See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/26263227

Influence of Cavity Lining and Remaining Dentin Thickness on the Occurrence

of Postoperative Hypersensitivity of Composite Restorations

Article  in  The journal of adhesive dentistry · May 2009

DOI: 10.5167/uzh-20078 · Source: PubMed

CITATIONS READS

17 1,225

6 authors, including:

Florian J Wegehaupt Annette Wiegand

University of Zurich Universitätsmedizin Göttingen
75 PUBLICATIONS   1,012 CITATIONS    195 PUBLICATIONS   5,009 CITATIONS   

SEE PROFILE SEE PROFILE

Thomas Attin
University of Zurich
557 PUBLICATIONS   12,968 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Molecular analysis of dentinal fluid View project

The dental biofilm matrix View project

All content following this page was uploaded by Annette Wiegand on 29 May 2014.

The user has requested enhancement of the downloaded file.

 pyrig
No Co

ht
t fo
rP

by N
ub

Q ui
lica
Influence of Cavity Lining and Remaining Dentin t tio
ess c e n
ot

n
fo r
Thickness on the Occurrence of Postoperative en

Hypersensitivity of Composite Restorations

Florian Wegehaupta/Herbert Betkeb/Nicole Sollochc/Ulrike Muscha,b/Annette Wieganda,b/
Thomas Attind,e

Purpose: To investigate the influence of the remaining dentin thickness after cavity preparation, calcium hydroxide
lining, and two restorative systems on the occurrence of postoperative pain or hypersensitivity.

Materials and Methods: One hundred twenty-three fillings were placed in 123 healthy patients. The remaining
dentin thickness after caries excavation was measured with the Prepometer device at the deepest area of the cavity.
The cavities were allocated to three different groups (shallow, medium, and deep) on the basis of the Prepometer re-
sults. The decision to use a calcium hydroxide liner or not was made by tossing a coin. Cavities which were to be later
treated with an indirect restoration were restored with a buildup material. The other cavities were treated with a hy-
brid composite. After 6 months, the patients were re-examined and interviewed concerning postoperative pain inci-
dents or hypersensitivity. A logistic regression was performed for the statistical analysis.

Results: Logistic regression showed no statistically significant influence of any of the three different variables “cavity
depth”, “calcium hydroxide liner” and “restorative material” on the occurrence of pain or hypersensitivity.

Conclusion: The occurrence of pain or hypersensitivity does not depend on the remaining dentin thickness, calcium
hydroxide lining, or the restorative system used in the present study.

Keywords: dentin thickness, calcium hydroxide liner, postoperative pain, hypersensitivity, composite, adhesive.

J Adhes Dent 2009; 11: 137-141. Submitted for publication: 14.12.07; accepted for publication: 05.03.08.

