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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 6  |  Page : 763-770

Repair potential of a new glass hybrid restorative system


Department of Restorative Dentistry, School of Dentistry, Hacettepe University, Ankara, Turkey

Date of Acceptance10-Feb-2019
Date of Web Publication12-Jun-2019

Correspondence Address:
Dr. U Koc Vural
Department of Restorative Dentistry, School of Dentistry, Hacettepe University, Sihhiye, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_551_18

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   Abstract 


Background: Repair of a failed amalgam or composite resin (CR) restoration has been extremely studied and proposed as a routine clinical treatment option; however, repair potential of glass ionomer-based restorative materials was not studied sufficiently in the literature. Aim: The aim of this study is to evaluate the repair potential of a glass hybrid (GH) restorative repaired either by the same material (GH) or CR after different surface treatments using microtensile bond strength (μTBS) test. Methods and Materials: One hundred and twenty bar-shaped (2 × 2 × 8 mm) GH blocks were prepared. After aging, the specimens were divided into two groups (n = 60) and five subgroups (n = 12). The specimens in Group I were repaired with the following protocols: (a) no treatment + GH, (b) diamond bur (B) + GH, (c) cavity conditioner + GH, (d) cavity conditioner + universal adhesive (A) + GH, (e) A + GH, and specimens in Group II were repaired with (a) no treatment + CR, (b) B + CR, (c) B + A + CR, (d) 40% phosphoric acid + A + CR, (e) A + CR. The specimens that were subjected to μTBS testing, scanning electron microscopy evaluations, and fracture modes were determined. Data were analyzed using Kruskal–Wallis and Mann–Whitney U tests (P = 0.05). Results: Repair using CR resulted in higher bond strengths (P < 0.001). The lowest bond strength was obtained in Group Ie. The highest bond strength was obtained when GH was roughened in Group IIc. Conclusion: Repair of restorative GH with CR appears as a preferred option to improve the bond strength.

Keywords: Composite resin, microtensile bond strength, repair, restorative glass ionomer


How to cite this article:
Vural U K, Gurgan S. Repair potential of a new glass hybrid restorative system. Niger J Clin Pract 2019;22:763-70

How to cite this URL:
Vural U K, Gurgan S. Repair potential of a new glass hybrid restorative system. Niger J Clin Pract [serial online] 2019 [cited 2019 Jun 25];22:763-70. Available from: http://www.njcponline.com/text.asp?2019/22/6/763/260040




   Introduction Top


Glass ionomers (GIs) became available as a result of the pioneering studies of Alan Wilson and Brian Kent in the late 1960s and have started to gain popularity as direct restorative materials after the late 1970s.[1] They have unique properties such as adhesion to moist tooth structures, low-toxicity, anticariogenic properties due to fluoride release, thermal compliance with tooth hard tissues, and biocompatibility.[2] However, some disadvantages were also reported in handling, low strength, esthetic, and tendency to degradation in acidic environments.[3]

The use of GIs in restorative dentistry became routine with the improvements in their chemical and physical properties. Today, high viscous GIs achieve superior physical properties compared to traditional GIs.[1],[2] In 2007, a GI-based restorative system called Equia was introduced as a long-term restorative material.[4],[5] Considerable improvements have been made in the properties of this restorative system over the years. The manufacturer claims that the matrix of this new system combines fillers, fluoroaluminosilicate glasses (FAS) of different size similar to hybrid composite resins (CRs), and named as “glass hybrid restorative system” (GH). The larger glass fillers of this system are supplemented by smaller highly reactive FAS fillers that strengthen the matrix of the restorative material.[5],[6] However, failures or fractures could still occur like the other restorative materials resulting sometimes in clinical problems.[7],[8]

Improvements in adhesive technologies influenced current concepts by preserving healthy dental tissues and reducing the number of interventions needed. New strategies such as repair or refurbishment of defective restorations were proposed to increase the longevity of restorations through minimal intervention in recent years. Whenever possible, repair of restorations can be more cost-effective and acceptable to patients than restoration replacement, because it preserves tooth structure and it has the potential to allow patients to retain most of their teeth during their lifetime.[9],[10],[11]

Previous studies reported that repaired restorations showed the same or increased longevity as restorations that were replaced completely.[4],[9],[12],[13] Repair of a failed amalgam or CR restoration has been extremely studied and proposed as a routine clinical treatment option, which serves to the philosophy of “minimum intervention.”[4],[13],[14],[15],[16],[17] However, repair potential of GI-based restorative materials was not studied sufficiently in the literature. Although few articles have explored the repair of resin-modified glass ionomers (RMGI),[3],[18],[19],[20] reviews have indicated that to date no study regarding the repair of GH restorative systems has been reported. Thus, the aim of the present study was to investigate the microtensile bond strength (μTBS) of a GH restorative system using the same GH or a CR as the repair material and assessing the effect of different repair protocols as a prerepair treatment. The null hypothesis was that there will be no difference between two repair materials and different repair protocols.


