The microleakage of composite

and compomer restorations

follow ing cavity preparation with
an Erbium-YAG Laser

Elizabeth M. Roebuck
B.D.S., F.D.S.(Paed)R.C.S.

Thesis su b m itted fo r the degree o f

M a ster o f Science (Medical Science)
to the Faculty o f Medicine
U niversity o f G lasgow

The D epartm ent of Child D ental H ealth

Glasgow Dental H ospital and School NHS T rust

Copyright'; E. M. Roebuck, October 1998

 ProQuest Number: 13815583

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Contents
List of T ab les.........................................................................................................................vii

List of Figures.......................................................................................................................viii

A bbreviations.......................................................................................................................... x

A cknow ledgem ents............................................................................................................. xii

D eclaratio n...........................................................................................................................xiii

S um m ary............................................................................................................................... xiv

1 Introduction.......................................................................................................................1

1.1 D ental caries................................................................................................................ 1

1.2 Caries: a public health concern...............................................................................1

1.3 Barriers to dental ca re ...............................................................................................3

1.4 M anaging the anxious in d iv id u al.......................................................................... 3

2 Literature R eview ............................................................................................................5

2.1 Introduction.................................................................................................................5

2.2 C om position and structure of the dental crow n................................................. 5

2.2.1 Enamel of the perm anent to o th ........................................................................ 5
2.2.1.1 The enamel p rism ............................................................................................. 6
2.2.1.2 The mineral phase of enam el ......................................................................... 6
2.2.13 The organic phase of enamel.........................................................................7
2.2.2 Dentine of the perm anent to o th ....................................................................... 8
2.2.2.1 The mineral phase of dentine ......................................................................... 8
2.2.2.2 The organic phase of dentine ....................................................................... 10
2.2.23 The dentinal tubules ....................................................................................... 11
22.2.4 Dentine permeability ...................................................................................... 11
2.2.3 D ental p u lp ..........................................................................................................12

2.3 Direct restorative m aterials.,..2...... 14

 2.3.1 Introduction..........................................................................................................14
2.3.2 D ental am algam .................................................................................................. 15
2.3.3 Com posite resin m aterials............................................................................... 16
2.3.3.1 The organic phase: resin technology .............................................................16
2.3.3.2 The dispersed phase: filler technology ......................................................... 18
2.3.3.3 The interfacial phase: coupling agents ........................................................ 24
2.3.4 Glass-ionom er cem ents......................................................................................24
2.3.5 Resin-m odified glass-ionom er cem ents........................................................ 26
2.3.6 Polyacid-m odified composite resins...............................................................27
2.3.7 The causes of restoration failure......................................................................28

2.4 M icroleakage..............................................................................................................29

2.5 ' M ethods of assessing m icroleakage...................................................................... 29

2.5.1 Introduction......................................................................................................... 29
2.5.2 Penetration of tracer m olecules.......................................................................30
2.5.2.1 Single section assessment of microleakage................................................... 30
2.5.2.2 Organic dye penetration ................................................................................32
2.5.2.3 Radioactive isotopes.......................................................................................35
2.5.2.4 Non-radioactive chemical tracers................................................................. 36
2.5.3 In vivo versus in vitro microleakage.................................................................. 37
2.5.3.1 Pulpal hydrostatic pressure .......................................................................... 38
2.5.3.2 Mechanical loading ....................................................................................... 38
2.5.3.3 Temperature change ...................................................................................... 39

2.6 M icroleakage in composite resin restorations.................................................... 39

2.7 The control of polym erisation shrinkage............................................................ 40

2.7.1 The resin com position....................................................................................... 41
2.7.1.1 The degree of polymerisation shrinkage ....................................................... 41
2.7.1.2 The degree of water absorption ..................................................................... 42
2.7.1.3 Coefficient of thermal expansion and thermal diffusivity .......................... 42
2.7.2 Restorative techniques...................................................................................... 44
2.7.2.1 Increased bonding to enamel ........................................................................ 44
2.7.2.2 Increased bonding to dentine ........................................................................ 45
2.7.2.3 The use of low viscosity resins: intermediate bonding and glazing ..........51
2.7.2.4 Altering the cavosurface angle of the restorations ......................................52
2.7.2.5 Modification of the restorative technique .................................................... 53

iii
 2.8 M icroleakage in polyacid-m odified com posite re sin s ....................................55
2.8.1 Sum m ary............................................................................................................. 56

2.9 Cavity p re p a ra tio n .................................................................................................. 56

2.9.1 C onventional cavity p re p a ra tio n .................................................................. 57
2.9.2 A lternative techniques for cavity p re p a ra tio n ............................................58

2.10 Lasers in d e n tistry ....................................................................................................59

2.10.1 Introduction........................................................................................................59
2.10.2 Lasers as optical 'd rills'....................................................................................60
2.10.3 M echanism of laser-tissue interactions....................................................... 62
2.10.3.1 Introduction ....................................................................................................62
2.10.3.2 Interaction of absorbed light with the dental hard tissues ..........................63
2.10.3.3 Thermal interactions ...................................................................................... 63
2.10.3.4 Non-linear processes ..................................................................................... 63
2.10.3.5 Thermomechanical processes......................................................................... 65
2.10.3.6 Laser parameters............................................................................................. 65
2.10.3.7 Optical and tissue parameters ....................................................................... 66
2.10.4 The early h ard tissue dental lasers................................................................67
2.10.5 The new generation of la se rs......................................................................... 68
2.10.6 The Erbium:YAG laser.....................................................................................70
2.10.6.1 Introduction ....................................................................................................70
2.10.6.2 Ablation ........................................................................................................... 71
2.10.6.3 Morphology .....................................................................................................74
2.10.6.4 Temperature ....................................................................................................75
2.10.6.5 Long-term pulp reaction.................................................................................76
2.10.6.6 Patient acceptance.......................................................................................... 76
2.10.6.7 Microleakage....................................................................................................77

