu; GCem, GC), was measured using a
standardized TBS protocol after 6month water storage. As control, a twostep selfetch adhesive(Clearfil
SE, Kuraray) combined with a microhybrid restorative composite (Clearfil APX, Kuraray) was used.
Twentyseven human third molars were used with specific preparation, and after 6month water storage,
microspecimens were prepared and subjected to a TBS test. Results: The mean TBS varied from 0
to 26.1 MPa, the latter being measured for the control adhesive composite combination. All specimens
prepared using the selfadhesive composite cements Maxcem and Monocem failed during specimen
processing. Most specimens failed at the dentincement interface, except the selfetch composite cement
Panavia F2.0 that failed in 53% of the cases at the cementceramic interface and the control of which
all specimens failed in the resin part of the microspecimens. Conclusion: The largely varying bonding
effectiveness recorded for the different composite cements highlights the need for material specifications.
Such specifications should also include a bond durability test as the specimens in the present study that
were subjected to 6month water storage. To lute ceramic restorations that allow light transmission to a
sufficient degree, a conventional lightcurable adhesive and composite should be considered.
where conventional composites are not indicated. The of the K.U. Leuven were stored in 0.5% chloramine/
clinical success of bonded ceramic restorations depends water at 4C and were used within 3months after
primarily on a good bond to tooth/dentin and an optimal extraction. Flat dentin surfaces were obtained by
marginal fit after cementation. Further, adhesive resin removing coronal enamel with an IsoMet lowspeed
type and the resin cement affected the mean bond diamond saw (IsoMet 1000, Buehler, Lake Bluff, IL,
strength.[2] USA). A standardized smear layer was produced first
grinding with a SiCpaper (600grit). Dentin surfaces
Todays composite cements can be classified into three were verified for the absence of enamel and/or pulp
groups according to the adhesive approach employed to tissue using a stereomicroscope(Wild M5A, Heerbrugg,
bond the cement to the tooth structure. Etchandrinse Switzerland). Subsequently, they were cleaned with
composite cements utilize an etchandrinse adhesive, pumice paste, rinsed with water, and airdried(without
including a phosphoric acid etching step, followed by desiccating dentin), unless mentioned differently, as for
a rinse phase. Selfetch composite cements utilize a the selfadhesive composite cement MonoCem as per
selfetch adhesive that does not need to be rinsed off manufacturers instructions.
while finally, selfadhesive cements as per manufacturers
instructions do not require any pretreatment at all, Ceramic block preparation
simplifying the clinical procedure considerably.[3] At The feldspathic ceramic computeraided design/
the restoration side, glasscontaining ceramics are best computeraided manufacturing(CAD/CAM) blocs(VITA
etched with hydrofluoric acid, silanized, and coated Mark II for Cerec/inlab, Vita, Bad Sckingen, Germany)
with an unfilled resin[4] while oxideceramics require were sectioned in 3 smaller blocs of approximately
specific primers though currently there is no consensus 8mm8mm and a thickness of 4.15mm. The
which luting protocol is most effective. Many of the ceramic surface was etched with hydrofluoric acid(IPS
multistep composite cements have been documented to Ceramic Etching Gel, IvoclarVivadent, Schaan,
perform satisfactory.[5] Nonetheless, little information is Liechtenstein) for 60 s after which the ceramic surface
available in the literature about their longterm bonding was thoroughly rinsed with water and airdried. Next,
effectiveness, this to even a much larger extent for silane (Monobond S, IvoclarVivadent) was applied and
selfadhesive composite cements. left undisturbed for 60 s after which the surface was again
airdried. Finally, to improve resin infiltration into the
Therefore, the aim of this study was to evaluate the bond etchpits in the ceramic block, fluid, unfilled bonding
durability of different composite cements that were resin, Heliobond (IvoclarVivadent) was applied but
used to lute feldspathic ceramic blocks onto dentin. The not lightcured.
hypothesis tested was that after 6month water storage,
no difference in microtensile bond strength (TBS) to Luting procedures
dentin exists for the different cements tested. The ceramic blocks were luted to dentin using the
different cements, each strictly following the respective
MATERIALS AND METHODS manufacturers recommendations[Table1]. Each block
was luted under a fixed pressure of 1kg and lightcured
This study follows a previous study[5] that investigated for 20 s from each side(5 s20 s)(Demetron Optilux500,
the shortterm or immediate bonding effectiveness of Kerr, Orange, USA), with a light output of not less than
composite cements that were employed to lute feldspathic 550mW/cm2(100 s of light emission in total).