   Materials and Methods Top


Materials used in the study are presented in [Table 1].
Table 1: Description of the materials

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Preparation of glass ionomer-based restorative specimens

To prepare bar-shaped specimens (substrates), 16 × 2 × 2 mm stainless steel molds were produced and metal blocks were placed into the half of the molds leaving the remained 8 × 2 × 2 mm empty. The encapsulated GH restorative material (Equia Forte Fil, GC, Tokyo, Japan) was tumbled for 5 s before activation to aerate the powder inside the capsule as stated by the manufacturer and mixed for 10 s using a mixing device (Softly, Satelec Acteon, Merignac Cedex, France). It was injected to the molds placed on a glass slab and covered with a transparent matrix strip. Then, another glass slab was pressed gently over the mold with finger pressure to evenly spread the material. The glass slab and transparent matrix strip were removed after GH was set, and the excess material was removed using a 1200 grit silicon carbide paper (LECO, St. Joseph, MI, USA). The specimens were briefly dried; the coating material (Equia Forte Coat/GC, Tokyo, Japan) was applied to the top surfaces and light cured for 20 s using a curing light (Cromalux LED 1200, 1400 mW/cm2, Rastaat, Germany).

After the preparation of 120 GH sticks, the specimens were stored at a temperature of 37°C for 1 day in distilled water and subjected to thermo cycling by 5000 cycles, between 5 and 55°C, and a dwell time of 30 s for aging.[17] All the specimens were kept in distilled water at 37°C during the research protocol.

Surface conditioning and repair protocols

The aged specimens were placed into original molds. The metal blocks in the molds were removed to apply the repair protocols. The specimens were randomly divided into two groups (n = 60) depending on the repair material and subjected to five subgroups (n = 12) depending on surface conditioning method. In Group I, the repair material was GH, while the repair material was a CR (G-aenial posterior, GC, Tokyo, Japan) in Group II.

Group I

  • Group Ia (n = 12): GH was added to the substrate (to the remaining 8 × 2 × 2 mm blocks) without any surface treatment.
  • Group Ib (n = 12): The substrate was roughened using a diamond coarse fissure bur (B) (DIATECH, Swiss Dental, Heerbrugg, Switzerland) under water-cooling and then GH was added.
  • Group Ic (n = 12): A cavity conditioner (20% mild polyacrilic acid) (cavity conditioner, GC, Tokyo, Japan) was applied with a microbrush for 20 s to substrate surface and washed and dried briefly before the GH was added.
  • Group Id (n = 12): After the cavity conditioner was added with the same way as group Ic, a universal adhesive (G-premio BOND, GC, Tokyo, Japan) was applied to the conditioned substrate using a microbrush and left 10 s undisturbed. The surface was then dried thoroughly for 5 s under maximum air pressure and light cured using a LED light device. Finally, GH was added.
  • Group Ie (n = 12): GH was added to the substrate after universal adhesive was applied as in group Id.


Group II

  • Group IIa (n = 12): CR was added to substrate without any surface treatment.
  • Group IIb (n = 12): CR was added to substrate after roughening with the coarse diamond bur.
  • Group IIc (n = 12): CR was added to substrate after roughening with coarse diamond bur and applying universal adhesive with the same way as in group I.
  • Group IId (n = 12): The substrate was etched with 40% phosphoric acid (GC. Tokyo, Japan) for 15 s and rinsed and dried with air thoroughly. Then, the universal adhesive was applied in the same way before adding fresh CR.
  • Group IIe (n = 12): CR was added to substrate after the application of universal adhesive with the same way.