2.11 General su m m ary ....................................................................................................81

2.12 Aims and objectives............................................................................................... 81

3 M aterials and m eth o d ................................................................................................... 82

3.1 M aterials................................................................................................................... 82
3.1.1 Z100.....................................................................................................................82
3.1.2 Scotchbond M ulti-Purpose............................................................................. 82
3.1.3 C om poglass....................................................................................................... 84

iv
 3.1.4 C om poglass Single C om ponent A d h esiv e.................................................85

3.2 M e th o d ........................................................................................................................85
3.2.1 Tooth selection.................................................................................................. 85
3.2.2 Cavity p re p a ra tio n ...........................................................................................85
3.2.2.1 Laser parameters............................................................................................ 88
3.2.3 Cavity resto ratio n .............................................................................................88
3.2.4 Storage and therm ocycling............................................................................ 91
3.2.5 M icroleakage assessm ent............................................................................... 91
3.2.6 Statistical analysis.............................................................................................93

4 R esu lts.............................................................................................................................. 98

4.1 In troduction............................................................................................................... 98

4.2 Enamel m a rg in s........................................................................................................98

4.2.1 C onventionally-prepared enam el m argins.................................................98
4.2.1.1 Within-group analyses ..................................................................................98
4.2.1.2 Intergroup analyses .......................................................................................98
4.2.2 Lased enam el m arg in s................................................................................... 100
4.2.2.1 Within-group analyses ............................................................................... 100
4.22.2 Intergroup analyses .................................................................................... 103
4.2.3 C onventionally-prepared versus lased enam el m arg in s....................... 103

4.3 D entine m a rg in s .................................................................................................... 106

4.3.1 C onventionally-prepared dentine m arg in s..............................................106
4.3.1.1 Within-group analyses ............................................................................... 106
4.3.1.2 Intergroup analyses .................................................................................... 106
4.3.2 Lased dentine m argins.................................................................................. 106
4.3.2.1 W ithin-group analyses ............................................................................... 106
4.32.2 Inter group analyses .................................................................................... 109
4.3.3 C onventionally-prepared versus lased dentine m argins....................... 109

4.4 Enamel versus den tin e........................................................................................... 112

4.4.1 C onventionally-prepared m argins............................................................. 112
4.4.2 Lased m arg in s.................................................................................................112

4.5 Sum m ary.................................................................................................................. 115

5 D iscussion......................................................................................................................117

v
 5.1 Intro d u ctio n ............................................................................................................ 117

5.2 M eth o d o lo g y.......................................................................................................... 117

5.3 O utline of d isc u ssio n ........................................................................................... 119

5.4 The en am el/resto ratio n in terface..................................................................... 120

5.4.1 C onventionally-prepared enam el m argins............................................... 120
5.4.2 The influence of the Er:YAG laser on the enam el
cav ity /re sto ratio n interface.......................................................................... 123

5.5 The d e n tin e /re sto ratio n interface..................................................................... 126

5.5.1 C onventionally-prepared dentine m arg in s...............................................126
5.5.2 The influence of the Er:YAG laser on the dentine cavity
re sto ratio n /in terface...................................................................................... 130

5.6 C o nclusions............................................................................................................ 132

6 Future re se arch ............................................................................................................134

B ibliography........................................................................................................................ 137

vi
List of Tables
Table 2.1 Classification of coronal dentine by location, patterns o f mineralisation and
development ........................................................................................................................ 9
Table 2.2 Chemical versus light curing ................................................................................ 19
Table 2.3 Filler types found in composite resin ................................................................... 20
Table 2.4 A summ ary of the advantages and disadvantages o f some microleakage tests..31
Table 2.5 The five generations of dentine bonding agents ................................................. 48
Table 2.6 Potential soft and hard tissue applications o f lasers in dentistry ...................... 61
Table 2.7 Hard lasers which ablate enamel and dentine .....................................................69
Table 2.8 The range ofE r:YA G laser parameters used in referenced reports ...................72
Table 4.1 Microleakage scores for all cavities...................................................................... 99
List of Figures
Figure 2.1 Classifications of composite resin materials .......................................................22
Figure 3.1 Z100 composite resin and Scotchbond M ulti-Purpose bonding a g en t ........... 83
Figure 3.2 Compoglass compomer resin and Compoglass Single Component Adhesive..83
Figure 3.3 The Erbium:YAG Twinlight Dental Laser......................................................... 86
Figure 3.4 Cavity preparation using the Erbium:YAG laser ............................................. 86
Figure 3.5 Line drawing showing the position of the cavity at the cervical margin o f the
tooth; a) aproximal surface b) buccal surface .............................................................. 87
Figure 3.6 The metal templates used during cavity preparation ........................................ 89
Figure 3.7 The control panel of the ErbiumiYAG Twinlight Dental Laser....................... 89
Figure 3.8 Dentine charring during cavity preparation with the 300 m j pulse energy...90
Figure 3.9 The thermocycling u n it ....................................................................................... 92
Figure 3.10 The Labcut microtome used for sectioning .......................................................94
Figure 3.11 Microleakage scoring: enamel margin = 0, dentine margin = 0 ...................94
Figure 3.12 Microleakage scoring: enamel margin = 1, dentine margin = 3 with
extensive dye penetration in the dentinal tubules ........................................................ 95
Figure 3.13 Microleakage scoring: enamel margin = 1, dentine margin = 2 with
minimal dye penetration in the dentinal tubules ......................................................... 95
Figure 3.14 Microleakage scoring: enamel margin = 2, dentine margin = 4 with
minimal dye penetration in the dentinal tubules ..........................................................96
Figure 3.15 Microleakage scoring: enamel margin = 2, dentine margin = 4 with
extensive dye penetration in the dentinal tubules ........................................................ 96
Figure 4.1 Microleakage seen at the enamel margins o f conventionally-prepared cavities
101
Figure 4.2a-c Microleakage seen at the enamel margins of lased cavities in groups A, B
and C ............................................................................................................................. 102
Figure 4.3 Intergroup analysis of microleakage seen at the enamel margins of lased
cavities in groups A and B ........................................................................................... 104
Figure 4.4 Intergroup analysis of microleakage seen at the enamel margins o f lased
cavities in groups B and C ........................................................................................... 104
Figure 4.5a-c Analysis of the microleakage seen at the lased and conventionally-prepared
enamel margins in groups A, B and C ........................................................................ 105
Figure 4.6 Microleakage seen at the conventionally-prepared dentine margins ............. 107
Figure 4.7a-c Microleakage seen at the dentine margins of lased cavities in groups A, B
and C .............................................................................................................................. 108
Figure 4.8 Intergroup analysis of microleakage seen at the dentine margins o f lased
cavities in groups A and B ........................................................................................... 110
Figure 4.9 Intergroup analysis of microleakage seen at the dentine margins o f lased
cavities in groups B and C ........................................................................................... 110
Figure 4.10a-c Analysis of the microleakage seen at the lased and conventionally-
prepared dentine margins in groups A, B and C ........................................................I l l
Figure 4.11 Analysis o f the microleakage seen at the enamel and dentine margins o f
conventionally-prepared cavities .................................................................................. 113
Figure 4.12a-c Analysis of the microleakage seen at the enamel and dentine margins in
the lased cavities o f groups A, B and C ....................................................................... 114