ceramic blocks onto dentin. All materials presently
employed were exactly the same(same batch numbers) Microtensile bond strength testing
as in the previous study, with the tests executed by the After 6months of water storage at 37C, the specimens
same operators following the same experimental protocol. were sectioned with a watercooled diamond saw(IsoMet
Eight composite cements were used that include two 1000) in both x and y directions, perpendicular to
etchandrinse, two selfetch, and four selfadhesive the adhesive interface to obtain about 16 sticks with
composite cements[Table 1]. As control, the mild, a crosssectional area of approximately 1 mm2. The
twostep selfetch adhesive Clearfil SE(Kuraray, Tokyo, dimensions of the sticks were measured by means of a
Japan) that can be regarded as the gold standard selfetch digital caliper(Mitutoyo, Kanagawa, Japan). The sticks
adhesive was used in combination with the microhybrid originating from the outer area, where the ceramic
restorative composite Clearfil APX(Kuraray). block was bonded to enamel, were excluded from the
study. After examination under a light microscope for
Tooth preparation the absence of enamel, the specimens were fixed to a
Noncarious human molars gathered following informed BIOMAT jig[6] with cyanoacrylate glue (Model Repair
consent approved by the Commission for Medical Ethics II, DentsplySankin, Ohtawara, Japan). This jig was then
fixed in an LRX testing machine(Lloyd, Hampshire, UK) failed at the cement/ceramic interface. The specimens
with a load cell of 100 N after which the specimens were of the control selfetch adhesive/restorative composite
stressed in tension at a crosshead speed of 1.0mm/min. combination failed entirely in the resin part of the
The bond strength was calculated in MPa, derived from TBS stick.
dividing the imposed force(in N) at the time of fracture
by the bond area(in mm2). Specimens that failed prior to Comparing the aged 6month TBS data to the
testing(socalled pretesting failure[ptf]) were explicitly immediate 1week TBS data, a significant reduction
noted and assigned 0 MPa in further analysis. The mode in TBS was observed for all cements except the
of failure was determined with a stereomicroscope(Wild selfetch multistep composite cements. Arelatively
M5A, Heerbrugg, Switzerland) at magnification of50 small TBS reduction was also observed for the control
and recorded as cohesive failure in dentin, failure selfetch adhesive/restorative composite combination,
at the resindentin interface, cohesive failure in the of which the TBS remained the highest of all groups
cement, failure at the cementceramic interface, after 6month water storage. The highest bond strength
cohesive failure in the ceramic, or as mixed failure reductions were recorded for the selfadhesive composite
for any combination of the previous. cements Maxcem and MonoCem, with also a reduction in
TBS of 92% measured for the etchandrinse composite
Statistical analysis cement Variolink II.
The bond strength values were subjected to a
KruskalWallis test at a level of significance of 5%. DISCUSSION
To assess reduction in bonding effectiveness, the
immediate and aged bond strengths were pairwise The study hypothesis that after 6month water storage,
compared to the results of the former study using an
no difference in TBS to dentin exists for the different
unpaired nonparametric MannWhitney Utest.
composite cements tested was rejected.