I n the last 50 years, different studies have shown that

caries-linked dental hard tissue loss is directly related to
the presence and fermentation processes of oral bacte-
ria.15,25 The aim of caries treatment is the removal of bac-
teria and softened hard tissue. When caries has progressed
a Assistant Professor, Clinic for Preventive Dentistry, Periodontology and Cariol-
ogy, University of Zürich, Zürich, Switzerland.
b Assistant Professor, Department of Operative Dentistry, Preventive Dentistry
and Periodontology, Georg August University of Göttingen, Göttingen, Ger-
many.
c Dentist in Private Practice; Department of Operative Dentistry, Preventive
Dentistry and Periodontology, Georg August University of Göttingen, Göttin-
gen, Germany.
d Professor, Department of Operative Dentistry, Preventive Dentistry and Peri-
odontology, Georg August University of Göttingen, Göttingen, Germany.
e Professor and Chair, Clinic for Preventive Dentistry, Periodontology and Cari-
ology, University of Zürich, Zürich, Switzerland.
Correspondence: Dr. F. Wegehaupt, Clinic for Preventive Dentistry, Periodontol-
ogy and Cariology, University of Zürich, Plattenstr. 11, CH-8032 Zürich,
Switzerland. Tel: +41-44-634-3439, Fax: +41-44-634-4308. e-mail:
florian.wegehaupt@zzmk.uzh.ch
into deep dentin areas, the remaining dentin thickness af-
ter excavation can be distinctly reduced. The remaining
dentin thickness estimated to be necessary for protection of
the dental pulp against injury or inflammation has changed
over the years. Stanley31 suggested that the remaining
dentin under the cavity preparation should be at least 2 mm
thick to guarantee protection of the pulp. Other investiga-
tions found a minimum thickness of 1 mm or even 0.5 mm
to be necessary for pulp protection.21,26 During treatment,
it is often difficult for the dentist to decide how much dentin
is left over the pulp. The dentist can perform only a rough es-
timation of the remaining dentin thickness, since the vari-
ability of different teeth and different calcification degrees
of the pulp chambers render a clear estimation difficult.22,28
Hypersensitivity after adhesive restorations is observed
with a frequency of 5% to 26%.5 This phenomenon might
be caused by penetration of components of the adhesive
systems into the pulp, or by micro-/nanoleakage, allowing
movement of the dentin liquid in those dentin areas where
optimal adhesion and sealing of the dentin was not ac-
complished. It can also be speculated that parts of the ad-
hesive systems might enter the pulp via a thin dentin

Vol 11, No 2, 2009 137

 pyrig
No Co

ht
t fo
Wegehaupt et al rP

by N
ub

Q ui
lica
Table 1 Application protocols for the two kinds of adhesives and restorative materi- tio
als used in the study te n ot

n
ss e n c e fo r
Definitive filling: Buildup filling:
Prime & Bond NT and Spectrum Clearfil Liner Bond 2V and LuxaCore

Enamel etching for 40 s, dentin etching Mixing primer liquid A+B

for 20 s with 37% phosphoric acid
↓ ↓
Rinsing with water for 30 s and Application of the primer liquid mixture for
gently drying with oil-free air 30 s on the cavity surface
↓ ↓
Application of Prime&Bond NT Gentle air drying for 30 s
on the cavity surface for 20 s ↓
↓ Mixing bond liquid A+B
Gentle air drying for 5 s ↓
↓ Application of the bond liquid mixture on