ix
Abbreviations
ADJ: am elodentinal junction
Ar-F: argon fluorine
Av: average
BisGMA: bisphenol-glycidyl m ethacrylate
Ca: calcium
CRI: cavity w a ll/to o th restoration interface
C 0 2: carbon dioxide
DCMA: dicarbonic acid dim ethacrylate
Dia: diam eter
EDA: electronic dental anaesthesia
EGMA: ethylene glycol dim ethacrylate
Er:YAG: erbium yttrium alum inium garnet
Er:Cr:YAG: erbium chrom ium yttrium alum inium garnet
FDA: Food and D rug A dm inistration
HEMA: 2-hydroxyethyl-m ethacrylate
Hz: H ertz
Ho:YAG: holm ium yttrium alum inium garnet
IR: infra-red
mj: millijoule
MPa: m egapascal
Mg: m icrogram s
iU m m icrom etre / m icron
jL/s: m icrosecond
mm: m illimetre
N H 2: am m onium
NHS: N ational H ealth Service
nm: nanom etre
nsec: nanosecond
Nd:YAG: neodym ium yttrium alum inium garnet
OH: hydroxyl
POp phosphate
pps: pulses per second
PRR: pulse repetition rate
PSI: p o u n d s per square inch
SEM: scanning electron m icroscopy
TEGMA: triethylene glycol dim ethacrylate
Th:YAG thullium yttrium alum inium garnet
UK: U nited K ingdom
UV: ultraviolet
W: w att
Xe-Cl: xenon chorine
YAG: y ttrium alum inium garnet

xi
Acknowledgements
I w ould like to express m y thanks and gratitude to the m any people w ho have
helped m e d u rin g the research and w riting of this thesis:

My supervisors, Professor W. P. Saunders, D epartm ent of A dult D ental H ealth

and Dr. C. J. W hitters, D epartm ent of Clinical Physics, both of the U niversity of
Glasgow, for their hum our, encouragem ent, and guidance th roughout the period
of this stu d y and d uring the preparation of this thesis.

To Professor N. McKay, P ostgraduate Dean of M edicine and Professor D. W ray,

Postgraduate Dean of Dental Studies for providing funding for the study.

Mr. R. Foye and Mr. A. C um m ings for their assistance an d advice in the
laboratory.

Mr. J. Davies, Mrs. K. Shepherd and Mrs. G. Drake of the D epartm ent of M edical
Illustration, U niversity of Glasgow for the 'focused' photography.

My family and friends, for their help, support and understanding.

A nd lastly b u t by no m eans least, m y husband Stuart for his love, patience and
support, for the T.T. helpline' and the regular 'meals on wheels' service. It is to
him that I dedicate this thesis.
Declaration

All the work submitted herein is the original work of the author

Elizabeth M. Roebuck

xiii
Summary
O ver the last thirty years there has been a m arked decline in the caries experience
in c h ild re n in the U n ited K ingdom . H o w ev er, the re s u lts of re c e n t
e p id e m io lo g ic a l s tu d ie s h av e sh o w n th a t this tre n d h as slo w e d d o w n
considerably, and m ay even have reversed in som e age groups. F urtherm ore,
th ere is an increasing cohort of children w ith significant levels of u n tre a te d
d en tin al decay. A nxiety is a m ajor barrier to the uptake of den tal care in the
U nited K ingdom , the tw o m ost com m on stressors being cited as the den tal drill
an d the local anaesthetic needle. The use of the h a rd tissue laser has been
p ro p o sed as one operative m ode of cavity p rep aratio n that obviates the use of
both of these anxiety-precipitating stimuli.

