NANO EN INDIRECTAS - PDF
NANO EN INDIRECTAS - PDF
NANO EN INDIRECTAS - PDF
Department of Operative Dentistry, School of Dentistry, Selcuk University, 42100 Selcuklu/Konya, Turkey
Corresponding author, Ali Riza CETIN; E-mail: alirizacetin@selcuk.edu.tr
The aim of this study was to assess the clinical performance of three direct composite resins and two indirect inlay systems in
posterior teeth using the modified USPHS criteria. A total of 100 restorations were placed in the molars of 54 patients by one
operator. All restorations were directly evaluated by two examiners at baseline, 6 months, and 12 months. Statistical analysis was
conducted using McNemar chi-square test at a significance level of 5% (p<0.05). Recall rate was 100% at 6 and 12 months, and all
the restorations evaluated (i.e., 100%) received Alpha rating for the criteria of retention and gingival adaptation. At 12 months for
the surface texture criterion, 80% of Filtek Supreme XT received Alpha rating while it was 95% for Tetric EvoCeram and AELITE
Aesthetic. For marginal discoloration, 85% of Tescera ATL and Filtek Supreme XT received Alpha rating while it was 95% for Tetric
EvoCeram and AELITE Aesthetic. Further, none of the restorative systems received a Charlie rating for any of the criteria at all
evaluation periods. In summary, all the restorations demonstrated clinically satisfactory performance with no significant differences
detected among them.
the upper arch. Their distributions in terms of location (Life, KerrHawe, Switzerland) was placed at the pulpal
and cavity type are summarized in Tables 1 and 2 and axial walls. Following which, a light-polymerized
respectively. All teeth were in occlusion and had at glass ionomer cement base (Fuji II LC, GC, USA) was
least one proximal contact with an adjacent tooth. placed to eliminate undercuts in deep areas of the
cavities and to replace lost dentin. Location of cervical
Restorative materials margins above or below the cementoenamel junction
Three nanofilled composite restorative systems (Filtek was documented after preparation. Complete arch
Supreme XT (FS), 3M ESPE; Tetric EvoCeram (TEC), impressions were taken with a C-silicone impression
Ivoclar Vivadent; AELITE Aesthetic (AA), Bisco) and material (Zetaplus, Zhermack, Italy). Provisional
two indirect inlay restorative systems (Estenia (E), restorations were placed with an eugenol-free, light-
Kuraray; Tescera ATL (TATL), Bisco) were used in this curing temporary restorative material (Systemp inlay,
study. Their compositions were summarized in Table Ivoclar Vivadent, Liechtenstein). One laboratory
3. technician of the School of Dentistry prepared all the
inlays following the manufacturers’ instructions.
Clinical procedure for indirect composite inlays The E inlays were built up in layers of 2.5 mm
All cavities were prepared according to the common maximally, and each layer was polymerized from the
principles for adhesive inlays. To achieve convergence occlusal direction for 120–180 seconds with a curing
angles between opposing walls at an estimated 10 to 12 unit (Hilux Expert, Benlioğlu Dental, Turkey). After
degrees, cavities were prepared with slightly tapered the composite inlays were removed from the stone
80-μm grit diamond bur and finished with 25-μm grit model, they were postcured in a light oven (CS-110
diamond bur (KG Sorensen, Brazil) under water Light and Heat Curing System, Kuraray, Japan) for
cooling. Care was taken to minimize increase in cavity 180 seconds and then in a heat oven for 10 minutes at
extension. The cavities were prepared with rounded 114°C to improve the physical properties. As for the
inner line angles and to a depth allowing at least 2 mm polymerization unit provided for TATL inlays (Tescera
of resin material at the occlusal contact area. All ATL™ Processing Unit, Bisco, USA), it comprised two
undercuts were eliminated. specialized cups (one for pressure/light and one for
Before placement of inlay liner, each tooth was water/pressure/light/heat). TATL inlays were built up
isolated with cotton rolls and a saliva suction device. in one increment and polymerized on the stone model
In most cases, a thin layer of calcium hydroxide liner in the light polymerization cup for 5 minutes. The
inlays were then removed from the stone model, and in a rubber cup to remove salivary pellicle and any
composite inlays were postcured in the heat cup remaining dental plaque. The cavity was opened (or
submerged in water at a temperature of 120°C and the existing restoration was removed) using a pear-
under a pressure of 6 bar. shaped diamond bur (Jota AG, Switzerland) on a high-
The processed inlays were adjusted as needed and speed air turbine. Caries was removed by low-speed
seated on the master model, and then polished with metal burs (Meisinger, Germany) and hand
silicone polisher, brushes, and polishing paste. After a instruments, leaving discolored but hard dentin at the
clinical tryout, the inner surfaces of the inlays were cavity floor. Cavities were prepared according to the
etched with 37% phosphoric acid. All inlays were principles of minimally invasive dentistry.