Light curing of the adhesive for 20 s the cavity surface and gentle air drying
↓ ↓
Application of small increments Light curing for 20 s
of Spectrum ↓
↓
Light curing of the composite for 20 s Filling of cavities with LuxaCore in bulk technique
each increment

bridge,29,36 thus provoking some postoperative pain sen-
sations. To avoid penetration of components of adhesive
systems into the pulp, a calcium hydroxide liner can be
placed onto the dentin at the deepest points of the cavity.
This procedure was previously recommended especially
for nonadhesive restoration and was referred to as indirect
pulp capping. Thus, a calcium hydroxide liner may prove
effective in reducing postoperative hypersensitivity occur-
ring after application of an adhesive restoration.
Various formulations of calcium hydroxide have been in-
vestigated over the years. 4,30 Calcium hydroxide has
demonstrated its potential for inducing pulp healing and
dentin bridging. Despite a certain degree of controversy,
some recent studies have also reported the possibility of
pulp healing and dentin bridging by the use of adhesive
systems for pulp capping.1,10
Thus, the aim of the present study was to identify the
influence of the use of a calcium hydroxide liner in cavities
with different remaining dentin thicknesses and two differ-
ent adhesive restorative materials on the occurrence of
pain or postoperative hypersensitivity.
MATERIALS AND METHODS
Approval (No. 5/11/02) was issued prior to the study by
the Ethics Committee of the University of Göttingen. A total
of 123 fillings was placed in 123 patients, after they
signed an informed consent form prior to their participa-
tion in the study. Exclusion criteria were: patients under 18
years, pregnancy, breastfeeding, immunosuppressed or
addicted patients.
Only teeth fulfilling the following criteria were included
in the study: caries media or caries profunda (according to
bitewing radiographs), insufficient fillings, positive reaction
to a vitality test (cold test), no signs of pulp inflammation,
no spontaneous pain attacks before treatment, only pre-
molars and molars, only one filling per tooth, and a mini-
mum extension of the cavity of 1 mm in width. This cavity
size was necessary, since the probe of the Prepometer de-
vice (Hager & Werken; Duisburg, Germany) described
below has a diameter of 1 mm.
Treatment was performed under local anesthesia (Ultra-
cain D-S, Hoechst Marion Roussel Deutschland; Frankfurt
am Main, Germany) and the use of rubber-dam. Caries re-
moval was performed with tungsten burs until CariesDe-
tector (Kuraray Dental; Frankfurt am Main, Germany)
induced no further staining of the cavity. After total caries
removal, the cavity was rinsed with 0.2% chlorhexidine so-
lution.
After cavity preparation, the remaining dentin thickness
in the deepest cavity area was measured with a remaining
dentin thickness measuring device, hereafter referred to
as RDTMD (Prepometer, Hager & Werken). Before measur-
ing, the RDTMD was calibrated by touching the dentin sur-
face with the calibration and sensor electrode at the same
time. During measurement, the reference electrode was
placed in the buccal vestibule. For measuring the remain-
ing dentin thickness, the sensor electrode was gently
moved over the cavity floor.