This in vitro stu d y investigated the affect of one such instrum ent, the Erbium -
YAG laser, on the m icroleakage of sta n d a rd is e d C lass V cavities a t the
am elodentinal junction in extracted hum an prem olar teeth. Extracted prem olar
teeth w ere selected and random ly divided into three groups (A, B an d C). Each
tooth h o sted one test cavity p rep ared w ith one of three laser energies (200 mj,
240 m j or 300 m j w ith a 100 m j finish), and one control cavity, p rep ared w ith a
conventional diam ond b u r in a high-speed handpiece. The cavities w ere restored
w ith either a com posite resin or a com pom er m aterial; gro u p s A an d B w ere
restored w ith a fourth generation bonding agent, Scotchbond M ulti-P urpose and
Z100 com posite resin and were stored in 0.12% thym ol solution for 24 hours and
three m o n th s respectively. Cavities in g ro u p C w ere resto red u sin g a fifth
g en e ra tio n b o n d in g agent, C om poglass Single C om ponent A dhesive an d a
polyacid-m odified resin, Com poglass and w ere then stored for three m onths.
F ollow ing sto rag e an d th erm al stressing (eight hours), m icro leak ag e w as
assessed using a dye penetration technique and single section num erical scoring
system . The d a ta w as then analysed using the K ruskal-W allis a n d M ann-
W hitney U tests.

For the pulse energies used, it w as found that the Er:YAG laser varied in its effect
on b o th the enam el and d en tin e m argins w h en co m p ared to con v en tio n al

xiv
p rep aratio n . At the enam el m argin, p rep aratio n w ith either of the three pulse
energies com pared favourably to the use of the diam ond b u r for both m aterials.
H ow ever, optim u m cavity sealing was achieved w ith energies of at least 240 mj.
In com parison, d entine leakage following laser p reparation w as com parable to
th a t fo u n d w ith co n v en tio n al p re p a ra tio n for all laser p a ra m e te rs w h en
C om poglass w as used. H ow ever, there w ere statistical differences in leakage at
the d en tin e m argins of Z100 restorations. Low er energies of 200 m j or higher
w ith a low finish such as the 300 m j w ith 100 m j finish u sed in this stu d y
p ro v id e d better long-term m arginal adaptation in dentine for this m aterial. Of
th ese tw o laser energy su b groups, the 300 m j w ith 100 m j finish com pared
favourably w ith conventional cavity preparation.

It w as therefore concluded that, w ith in the constraints of this study, cavity

p re p a ra tio n w ith the Er:YAG laser did not have a deleterio u s effect on the
m icroleakage of Class V restoration w hen com pared to conventional preparation,
p ro v id in g care w as taken w ith the choice of laser p aram eters for dentine and
enam el for the restorative m aterial used.

xv
1 Introduction

1.1 Dental caries

D ental caries is defined as 'a bacterial disease of the calcified tissues of the teeth
characterised by d em in eralisatio n of the inorganic, an d d estru c tio n of the
organic, substance of the tooth' (Soames & Southam , 1993). Several aetiological
th e o rie s have been p ro p o s e d (Blackwell, 1955). H o w e v e r, M ille r's
C hem oparasitic Theory of 1889, now referred to as the acidogenic theory, is
currently the m ost accepted.

1.2 Caries: a public health concern

Caries is a potentially infectious and transm issible disease (Keyes, 1960) and,
along w ith its sequelae, has been recognised throughout history. Lesions have
been found in the teeth of N eolithic skulls and there are several references to
caries-related p ain an d discom fort in the classical an d historical literatu re.
H ow ever, enam el caries w as uncom m on and w h en it d id occur, it u su ally
p ro g ressed slow ly. Caries of the root surface w as m ore com m on an d w as
inevitably related to periodontal disease.

In the eig h teen th century, the p attern and incidence of caries b eg an to rise
significantly in E urope an d N o rth A m erica. As w ith any change in the
prevalence or nature of a disease, several causative factors have been given for
this change. H ow ever, a significant correlation betw een the con su m p tio n of
refined sugars and the incidence of caries has been noted (H ardw ick, 1960). The
in d u strial rev o lu tio n led to changes in lifestyle and the tra d itio n al d ietary
p attern s of m uch of the p opulation. This, along w ith dev elo p m en ts in the
m anufacture, distribution and m arketing of sucrose, led to an increase in sugar
co nsum ption w hich in 1957, w as twice that of 1880 (H ardw ick, 1960). The
increasing availability of sucrose resulted in a population of children and young

1
a d u lts w ho exhibited rap id ly ad vancing coronal caries w ith its associated
sequelae of p ain and infection, to the extent that, at the in a u g u ra tio n of the
N ational H ealth Service (NHS) in 1948, dental caries w as considered a m ajor and
increasing public health problem in the United Kingdom (UK).

The first tw en ty to th irty years of d en tistry in the NHS in v o lv ed extensive

m anagem ent of the dam aging effects of caries and its sequelae. H ow ever, w ith
an im provem ent in the know ledge of the nature and m anagem ent of the disease,
a reduction in the incidence of caries in children and adults has been seen during
the last tw enty years (Todd & Lader, 1991c; Downer, 1994). Several factors have
been im plicated in this red u ctio n such as im proved oral hygiene a n d dietary
control, and the increased use of antibiotics. However, m any experts believe that
the m ost im p o rtan t factor is the increased exposure to fluoride, particu larly in
toothpaste (Bratthall et a l, 1996). W hile this im provem ent in the oral health of
the nation is to be applauded, the m ost recent surveys suggest th at the decline in
caries levels has now slow ed dow n considerably and m ay even have started to
reverse in younger individuals (Todd & Lader, 1991c; D owner, 1994).