μTBS testing

Specimens were secured with thermoplastic impression compound (HeraeusKulzer, Hanau-Hessen, Germany) on an epoxy resin block, which were mounted on a cutting machine (Isomet, Buehler, Lake Bluff, IL, USA) and sectioned in two to obtain sticks with dimension of 1 × 1 × 16 mm. They were then attached to a μTBS testing machine (BISCO; Schaumburg, IL, USA) and were stressed at a crosshead speed of 1 mm/min until failure occurred. The load at failure was recorded in Newtons (N). The bond strength was calculated in megapascals (MPa) with the formula:

R = F/A

where R is the strength (MPa), F is the load required for rupture of the specimen, and A is the interface area of the specimen (mm2).[17]

Failure mode analysis

After the μTBS testing, the fractured specimens were examined under a stereomicroscope (American Optical, Buffalo, NY, USA, X40) to determine the exact type of failure and classify whether it was adhesive, cohesive, or mixed. Fracture in the substrate or repair material was classified as cohesive failure. If the residues of either GH or CR had been detectable, the specimen was assigned to the group of mixed failures. Fracture between the substrate and the repair material was classified as adhesive failure.

Scanning electron microscopy analysis

One specimen from each group was bisected vertically across the bonded interface and was sputter-coated with gold. The GH-GH and GH-CR bonded surfaces were observed under scanning electron microscopy (SEM) (JSM-6400 SEM, JEOL, Tokyo, Japan) at × 35, ×250, and × 500 magnifications.

Statistical analysis

SPSS 20.0 software for Windows (IBM Corp., Armonk, NY, USA) was used for statistical analysis. Assumption of normality was checked by Shapiro–Wilk test. Levene's test was used to test the homogeneity of variances. Mann–Whitney U test was performed for the comparison of two main groups. Comparisons of more than two groups were performed by Kruskal–Wallis test. After obtaining significant results, Dunn's correction was used for pairwise comparisons. A two-sided P value <0.05 was considered statistically significant. The box plot was used for the graphical illustration. Pretest failures were not involved in the microtensile bond test calculations.


   Results Top


According to the Shapiro–Wilk test, the distributions of MPa values for two main groups were not normally distributed (P < 0.001 for group I and P < 0.001 for group II). Among the 10 subgroups, the P value was ranged between 0.000423 and 0.704. Therefore, the MPa value distributions of some subgroups (Ia, Ic, IIe) were not normally distributed.

Mean, median, standard deviation (SD), minimum (min) and maximum (max) values, and interquartile ranges of μTBS strengths (MPa) for all test groups are presented in [Table 2] and [Figure 1].
Table 2: Mean, median, standard deviation (SD), minimum (min) and maximum (max) values, and interquartile ranges (IQR) of bond strengths (MPa) for the subgroups (Kruskal-Wallis test)

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Figure 1: The median microtensile bond strength values (MPa) for subgroups in box plots. Horizontal line in the middle of each box plot shows median value; horizontal lines in the box give 25% and 75% quartiles

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A comparison between Group I and Group II revealed that there was a significant difference between the groups (P < 0.001). Repair with the CR showed significantly higher bond strength than the repair with GH. The lowest bond strength was obtained when additional GH was used with the application of universal adhesive (Group Ie), whereas the highest bond strength was observed when GH was roughened with a diamond bur and repaired with a CR after the application of universal adhesive (Group IIc) [Table 2]. The subgroups that showed significant differences with pairwise comparisons were shown at [Table 3] (P < 0.001).
Table 3: Pairwise comparisons of the subgroups* (Dunn's correction)

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The results of the failure mode analysis of the specimens are presented in [Table 4]. Adhesive failure was the mostly observed failure type (85%). Fifty-five (45.8%) adhesive failures were observed in Group I and 47 (39.2%) failures were observed in Group II. All cohesive failures were in the substrate (GH) (n = 11, 9.2%). There were only seven (5.8%) mixed failures.
Table 4: Failure mode analysis of the groups

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The SEM images of specimens from Group Ib (showing highest bond strength in Group I), Group Ie (lowest bond strength in Group I), Group IIa (lowest bond strength in Group II), and Group IIc (highest bond strength in Group II) are shown in [Figure 2],[Figure 3],[Figure 4],[Figure 5].
Figure 2: SEM image of adhesive interface of one specimen from group Ib. (a) ×35, (b) ×250, and (c) ×500 magnification. (d) The mode of failure was documented as adhesive

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Figure 3: SEM image of adhesive interface of one specimen from group Ie. (a) ×35, (b) ×250, and (c) ×500 magnification. (d) The mode of failure was documented as adhesive