138 The Journal of Adhesive Dentistry

 pyrig
No Co

ht
t fo
r P et al
Wegehaupt

by N
ub

Q ui
lica
Table 2 Number of teeth according to allocation to the different cavity depth groups, the use of tio
calcium hydroxide liner, and the kind of restorative material te n ot

n
ss e n c e fo r
Calcium hydroxide liner Restorative material Cavity depth group
shallow medium deep

Yes buildup 6 8 9
definitive filling 14 21 17
No buildup 5 5 7
definitive filling 16 5 10

Table 3 Percentages (absolute number) of pain incidence or hypersensitivity of the buildup and defini-
tive restorations placed in either shallow, medium or deep cavities after use of a calcium hydroxide lin-
ing or not

Calcium hydroxide liner Restorative material Cavity depth group

shallow medium deep

yes buildup 17% (1) 0% (0) 11% (1)

definitive filling 14% (2) 14% (3) 11% (2)
no buildup 40% (2) 0% (0) 29% (2)
definitive filling 13% (2) 40% (2) 40% (4)

On the basis of the RDTMD results, the cavities were di-
vided into three different groups (shallow, medium, or
deep cavity) of 40 teeth each. Cavities with RDTMD scores
1 to 5 (1.5 to 3.0 mm, green or yellow LEDs) were allo-
cated to group “shallow”, cavity scores 6 and 7 (0.9 to 1.5
mm, orange LEDs) were allocated to group “medium”, and
with results 8 to 10 (< 0.9 mm, red LEDs) to group “deep”.
In each group, cavities were treated either with or without
use of calcium hydroxide liner (Kerr Life, KerrHawe; Biog-
gio, Switzerland). The decision to use a calcium hydroxide
liner or not was made by tossing a coin. This resulted in
20 liners being placed in the shallow group, 29 in the
medium-depth group, and 26 in the group of deep cavities
(Table 2).
To make the calcium hydroxide liner, a small drop of
Kerr Life was placed on the deepest part of the cavity and
allowed to set until its surface was hard upon probing.
The restoration of the teeth was performed either with a
buildup composite (n = 40) (LuxaCore, DMG; Hamburg,
Germany) or a hybrid composite (n = 83) (Spectrum,
Dentsply DeTrey; Konstanz, Germany). For the buildup
composite restorations, a self-etching nonrinse adhesive
system was used (Clearfil Liner Bond 2V, Kuraray Dental).
The buildup composite was used when a large amount of
dental hard tissue was lost and an indirect restoration was
required (crown or partial crown) later to stabilize the in-
tegrity of the tooth or when the cervical margin was lo-
cated subgingivally. An etch-and-rinse adhesive
(Prime&Bond NT, Dentsply) was used in the remaining cav-
ities that were restored with the hybrid composite Spec-
trum. These were Class I and II restorations (O, OM/OD,
and MOD) with the cervical margin located para- or
supragingivally. During the restoration, steel matrices were
used and fixed with wooden wedges. The hybrid composite
for the definitive restorations was applied in the cavities in
small horizontal increments with a maximum height of 1
mm. Application protocols for the two kinds of adhesives
and restorative materials are given in Table 1.
The patients were not told to which cavity-depth group
their tooth was allocated and if calcium hydroxide was
used or not. The patients were asked to record whether
any hypersensitivity, pain, or discomfort occurred following
treatment.
During a second appointment 6 months later, the pa-
tients were re-examined by one dentist evaluating the fol-
lowing criteria:
• Vitality test (yes/no): vitality testing was performed with
a cold foam pellet pressed on the buccal surface of the
tooth. The patients were asked to report whether they
felt the cold.
• Occurrence of hypersensitivity (yes/no): the patients
were asked if they had noticed any pain, hypersensitiv-
ity, or discomfort in the teeth after the application of
the filling.
Reacting negative to the vitality test and reported pain
or hypersensitivity were ranked as failure.
To evaluate the influence of the three different vari-
ables “cavity depth”, “calcium hydroxide liner”, and “resto-