Of concern also, is the volum e of u ntreated caries. A decrease in the restorative

index in 1983 of 72% to 1993 of 58% in 12 year olds is set against the m arked rise
in the prop o rtio n of that age group w hich is caries free (21% to 50% d u rin g the
ten year period). This suggests th at there is a core of children w ith relatively
high caries levels w ho are not being reached by the dental care services currently
(Downer, 1994). A sim ilar scenario is found in the adult population of the UK.

There are several possible reasons for this, for exam ple, poor co-operation, cost
an d non-attendance. The m ost recent national ad u lt an d child d en tal health
su rv ey s in the U nited K ingdom e n q u ired ab o u t the freq u en cy of d en tal
attendance (Todd & Lader, 1991b; O'Brien, 1994). W hen edentulous people were
excluded, only 50% of ad u lts an d 59% of 5 year-old ch ild ren w ere regular
attenders. In order to further reduce the levels of decay, and to restore current
active decay, it is essential th at there is an increase in the n u m b er of people
attending the dentist for regular care.

2
1.3 Barriers to dental care

Several b arriers to reg u lar d en tal care have been rep o rted . O th er th an the
dem o g rap h ic variables; gender, age, education and social class (B erggren &
M eynart, 1988), a lack of sym ptom s or concern and dental fear are rep o rted as the
m ain reasons for not seeking reg ular dental care (Friedl et ah, 1995; M urray,
1996).

In the 1988 A d u lt D ental H ealth Survey in the U nited K ingdom , anxiety w as

fo u n d to be a m ajor b arrier to dental care for non-atten d ers (Todd & Lader,
1991a). H ow ever, 39% of regular attenders also expressed som e level of fear. In
ad d itio n , d en tal anxiety is associated w ith an increase in caries incidence,
u n tre a te d lesions (O'Brien, 1994), cancelled an d m issed a p p o in tm e n ts an d
avoidance of dental care (Kleinknecht et ah, 1973). As such it is fast becom ing the
dental public health problem of the tw enty first century.

Studies in vestig atin g the origin of dental anxiety have h ig h lig h ted learned
responses from fam ily m em bers and peers (Shoben & Borland, 1954), previous
traum atic d en tal experiences (Bernstein et al.f 1979) and p erso n ality traits as
aetiological factors. H ow ever, the greatest fear-provoking factors in the dental
environm ent have been reported as fear of the drill and local anaesthesia needle
(Rankin & H arris, 1984). In addition, surveys of dentists have highlighted the
m anagem ent of anxious patients as the m ost stress-producing feature of their
daily w ork (O'Shea et al., 1984). In light of this, in a d d itio n to co n tin u ed
m easures to reduce the levels of decay, significant resources have been invested
into the research and d ev elo p m ent of alternative m eth o d s of tre atm e n t to
p rovide a m eans of m anaging the ever increasing cohort of dentally-anxious
individuals.

1.4 Managing the anxious individual

To date, alternative m ethods to m anage the anxious patient have fallen into two
m ajor categories; firstly, b e h av io u ral m an ag em en t te c h n iq u e s such as
in fo rm a tio n p ro v is io n , d is tra c tio n , b io fe e d b a c k and n e u ro lin g u is tic
program m ing, all of w hich increase the individual's coping skills, an d secondly,
m od ification s to co n ventional d en tal treatm en t. The la tte r has in clu d ed

3
pharm acological m ethods w hich alter the individuals' level of consciousness to
allow conventional dental treatm ent. Such treatm ent m odalities have inclu d ed
the use of general anaesthesia, nitrous oxide inhalation sedation and intravenous
or oral sedation. In addition, m odifications to the two dental stressors, the local
an aesth etic n eed le (Q u arn stro m & Libed, 1994; M eechan & W in ter, 1996;
M oderesi et al., 1996) and the dental drill have been investigated. The options for
the latter are considered further in Section 2.9. However, the use of a laser as an
o p tical c u ttin g device h as b een a d v o cated as one m ean s of m o d ify in g
conventional treatm en t w hich does not require local analgesia (G oldm an et ah,
1965; Keller & Hibst, 1997).

To be accepted as an alternative to the dental drill, the use of the laser m u st fulfil
certain criteria. These are discussed m ore fully in Section 2.10, b u t one essential
quality is th at the use of the laser in cavity p rep aratio n sh o u ld not ad v ersely
affect the longevity of the restoration placed. This study looks at one aspect of
this; the efficacy of an Erbium-YAG laser on the microleakage (m arginal seal) of
direct com posite and com pom er fillings.

4
2 Literature Review

2.1 Introduction

A n investigation into the effect a laser has on the m arginal seal of restorations
requires an u n d erstan d in g of the physical phenom enon of m icroleakage an d the
factors th a t influence it. This review of the literatu re begins w ith a brief
d escription of the tissues found in the crow n of a tooth. A know ledge of the
structure and com position of these tissues, enamel, dentine and pulp, is essential
if the interaction of restorative m aterials and lasers w ith these tissues is to be
fully appreciated. C urrent direct restorative m aterials are then review ed, looking
particularly at the developm ents in the field of aesthetic m aterials. Follow ing
this, m icroleakage is discussed. In this section, the process of m icroleakage and
m ethods of its assessm ent are first described. M icroleakage in com posite and
com pom er resins, the tw o m aterials used in this study, is then considered, w ith
p artic u la r em p h asis on the m aterial factors and the resto rativ e techniques
p u rp o rtin g to control it. Finally, a brief review of the use of lasers in dentistry is
given, before considering the Erbium YAG laser more fully.

2.2 Composition and structure of the dental crown

The dental crow n is com posed of two hard tissues, enam el and dentine, and a
soft tissue, the pulp. Extracted perm anent prem olars w ere used in this study and
therefore this review will be restricted to a description of the features of the
structure and com position of these tissues in perm anent, vital crow ns w hich are
pertinent to this study.