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Figure 4: SEM image of adhesive interface of one specimen from group IIa. (a) ×35, (b) ×250, and (c) ×500 magnification. (d) The mode of failure was documented as adhesive

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Figure 5: SEM image of adhesive interface of one specimen from group IIc. (a) ×35, (b) ×250, and (c) ×500 magnification. (d) The mode of failure was documented as adhesive

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In SEM micrographs of group Ib [Figure 2]a,[Figure 2]b,[Figure 2]c, the repair interface was almost invisible. An obvious, continuous, and uniform appearance was seen. GH fillers of GH were observed. The mode of failure was documented as adhesive failure [Figure 2]d.

In SEM micrographs of group Ie [Figure 3]a,[Figure 3]b,[Figure 3]c, a crack parallel to the interface was observed. The repair interface was visible. The mode of failure was documented as adhesive failure [Figure 3]d.

In SEM micrographs of group IIa [Figure 4]a,[Figure 4]b,[Figure 4]c, a void in the interface was observed. The repair interface was visible. The typical appearances of GH and CR were seen. The surface of CR revealed smoother appearance than GH. The mode of failure was documented as adhesive failure [Figure 4]d.

In SEM micrographs of group IIc [Figure 5]a,[Figure 5]b,[Figure 5]c, cracks close to the interface were observed. The repair interface was visible but looks continuous and uniform. The mode of failure was documented as adhesive failure [Figure 5]d.


   Discussion Top


Today, GIs are considered as permanent restorative materials of minimal invasive and low-cost treatment option in an attempt to prolong the clinical service of lifetime restorations.[5],[21],[22],[23] Different results were reported with regard to survival rate of restorative GIs.[21],[22],[24],[25] Hickel et al.[24] reviewed annual failure rates in posterior cavities under heavy occlusal stress and reported the median annual failure ranged between 1.9% and 14.4%. However, Diem et al.[21] reported 92.5% of success at the end of 3-year, whereas Gurgan et al.[5],[22] reported 92.3% of success at the end of 4 and 100% at the end of 6 years for class II restorations. They all stated fracture as a main reason for failure.

A total removal of a deficient restoration is not always necessary or a choice. Since the replacement of the restoration often results in extended preparation size and increases the risk of pulpal damage and cost,[26],[27] repair of defective restorations is recommended.[10],[14],[21]

Although the repairs of RMGIs were explored,[3],[18],[19],[20] no other studies that examine the repair potential of GI-based restorative materials have been identified. So, the present study investigated the influences of different material combinations on μTBS of a GI-based restorative material.

In-vitro analysis of bonding of materials can be done by shear or microtensile tests.[28],[29] Shear bond strength evaluation requires easier specimen preparation and alignment during measurements and has been suggested to be less reliable than μTBS evaluation. On the other hand, the adhesive interface in μTBS analysis is relatively small, invoking a more uniform stress distribution and therewith allowing better access to the true interfacial bond strength.[30] Sano et al.[31] also suggested the μTBS test with reduced areas of adhesive joint where fractures occur basically at the adhesive interface. Besides, there is no report on the repair μTBS of restorative GHs. For this reason, in this study, the μTBS test was used.

As repair may occur sometime after the initial placement of the restoration, the aging of restorative material is important. The influence of storage time for aging was examined in different studies.[26],[30],[32] As there is a lack of a standard protocol for artificial aging process, studies are usually based on different procedures. Thermocycling and water storage are well-accepted methods to simulate aging and to stress interfacial bonds.[14] Thermal cycling stimulates the thermal strain on the bonding surface by the influence of liquids and a temperature change between 5 and 55°C. Repeated temperature changes lead weakening of the bonding surfaces.[15] In the present study, the GH specimens were stored for 24 h in water and then subjected to thermo cycling.

Studies on conventional chemically cured GIs have showed that repair of GIs may be successfully achieved by the pretreatment of surfaces.[33],[34] In this study, the repair of a GH restorative material with the same material (GH) or with a CR with different surface treatments were evaluated.

Parra and Kopel[35] investigated shear bond strength of repaired GIs and reported that GIs can be repaired using a fresh GI layer in combination with some specific surface treatment. They concluded that the surface treatment that best enhances the bond was either 20 s of etching with phosphoric acid or roughening the surface followed by acid etching. Pearson et al.[34] reported that water-based polyacrylic acid materials could not generate bond strength between fresh and aged materials, whereas Yap et al.[19] stated that the exposed glass particles in the old GI could react with the polyacrylic acid in the new material and thus establish a chemical bond.