Vol 11, No 2, 2009 139


Wegehaupt et al
ration material” a logistic regression was carried out. The
significance level was set at p ≤ 0.05.
The allocation of the tooth to the cavity groups, use of
calcium hydroxide lining, and the kind of restorative mater-
ial is shown in Table 2.
RESULTS
All patients were re-examined after 6 months; all 123 fill-
ings were still in situ. No fractures or any other distinctive
features were visible in the clinical examination. All teeth
exhibited a positive reaction in the vitality test. Percentage
distribution of pain incidents or hypersensitivity according
to the cavity groups, calcium hydroxide lining use, and the
kind of restorative material are shown in Table 3.
The logistic regression showed no statistically signifi-
cant influence of any of the three different variables “cav-
ity depth” (p = 0.65), “calcium hydroxide liner” (p = 0.086),
and “restoration material” (p = 0.71) on the occurrence of
pain or hypersensitivity.
DISCUSSION
The present study aimed to investigate the influence of dif-
ferent thickness of remaining dentin on pain occurrence of
adhesively luted restorations under in vivo conditions.
Since the treated teeth were not extracted afterwards, no
histological examination was possible to determine dentin
thickness. Thus, for determining dentin thickness and to
allow the allocation of the teeth to different categories of
remaining dentin thickness, the RDTMD was used. The
measurement with the RDTMD depends on the electrical
resistance of the dentin.14
Studies performing histological examination of restored
teeth mostly use teeth planned to be extracted for ortho-
dontic reasons.6,21 This procedure has the disadvantage
that these teeth are often free of caries, thus not mirroring
the usual clinical situation. An advantage of using the
RDTMD in the present study was that teeth with clinically
common carious lesions could be included in the study.
However, the use of the RDTMD for allocation of the teeth
to different categories of remaining dentin thickness is a
topic of some discussion. Gente13 observed a higher elec-
trical resistance with longer dentin tubules and greater
remaining dentin thickness. 12,14 The same author 13
reported the remaining dentin thickness as being 2.1 to
3.0 mm for the green LEDs, 1.5 to 2.1 mm for the yellow
LEDs, 0.9 to 1.5 mm for the orange LEDs, and less than
0.9 mm for the red LEDs. Thus, our definition of shallow,
medium, and deep corresponds to 1.5 to 3.0 mm, 0.9 to
1.5 mm, and less than 0.9 mm remaining dentin thick-
ness, respectively. In contrast, Tielemans et al32 found the
use of RDTMD to be reproducible, but in their study, the
electrical resistance showed no statistically significant cor-
relation with the histologically determined dentin
thickness. It should be mentioned that in the study by
Tielemans et al,32 only two patients with a total of 12
teeth were examined. Moreover, the present study using
140
pyrig
No Co
ht
t fo
rP
by N
ub
Q ui
li
the RDTMD was started before the discrepant findingsca byti
the contradic- n
Tielemans et al32 were published. To clarifyt e
ot o
n
ss e n c ein
tory findings regarding the RDTMD, a comprehensive
fo r
vivo study with an appropriate number of test teeth must
be performed.
In the present study, two different kinds of restorative
materials were used to reflect different treatment require-
ments. The definitive fillings were made with the hybrid
composite in an incremental technique. This material has
shown good clinical performance in various previous clini-
cal studies.18,27,33,34 The buildup composite in combina-
tion with the self-etching adhesive system was applied in
bulk in the cavities with greater extension. This procedure
presents a fast, economical, and less technique-sensitive
approach, and is often used to build up teeth prior to indi-
rect restorations.
The overall occurrence of postoperative pain in the pre-
sent study amounted to 17%. This corresponds well with
the findings of another recent study,5 showing postopera-
tive pain incidence of 5% to 26% after adhesive restora-
tions with different cavity sizes.
Our finding that there was no statistically significant in-
fluence of use of a calcium hydroxide liner on hypersensi-
tivity corresponded with the results of Whitworth et al.35
They also found no difference in the protection of the pulp
by calcium hydroxide lining or conditioning and sealing
with adhesive resins only. This might be explained with the
precipitation of crystalline salts in the dentin tubules after
the use of calcium hydroxide liner19 or the sealing of the
dentin with light- or self-curing resin after the use of a hy-
drophilic adhesive, creating a continuous resin-dentin hy-
brid layer.23 Both may lead to a reduction of the dentin
permeability for potential cytotoxic components of restora-
tive materials or bacteria,8 thus protecting the pulp tissue.
Moreover, with respect to the hydrodynamic theory of
Brännström,3 which states that movement of dentinal liq-
uid is responsible for hypersensitivity, both precipitation of
calcium salts and formation of the hybrid layer might be
able to counteract hypersensitivity.
In the present study, no statistically significant influ-
ence of the cavity depth on the occurrence of pain was ob-
served. Murray et al 21 also did not find the remaining
dentin thickness to be statistically correlated to signs of
pulp inflammation as histologically proven. In contrast,
Whitworth et al35 estimated the residual dentin thickness
to be a key determinant for the pulp reaction. It should be
mentioned that in that study,35 teeth with pulp exposure
were also included in the group of deep cavities; further-
more, there was no requirement for the dentists to use
rubber-dam during treatment. The use of rubber-dam
might have an impact on the pulp response after cavity
preparation, as shown by Camps et al6, who found remain-
ing dentin thickness to be of only minor importance in the
reaction of the pulp, as compared to bacteria left in the
cavity prior to filling. It might be assumed that lesser
amounts of bacteria are still present on the cavity walls
when rubber-dam is used during treatment.
The effect of restorative materials on the vitality of the
pulp and the occurrence of postoperative pain is a con-
tentious issue in the literature.9,16,24,37 In the present
The Journal of Adhesive Dentistry