2.2.1 Enamel of the permanent tooth

M ature h u m an enam el is a unique body tissue; it is acellular, it is the only

m ineralised epithelial tissue and is also the hardest and m ost calcified tissue in
the body. Its physical properties vary over the crow n surface; thickness, of the

5
order of 2.5 mm, and hardness are greatest at the in cisal/cu sp al tip and decrease
steadily to the cervical m argin and fissure region. In health, enam el provides a
protective covering for the underlying dentine and p u lp and consists of 96-97%
inorganic an d 0.4-0.8% organic m atter and 3% w ater by w eig h t (86%, 2% and
12% by volum e respectively).

22.1.1 The enamel prism

The basic stru c tu ral u n its of h u m an enam el are the enam el p rism s (rods).
Form ed as a m ineralised secretory product of the ameloblasts, they are 'key-hole'-
shaped in cross-section, w ith a head and tail region, and can be seen th roughout
the w hole of the enam el tissue except for the surface 20-40 ^m . They are thin
stru ctu res w ith an average diam eter of 5 p m and follow an u n d u la tin g course
from the am elodentinal junction (ADJ) to the subsurface. In the cervical area,
w here the enam el is thin, the rods are short and the surface enam el is prism less
(Gwinnett, 1967).

2.2.1.2 The mineral phase of enamel

The principle com ponent of the rods is the apatite crystal. W ith the exception of
the tail region, w here there is a shift in crystal orientation, these are arranged
w ith their long axis parallel to the long axis of the rod. They are elongated
hexagons, 30 nm thick, 65 nm w ide and several m icrons in length. Their basic
crystallographic form ula is that of hydroxyapatite; Cai0(PO4)6(O H )2. H ow ever,
enam el crystals vary from other apatite crystals in the bod y in th a t they are
slightly deficient in calcium , and there are m inor su b stitu tio n s of strontium ,
carbonate, m agnesium , lead and fluoride ions in the crystal lattice. W ith the
exception of fluoride, these ions cause a sm all increase in the solubility of the
crystal at acidic pH s. The application of acid solutions to enam el results in two
changes; firstly, preferential dissolution of the crystals in the rod h ead area
occurs leav in g a ro u g h e n e d surface. Secondly the en am el is p a rtia lly
dem ineralised to several m icrons below the surface, leaving hollow crystal cores
and spaces betw een the partially dem ineralised crystals. W hen dry, these zones
can be penetrated w ith resins. These changes form the basis of the acid-etching
procedure used to provide m icrom echanical retention for com posite resins and
related m aterials (Section 2.7.2.1). The depth of the etch p attern varies betw een

6
acids, w ith h ig h ly d issociated acids such as p h o sp h o ric p ro d u c in g d eep er
p attern s th an w eaker acids such as polyacrylic, citric and m aleic acids for the
sam e application time (M eryon et al., 1987; Glasspoole & Erickson, 1994).

Because of its high inorganic content, enam el is a brittle tissue and is susceptible
to fractu re along the p rism borders. The organic m aterial, fo u n d in the
intercrystal space, provides a n etw ork for the crystals w hich stren g th en s the
enam el by red u cin g the tendency for the crystals to fracture a n d separate.
N evertheless, if enam el prism s at the m argin of a cavity are left u n su p p o rted by
dentine, they are likely to fracture, resulting in breakdow n of the cavity m argin.

In addition, the high inorganic content is responsible for the optical an d therm al
properties of the tissue. H ydroxyapatite has absorption bands in the ultraviolet
(UV) and m id- to far-infra-red (IR) regions because of the phosphate, carbonate
and hydroxyl groups in the crystal structure. W ater also has a sim ilar absorption
pattern. Thus, on im pinging the surface of healthy enam el, the m ajority of light
in the visible and low- to mid-IR ranges is either reflected or transm itted. This
has significance for the appearance of a tooth, and has clinical im plications for
the use of transillum ination in the diagnosis of caries, for the therapeutic effects
of lasers on enam el, and on the polym erisation of photopolym erised restorative
m aterials.

2.2.13 The organic phase of enamel

The organic m atrix com prises the m inor com ponent of m atu re enam el and is
distributed, w ith w ater, betw een the hydroxyapatite crystals to form the prism
sheath. It is m ade up of soluble and insoluble protein, peptides, lipids and citric
acid, the m ajority of w hich are produced by the ameloblasts. Unlike some of the
inorganic com ponents of bone, dentine and cem entum , they are not fibrous
collagen proteins and are therefore unique am ong the m ineralised tissues. In
ad d itio n to su p p o rtin g the inorganic phase (Section 2.2.1.2), organic m aterial is
found as ribbon-like structures, the lamellae and tufts, found m ainly in the inner
p art of the enamel.

Enam el has a low therm al conductivity and coefficient of therm al expansion

(11.4,10'6 °C'1), and a high therm al capacity. These properties serve to protect the

7
u n d erly in g structures from the environm ental variations found in the oral cavity
an d also have a bearing on the tissue interactions w hich occur w h en lasers are
used to 'cut' (ablate) enam el (Section 2.10.3).

2.2.2 Dentine of the permanent tooth

D entine form s the bulk of the tooth, providing a cushion for the overlying brittle
en am el a n d p ro tectio n to the p ulp. It differs from en am el in s tru c tu re ,
com position and function, the m ost significant difference being the vital nature of
the tissue w hich enables continued post-eruption d evelopm ent in response to
both physiological an d pathological stim uli. The cells conveying vitality to
dentine are the odontoblasts and the sensory neurones, both of w hich are located,
w ith the dentinal fluid, in the lum en of the dentinal tubules. Their cell bodies are
fo u n d in the p e rip h e ry of the p u lp an d therefore d en tin e v itality is also
d ep en d en t on the health of this tissue. For this reason, w hen considering post-
eruptive changes, it is custom ary to consider the pulp and dentine as one entity,
the pulpodentinal complex.