Surface pretreatments are important for dental adhesion. A wide range of methods of surface conditioning have been introduced to increase the repair bond strength of different restorative materials, such as roughening with coarse diamond burs, acid etching, air abrasion with aluminum oxide, and application of silane or adhesive systems.[36] However, there is not an optimal method as to the best surface conditioning for highest repair bond strength.

Numerous surface treatment procedures are recommended in order to improve the bond strength of GIs but they are mainly for RMGIs.[2],[15],[16],[17],[26],[30],[37],[38],[39] A review of the literature reveals many controversial reports about the conditioning of GI/RMGIs.[3],[18],[19],[20] The surface-conditioning techniques suggested for GI repairs are often based on simply using etching agents.

Acid etching is an important factor that has significant effect on bond strength. Yap et al.[19] proposed acid etching followed by resin application to repairing of RMGI. On the other hand, Taher and Ateyah[40] and Tate et al.[41] reported that acid etching has no significant effect on the bond strengths of RMGIs. In the present study, acid treatment of the GH surface did not show a major effect. Maneenut et al.[3] also stated that acid treatment of RMGI showed similar results. They reported that use of polyacrylic acid conditioner as a pretreatment of the old surface did not have any effect on bond strength same as in the present study.

Although the uses of total etch or self-etch adhesives in the repair of GI or RMGIs have been adequately explored,[3],[19],[20],[42],[43],[44] there is no study about the use of universal adhesives with GH restorative materials.[42],[43] Universal adhesives have recently been introduced and are designed to bond to tooth structures via the total-, self-, or selective-etch techniques. In addition, some universal adhesives are also capable of bonding to various substrates, including glass ceramics, zirconia, and metal alloys, with no need for additional primers. However, because of the recent introduction of these adhesives, little information is currently available about the bond durability of universal adhesives to various substrates.[45],[46],[47] Previous studies concluded that mild self-etch adhesives had higher bond strength than the strong self-etch or total etch adhesive when they were applied on the GI.[42],[43] In the present study, a universal adhesive was applied for surface conditioning of GH and the CR.

The highest repair bond strength between substrate and repair material was reported to be achieved by using macro–micromechanic retention. Macromechanical retention can be achieved by roughening the surface or creating retention holes and undercuts using burs,[16] while micromechanical retention can be achieved by dissolving partially the particles in the substrates by etching.[32],[48],[49]

In correlation with previous studies,[16],[50] in the present study, the highest repair μTBS between GH and fresh GH was achieved when the GH was roughened using a diamond bur. The highest repair μTBS between GH and CR was achieved with the use of universal adhesive after the GH was roughened macromechanically (diamond bur). Macromechanical retention followed by adhesive application resulted in higher bond strength when compared with all other surface conditioning methods. These results correlate with the literature.[16],[50]

In the present study, repair of GH with the same material showed significantly lower repair μTBS compared to CR. So, the null hypothesis was rejected, as there were significant differences between the two main groups and subgroups.

It is difficult to specify a minimum value for bond strength after a repair but a reference value of 18–29 MPa can be found in the literature.[14] The bond strength values measured in this study seem very low (μTBS of GI repair ranged from 1.0 to 3.2 MPA and μTBS of CR ranged from 1.6 to 6.1 MPa), but Maneenut et al.[3] also reported that RMGI-to-RMGI repair shear bond strengths ranged from 0.61 to 2.89 MPa.

In the present study, adhesive failures appeared much more frequent than cohesive failures (85%) and all cohesive failures were observed in the substrate. Similarly, Pamir et al.[51] reported that when the CR was bonded to the conventional GI, the adhesive failure was observed. In the study, the failure mode of fresh GH to old GH was mostly adhesive, regardless of the surface treatment. This was also observed in SEM evaluations.

Within the limitation of this study, the results suggest that repair of GH restorative material with CR would appear much more successful; however, future studies are warranted.


   Conclusion Top


Based on this laboratory study, although the μTBS values seem to be low, repair of restorative GH with CR provided higher μTBS values compared to repair with the same material (GH). The findings of this study may show a positive clinical outcome that involves the repair of restorative GIs as permanent restorative material.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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