study, no statistically significant influence of the restora-
tive material was found. This finding agrees with prior find-
ings that even a thin layer of residual dentin may protect
the pulp against both material and bonding system toxic-
ity,2,20 so that different restorative materials or adhesives
will not have a significant influence on the pulp tissue.24
Cox7 also showed the restorative materials to have a mini-
mal influence on postoperative pulp reactions. In contrast
to these findings, a recent study by Whitworth et al35 ob-
served a correlation between restorative materials and
pulp breakdown only in the deep cavities and cavities with
pulp exposure. This finding may be explained with previous
investigations which showed that odontoblasts are already
injured by cavity preparations with a depth close to or into
the pulp tissue,11,17 which may lead to pulp inflammation
and pulp breakdown.
We suggest that the layer formed by the adhesive sys-
tems acts as a barrier to filling material contents reaching
the pulp. Similar to our finding that the materials used
here had no influence on the pulp vitality, Nayyar et al24
also observed no difference in the pulp response between
a self-etching adhesive and an etch-and-rinse adhesive.
CONCLUSION
The results of the present study showed that neither the
thickness of the remaining dentin, the use of calcium hy-
droxide liner, nor the adhesive and restorative system
used in the study have an impact on the incidence of post-
operative pain.
REFERENCES
1. Akimoto N, Momoi Y, Kohno A, Suzuki S, Otsuki M, Suzuki S, Cox CF. Bio-
compatibility of Clearfil Liner Bond 2 and Clearfil AP-X system on nonex-
posed and exposed primate teeth. Quintessence Int 1998;29:177-188.
2. Bergenholtz G. Evidence for bacterial causation of adverse pulpal re-
sponses in resin-based dental restorations. Crit Rev Oral Biol Med
2000;11:467-480.
3. Brännström M, Linden LA, Astrom A. The hydrodynamics of the dental
tubule and of pulp fluid. A discussion of its significance in relation to denti-
nal sensitivity. Caries Res 1967;1:310-317.
4. Brännström M, Nordenvall KJ. Bacterial penetration, pulpal reaction and
the inner surface of Concise enamel bond. Composite fillings in etched
and unetched cavities. J Dent Res 1978;57:3-10.
5. Briso ALF, Mestrener SR, Delicio G, Sundfeld RH, Bedran-Russo AK. Clini-
cal assessment of postoperative sensitivity in posterior composite restora-
tions. Oper Dent 2007;32:421-426.
6. Camps J, Dejou J, Remusat M, About I. Factors influencing pulpal response
to cavity restorations. Dent Mater 2000;16:432-440.
7. Cox CF. Effects of adhesive resins and various dental cements on the pulp.
Oper Dent 1992;(suppl 5):165-176.
8. Cox CF. Evaluation and treatment of bacterial microleakage. Am J Dent
1994;7:293-295.
9. Cox CF, Felton D, Bergenholtz G. Histopathological response of infected
cavities treated with Gluma and Scotchbond dentin bonding agents. Am J
Dent 1988;1(special issue):189-194.
10 . Cox CF, Hafez AA, Akimoto N, Otsuki M, Suzuki S, Tarim B. Biocompatibility
of primer, adhesive and resin composite systems on non-exposed and ex-
posed pulps of non-human primate teeth. Am J Dent 1998;11(special
issue):S55-63.
11. Darvell BW. Effect of dentine thickness on pulpal changes beneath restora-
tive materials. Aust Dent J 1981;26:80-81.
12. Gente M. Begrenzung der Präparationstiefe durch elektrische Widerstands-
messungen. Dtsch Zahnarztl Z 1995;50:658-660.
Vol 11, No 2, 2009
pyrig
No Co
ht
t fo
r P et al
Wegehaupt
by N
ub
Q ui
13. Gente M. Untersuchung zur Begrenzung der Präparationstiefe bei der Kro-
lica
nenpräparation durch elektrische Widerstandsmessung. Marburg, Ger- tio
te ot n
n
many: Thesis, 1992
14. s s
fo r c e
e nof the
Gente M, Becker-Detert D. Studies on the specific electric resistance
dentin of human teeth [in German]. Dtsch Zahnarztl Z 1991;46:803-806.