D entine is deposited increm entally throughout life in a rhythm ic m anner unless

environm ental factors stim ulate a localised increase in production. T hus it can be
classified into distinct types based on the location, m atrix calcification, structure
and developm ental pattern (Table 2.1). Pathological stim uli such as caries, w ear,
iatrogenic and non-iatrogenic traum a, and irritan t chem icals can stim ulate the
form ation of tertiary (reparative) dentine and sclerotic (translucent) dentine.
These form p art of the defensive m echanism of the pulpodentinal com plex and
their form ation is considered further in Section 2.2.3.

M ature dentine has a low coefficient of therm al expansion (8.3, 10‘6 ° C 1) an d is

approxim ately 70% mineral, 20% organic matrix, and 10% w ater by w eight (50%
mineral, 30% organic and 20% w ater by volume).

22.2.1 The mineral phase of dentine

W hile trace am ounts of calcium carbonate, fluoride, m agnesium , zinc and other
m inerals are found in dentine, the principal m ineral com ponent, like enam el, is
hydroxyapatite. The organisation and m ineralisation of the tissue differs from
that of enam el. In dentine, the crystals (calcospherites) are in the form of
 Table 2.1 Classification of coronal dentine by location, patterns of
mineralisation and development
Location
Intertubular dentine: found
around and between dentinal
tubules
Intratubular dentine :
(Peritubular):
hypermineralised structure
formed and found within
dentinal tubules
Mantle dentine: first dentine
to form in crown and
becom es outer coronal
dentine. Merges with the
enamel at the ADJ in a
scalloped margin
Circumpulpal dentine:
closest to pulp and forms the
bulk of the dentine. Is
formed after mantle
deposition
Pattern of
mineralisation
Globular dentine: formed
by fusion of calcospherites
Interglobular dentine:
hypomineralised matrix
between fusing
calcospherites found
between mantle and
circumpulpal dentine in the
crown.
Sclerotic (translucent,
transparent) dentine:
hypermineralised,
progressive deposition
occluding intratubular dentine
i.e. change within deposited
dentine
9
Developmental pattern
Primary dentine formed
before and during active
eruption
Secondary dentine: forms a s
a result of physiological stimuli
beginning when teeth com e into
occlusion
Tertiary (reparative) dentine:
formed in resp on se to a
pathologic stimulus; caries,
cavity preparation, wear,
trauma
flatten ed plates of approxim ate dim ension 60-70 nm in length, 20-30 nm in
w idth, and 3-4 nm in thickness. M ineralisation occurs by the fusion of num erous
crystals (globular m ineralisation).

W hen com pared to the other m ineralised tissues of the body, the m ineral content
of d en tin e m akes it h ard er than cem entum or bone, b u t five tim es softer than
enam el. Furtherm ore, the post-eruptive changes result in variations in hardness
w ith in the tissu e. For exam ple, w ith ageing, ex ten siv e d e p o s itio n of
hydroxy apatite m ay occur (sclerotic and intratubular dentine). This results in the
dentine becom ing m ore brittle, harder, less resilient and m ore yellow in colour,
w hereas carious dentine is m uch softer than both sclerotic and non-sclerotic
dentine. This has clinical significance in both the diagnosis of caries an d the
assessm ent of cavity preparation. The variation in m ineral also has im plications
for the use of lasers as an 'optical drill' ( Section 2.10.3.7).

2.22.2 The organic phase of dentine

The odontoblast processes play an im portant role in the production of dentine in

that they are responsible for the synthesis and secretion of the com ponents of the
organic m atrix. Collagen m akes up approxim ately 91-92% of the m atrix and
p rovides the stru ctu ral fram ew ork for dentine. It m ay also play a role in the
in itiatio n of m ineralisation. The rem aining 8-9% consists of seven b ro ad
categories of non-collagenous m acrom olecules. W hile the detailed function of
these organic com ponents is beyond the scope of this review , it w ould appear
that they are im portant factors in the growth, developm ent and repair of the vital
m ineralised tissue (Piesco, 1994). The relatively high organic content enables
dentine, unlike enam el, to deform slightly u n d er com pression. This an d the
'hydraulic shock absorber' effect of the fluid-filled dentinal tubules dissipate the
forces of m astication, th u s prov id ing the cushioning of the overlying brittle
enam el. The organic m atrix also gives resilience and strength to the dentine. In
health, this is beneficial to the pulp. H ow ever, its rigidity produces a cham ber
w ith low com pliance and therefore if the pu lp becom es inflam ed, irreversible
pulpal dam age can occur.

10
2.2.23 The dentinal tubules

The m ost prom inent feature of dentine is the dentinal tubules. In the crow n, they
ex ten d from the ADJ in an S-shaped curve. They p ro v id e a p ath by w hich
bacteria (Kidd & Joyston-Bechal, 1997) and other noxious stim uli can gain direct
entry to the pu lp once the protective enam el layer is breached. In addition, they
are th o u g h t to act as 'optical fibres' transm itting radiation from the ADJ to the
p u lp al tissues (Zijp & Ten Bosch, 1991). The tubules are tapered and branched,
the narrow est, and m ost pronounced branching occurring near the ADJ. Tubule
d ensity also varies b etw een the occlusal and cervical dentine, w ith the low est
density found in the outer third of the latter (Fosse et a l, 1992).