definitively inserted within 1 week after the Tooth isolation by means of cotton rolls and a
impressions were made. The bonding of all restorations saliva suction device was used for each patient. All
was performed in a dry working field using cotton rolls cavities were restored using a sectional metal matrix
and a saliva suction device, but without a rubber dam. (Contact Matrix, Palodent, USA) which was fixed with
The E inlays were cemented with a dual-cure resin a ring and wooden wedges (Kerr, Switzerland), and
cement, Panavia F (Kuraray, Japan); similarly, the which was inserted with firm pressure. For all the
TATL inlays were also cemented with a dual-cure resin direct composites, the bonding procedure began with
cement, Duo-Link (Bisco, USA). The inserted applying freshly mixed self-etch primer (Clearfil SE
restorations were finished with 40-μm grit and 15-μm Primer, Kuraray, Japan) for 20 seconds to the cavity
grit diamond burs (Jota AG, Switzerland), polishing walls, and then dried with gentle air-drying for 5
disks and strips (Sof-Lex, 3M ESPE, USA), and a seconds. Bonding agent (Clearfil SE Bond, Kuraray,
composite polishing kit (Enhance, Dentsply, Milford, Japan) was applied with a microbrush and polymerized
USA). for 10 seconds. After application of the self-etching
primer and bonding agent, the cavities were filled
Clinical procedure for direct composite restorations incrementally with facially and lingually inclined
First, the color of the tooth that needed treatment was mesiodistal layers of maximally 2 mm. Between each
determined using a color key. If necessary, local increment (maximally at 2 mm), polymerization was
anesthesia was administered to prevent patient performed with a halogen light-curing unit (Hilux
discomfort during the restorative procedure. The teeth Expert, Benlioğlu Dental, Turkey; tip diameter: 8 mm)
to be restored were cleaned with a pumice-water slurry for 20 seconds (TEC, AA, FS) or 40 seconds (FS dentin
used in this study was 54 patients, as well as these — could be attributed to higher wear resistance. The
steps taken to comply with the guidelines: number of latter improvement was realized because the indirect
restorations (20 per material), distribution of composite inlays were postcured in a heat oven for 10
restorations (maximum of two pairs in the same minutes. On the other hand, in a two-year clinical
patient), ratio of 1:2 for Class I to Class II restorations. evaluation of direct and indirect composite restorations
At all the evaluation periods in this study, the in posterior teeth by Scheibenbogen-Fuchsbrunner et
recall rate was 100%. Indeed, availability was still al.7), no significant differences between these two
expected to be high at other prolonged evaluation different types of posterior composite systems were
periods because majority of the subjects in this study observed.
were young adult patients with a mean age of 23 years According to the results of this study, both direct
(range: 20–28 years), and that they were selected and indirect composite resin restorations demonstrated
among the volunteers from staff and students and their excellent clinical performance whereby no restorations
families. Moreover, such an age range could provide a were rated unacceptable in any aspect of the
better performance for clinical evaluations of posterior evaluation. Similarly, in a 12-month evaluation of two
restorations because of better occlusal harmony. posterior composite restorative systems by Neto et al.18),
On the isolation of the restoration site, it could be 94.1–100% Alpha ratings were obtained for the
carried out using different methods. In some clinical evaluated criteria according to the modified USPHS
studies on posterior composites, rubber dam was used system. In another two-year clinical evaluation by
to isolate the teeth21-23), whereas Turkun24), Kohler et Türkün and Aktener31), all the posterior composite
al.25), and Pallesen and Qvist26) opted for cotton rolls restorations evaluated were also rated as excellent. In
and saliva suction device. Raskin et al.27), in a 10-year a study by Efes et al.32), all the restorative materials
evaluation of posterior composites, did not observe showed only minor changes and that no statistically
significant differences between these two isolation significant differences in their performance were
methods. detected between baseline and the follow-up evaluation
According to Mitra et al.11), the nanofilled composite at 12 months. In particular, the performance exhibited
was shown to have equivalent — if not higher — by nanofilled composite resin after 1 year was similar
mechanical properties than the hybrid composite, since to the packable and microhybrid composite resins.
the nanocomposite showed high translucency, high In the present one-year clinical study; both the
polish and polish retention similar to those of direct and indirect composite restorations were rated
microfilled composite. In other words, these composites as clinically acceptable according to the evaluation
might render satisfactory clinical performance in criteria used and that there were no statistically
posterior teeth. Moreover, laboratory-processed significant differences in performance among the tested
indirect composite resin systems are an attractive materials. On the lack of statistically significant
esthetic alternative for intracoronal posterior differences, it could be due to the multiple similarities
restorations12,13). Then, apart from posterior — in terms of chemical composition and high filler
restorations, nanofilled composites could also double as content — underlying the composites used in this study
satisfactory materials for restorations in anterior teeth. (Table 3). However, differences might emerge over
In their four-year clinical study, Geurtsen and longer periods of use. Nevertheless, better clinical
Scholer28) claimed that the most important problem in performance might be obtained using E and TATL
posterior composite restorations is marginal since they are indirect composite resins specifically
discoloration. Marginal discoloration is classified based designed for restoring posterior teeth. Furthermore, it
on the penetration of dye into the pulp. In our study, is claimed that indirect composites, when tempered
statistical analysis showed that there were no with heat and light, could have an enhanced degree of
significant differences in marginal discoloration among cure, thereby leading to improved physical properties.
the restorative materials, despite the presence of
numerical differences. Amongst which, indirect E
CONCLUSION
restorations received 100% Alpha rating for marginal
discoloration at all the evaluation periods. In a study Results of the present study showed comparable clinical
by Türkün and Çelik29), a two-year clinical evaluation performance among the five composites evaluated.
of the FS restorations yielded similar marginal After 1 year, the clinical performance of FS, TEC, and
discoloration outcome as the present study. AA showed minor changes compared to baseline. Since
After 12 months of clinical service, more indirect the clinical performance of the posterior composite
composite inlays received Alpha rating for surface restorations was evaluated as acceptable after one-year
texture as compared to the direct composite use, the tested composites could be indicated for
restorations. However, in a study by Loguercio et al.30), restorations in posterior teeth. However, it is cautioned
the nanofilled and microfilled composites showed the that a longer observation period would be expedient for
best surface appearance after 12 months. In the further confirming the clinical validity of the composite
present study, better anatomic form and surface resin systems for posterior restorations.
texture results which were obtained for the indirect
composite inlays — although not statistically significant
626 Dent Mater J 2009; 28(5): 620–626