15. Keyes PH. The infectious and transmissible nature of experimental dental
caries. Findings and implications. Arch Oral Biol 1960;1:304-320.
16. Koliniotou-Koumpia E, Papadimitriou S, Tziafas D. Pulpal responses after
application of current adhesive systems to deep cavities. Clin Oral Investig
2007;11:313-320.
17. Lee SJ, Walton RE, Osborne JW. Pulp response to bases and cavity depths.
Am J Dent 1992;5:64-68.
18. Loguercio AD, Reis A, Hernandez PA, Macedo RP, Busato AL. 3-Year clinical
evaluation of posterior packable composite resin restorations. J Oral Reha-
bil 2006;33:144-151.
19. Mjör IA, Ferrari M. Pulp-dentin biology in restorative dentistry. Part 6: Reac-
tions to restorative materials, tooth-restoration interfaces, and adhesive
techniques. Quintessence Int 2002;33:35-63.
20. Murray PE, Hafez AA, Smith AJ, Cox CF. Bacterial microleakage and pulp in-
flammation associated with various restorative materials. Dent Mater
2002;18:470-478.
21. Murray PE, Smith AJ, Windsor LJ, Mjör IA. Remaining dentine thickness
and human pulp responses. Int Endod J 2003;36:33-43.
22. Murray PE, Stanley HR, Matthews JB, Sloan AJ, Smith AJ. Age-related odon-
tometric changes of human teeth. Oral Surg Oral Med Oral Pathol Oral Ra-
diol Endod 2002;93:474-482.
23. Nakabayashi N. Importance of mini-dumbbell specimen to access tensile
strength of restored dentine: historical background and the future perspec-
tive in dentistry. J Dent 2004;32:431-442.
24. Nayyar S, Tewari S, Arora B. Comparison of human pulp response to total-
etch and self-etch bonding agents. Oral Surg Oral Med Oral Pathol Oral Ra-
diol Endod 2007;104:45-52.
25. Orland FJ, Blayney JR, Harrison RW, Reyniers JA, Trexler PC, Ervin RF, Gor-
don HA, Wagner M. Experimental caries in germfree rats inoculated with
enterococci. J Am Dent Assoc 1955;50:259-272.
26. Pameijer CH, Stanley HR, Ecker G. Biocompatibility of a glass ionomer lut-
ing agent. 2. Crown cementation. Am J Dent 1991;4:134-141.
27. Perry RD, Kugel G, Habib CM, McGarry P, Settembrini L. A two-year clinical
evaluation of TPH for restoration of Class II carious lesions in permanent
teeth. Gen Dent 1997;45:344-349.
28. Polansky R, Reichhold C, Lorenzoni M. Die Topographie der Pulpa im
Seitenzahnbereich nach Stufenpräparation für Vollkeramische Kronen.
Eine experimentelle Untersuchung. Dtsch Zahnarztl Z 1998;53:643-647.
29. Schmalz G, Hiller KA, Nunez LJ, Stoll J, Weis K. Permeability characteristics
of bovine and human dentin under different pretreatment conditions. J
Endod 2001;27:23-30.
30. Snuggs HM, Cox CF, Powell CS, White KC. Pulpal healing and dentinal
bridge formation in an acidic environment. Quintessence Int 1993;24:501-
510.
31. Stanley HR. Dental iatrogenesis. Int Dent J 1994;44:3-18.
32. Tielemans S, Bergmans L, Duyck J, Naert I. Evaluation of a preparation
depth controlling device: a pilot study. Quintessence Int 2007;38:135-142.
33. Türkün LS, Aktener BO. Twenty-four-month clinical evaluation of different
posterior composite resin materials. J Am Dent Assoc 2001;132:196-203.
34. Wendt SLJ, Leinfelder KF. Clinical evaluation of a posterior resin compos-
ite: 3-year results. Am J Dent 1994;7:207-211.
35. Whitworth JM, Myers PM, Smith J, Walls AW, McCabe JF. Endodontic com-
plications after plastic restorations in general practice. Int Endod J
2005;38:409-416.
36. Wiegand A, Caspar C, Becker K, Werner C, Attin T. In vitro cytotoxicity of dif-
ferent self-etching dental adhesive systems. Schweiz Monatsschr Zahn-
med 2006;116:614-621.
37. Wisithphrom K, Murray PE, About I, Windsor LJ. Interactions between cavity
preparation and restoration events and their effects on pulp vitality. Int J
Periodontics Restorative Dent 2006;26:596-605.
Clinical relevance: Neither the thickness of the remain-
ing dentin, the use of calcium hydroxide liner, or the ad-
hesive and restorative systems have an impact on the
incidence of postoperative pain.
141
View publication stats