RESULTS In this study, the bonding effectiveness of eight
contemporary luting agents to bond ceramic blocks to
The TBS results are shown in Table2 and graphically
dentin was compared. As control, the gold standard
presented in Figure1. After 6month water storage,
twostep selfetch adhesive Clearfil SE in combination
significant differences in TBS were observed among
with the microhybrid restorative composite Clearfil APX
the cements tested (KruskalWallis, P<0.0001). The
was chosen. Since the composition of composite cement
multistep cements revealed a TBS that was not
resembles very much the composition of a restorative
different among each other, except for Variolink II,
for which almost all specimens failed before testing; composite, the latter can also be used as luting agent
thus, a very low TBS was recorded. The control on the condition that it is sufficiently fluid to reach a
selfetch adhesive/restorative composite combination sufficiently thin film thickness and that light can be
exhibited the highest bond strength after 6month water sufficiently transmitted through the ceramic restoration
storage, which was not significantly different from all to be adequately cured.[7] In this study, the ceramic
multistep cements, except Variolink II[Table2]. For blocks were made of feldspathic ceramic(VITA Mark II)
the selfadhesive cements MonoCem and Maxcem, on which transmits light relatively well, also considering
the other hand, 100% pretesting failures were recorded the small dimensions of the blocks. To ensure sufficient
after 6month water storage. In addition, almost 40% polymerization, every specimen was lightcured for in
of ptfs were recorded for GCem while Rely X Unicem total 100 s. All composite cements tested in this study
was the only selfadhesive cement to exhibit almost were dualcuring. Their polymerization can be initiated
no ptfs (4%) after 6month water storage. Failure by activation of light and chemical initiators due to
analysis revealed that after 6month water storage, which they remain the materials of choice to lute indirect
most specimens failed at the dentin/cement interface, toothcolored restorations with a thickness of 4mm or
except for Panavia F2.0, of which 53% of the specimens more.[7]
Table2: Mean microtensile bond strength and standard deviation after 6month water storage(pretesting failure included as
0 MPa)
6 months TBS Compared to 1week
MPa(SD) ptf/n Statistical Percentage Percentage Pc
groupsa interface failureb
Rely X Unicem 9.2(4.9) 2/46 c, d, e 99 55 <0.0001
Maxcem 0(0) 45/45 f 100 100 0.0017
MonoCem 0(0) 45/45 f 100 100 0.0125
GCem 4.4(4.9) 16/41 d, e, f 100 74 <0.0001
Panavia F2.0 20(7.6) 0/36 a, b, c 41 3 0.4715
Clearfil Esthetic cement 14.1(9.2) 3/32 b, c, d 95 3 0.9805
Calibra 14.6(6.1) 0/35 a, b, c, d 89 32 <0.0001
Variolink II 1.3(3.9) 40/47 e, f 100 92 <0.0001
Clearfil SE bond with APX 26.1(6.2) 0/34 a, b, c 0 18 0.0032
a
KruskalWallis(P<0.05), bFracture surface analysis by stereomicroscope, cMannWhitney Utest comparing 1week and 6 months TBS. SD=Standard deviation, SE=Standard error,
TBS=Microtensile bond strength, ptf=Pretesting failure
of pretesting failures(4%) and did not differ significantly Both etchandrinse composite cements tested
from the most betterperforming multistep cements. employ a twostep etchandrinse adhesive. Twostep
Compositionwise, this is the only cement that comes in etchandrinse adhesives are however not so reputed
a powderliquid formulation. For all other selfadhesive when it comes to bond durability.[19] This may explain
cements, both components are pastes that are mixed by the large reduction in bond strength, and the increased
application through an automix tip. This delivery may amount of interfacial failures observed for these two
appear more userfriendly as no mixing step is needed; cements upon 6month water storage.
however, as both types require neither any handmixing
nor pretreatment of the surface, both can be regarded In this study, the adhesion to the ceramic part of the
very easy to use. The powderliquid formulation may interface complex was not a variable. Therefore, we opted
have the advantage of dealing more effectively with for an optimized protocol comprising a micromechanical
different smear layer types, as suggested in a former and chemical pretreatment of the surface by air abrasion
study.[7] All these selfadhesive cements appear relatively and silane treatment.[15] This protocol proofed to be
wellbalanced cocktails that have to fulfill different tasks. effective, as no failures at this location were observed,
As a result, small differences in composition may have a despite the 6months water storage.
significant effect on the bonding performance as was also
observed in the current study. In addition, the physical CONCLUSION
integrity of the luting material itself is in part reflected
in the bond strength as this test measures the strength of The following conclusions could be retained:
the whole ceramiccementdentin assembly, to which the The longterm bonding effectiveness of some
material strength also contributes. These cements must selfadhesive cements is very questionable
also age differently as was proven before.[4] The restorative composite Clearfil APX is suitable
when used as cement for luting feldspathic ceramics.
When luted to smearcovered dentine, all selfadhesive
composite cements appeared equally effective and Acknowledgements
durable as the etchandrinse and selfetch The authors would like to thank the manufacturers for
multistep composite cements.[16] supplying materials for this study.
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