The continued deposition of dentine, coupled w ith a lack of internal rem odelling,
effectively red u ces the size of the p u lp cham ber over tim e resu ltin g in an
increased density (40,000 m m '2) of w ider d en tin al tu b u les to w ard s the p u lp
cham ber. The tubules therefore rep resen t a m uch larger p ro p o rtio n of the
dentine volum e near the p ulp (28% by volum e) w hen com pared to the ADJ (4%
by volum e). The clinical im plications of this are obvious; the deeper the cavity,
the g reater the num ber of tubules that are at risk from bacterial pen etratio n ,
cavity p rep aratio n and the application of potentially h arm fu l substances, and
therefore the greater the potential for causing pulpal dam age.

2.2.2.4 Dentine permeability

Unlike enamel, dentine is relatively permeable; in a vital tooth, fluids can readily
flow across or th ro u g h the dentine tubule com plex from the p u lp to the ADJ
(tran sd en tin al perm eability), or in the reverse direction w h en the enam el is
dam aged or lost (Brannstrom & Nyborg, 1972). The w ater content of dentine is
proportional to the cross-sectional area and density of the tubules and therefore
increases tow ards the pulp. Fluid arising from the cut surface of the dentinal
tubules is form ed as a transudate of plasm a and is alw ays u n d e r slight positive
pressure. This flow of dentinal fluid has a protective function; w h en irritants
such as bacterial toxins gain access to the pulp via the tubules, an inflam m atory
response is provoked. The resulting increase in p u lp al p ressu re causes an
increase in dentinal fluid flow w hich cleanses the tubules and hinders the entry
of bacteria into the pulp. In addition, this is also indirectly responsible for

11
initiating the production of sclerotic and reparative dentine (Section 2.2.3). Thus
dentin al fluid flow is im portant for the defence m echanism of the pu lp o d en tin al
com plex. H ow ever, conversely, the fluid m ovem ent also produces p ain and can
affect the m arginal ad ap tatio n of restorations adversely (S tu ev er et al., 1971).
F u rth erm o re, d en tin e w etness can also influence the b o n d in g of resto rativ e
m aterials to d en tin e (Section 2.72.2). D entine perm eability is re d u c e d by a
reduction in size or patency of the dentinal tubules. This is achieved by sclerosis
an d obliteration of the tubules, or by sealing the tubules w ith eith er a sm ear
layer, form ed d u rin g instrum entation (Section 2.72.2), a resin-reinforced hybrid
layer, form ed by the new er generations of dentine b o n d in g ag en ts (Section
2.7.22) or by the direct application of a restorative material.

The application of acid to dentine enlarges the dentinal tubule orifices an d m ay

also degrade the collagen m atrix (Gwinnett, 1984). In addition, w h en present, the
sm ear layer is rem oved by the application and subsequent rem oval of the acid
(Gwinnett, 1984; M eryon et al., 1987). Thus etching increases the perm eability of
dentine. Acids are applied to dentine in the total etching procedures used w ith
the m ore recent dentine bonding agents (Section 2.7.2.2), b u t the effect of the
procedure on the p u lp has until recently, been controversial (Kanca, 1990; Retief
et al., 1992; Cox & Suzuki, 1994). The adverse pulpal changes seen follow ing acid
application are now considered to arise either from irritation by com ponents in
the restorative m aterial or from m icroleakage, the effects of w hich are enhanced
by the increase in dentine perm eability, rather than from the direct action of the
acid itself.

2.2.3 Dental pulp

As noted in Section 2.2, the dynam ic changes seen in the structure an d function
of dentine are d ep en d en t on the presence of an intact, vital pulp. In the crown,
the dental pu lp is confined w ithin the pulp chamber, the size of w hich reduces
w ith age because of the continued deposition of dentine. The p u lp consists of
loose connective tissue and contains cells w hich provide odontogenic, nutritive,
sensory an d defensive functions (Chiego, 1994). W hen m ature, p u lp can be
divided into tw o com partm ents; the odontogenic zone and the pulp proper. The
odontogenic zone, situated in the periphery of the p u lp cham ber, includes the
odon to b last cell bodies, the cell-free zone, the cell-rich zone and the parietal

12
plexus of nerves. The p u lp p ro p er consists prim arily of fibroblasts an d their
extracellular matrix, blood vessels and nerves. The blood vessels are com posed of
venules and arterioles of betw een 100 to 150 /im and 50 to 150 ixm in diam eter
respectively, and term inal capillaries. These capillaries anastom ose w ith the
venules deep to the odontoblastic layer and provide the oxygen an d n u trien ts
necessary for cellular m etabolism . The nerve su pply consists of sensory and
postganglionic sym pathetic nerve fibres. From the p erip h eral p arietal plexus,
n o n -m y e lin ate d n erv es tra v erse the cell-rich and cell-free zo n es a n d the
o d o n to b last layer to enter the o dontoblast tu b u le alongside the o d o n to b last
processes. At present, three major theories have been p roposed to explain how
p a in is tra n sm itte d th ro u g h d entine; the tra n sd u c tio n th eo ry , the d irect
in n erv atio n theory and the hydro dynam ic theory. The in itiatio n of p ain as a
result of rap id dentinal fluid flow w as noted in Section 2.2.2. Evidence of this
n atu re has resu lted in the h y d ro dynam ic theory being the cu rren t favourite;
w hen dentinal fluid is disturbed, the nerve term inals in the dentinal tubules and
odontoblast layer are stim ulated, initiating an action potential an d hence pain.

In addition to stim ulating pain receptors, the flow of dentinal fluid also results in
the release of inflam m atory m ediators, invoking an inflam m atory reaction. If of
a sufficient size and duration, irreversible pu lp dam age and necrosis m ay occur.
H ow ever, as noted in Section 2.2.2, the inflam m atory exudate also initiates the
defensive m echanism ; increased flow of dentinal fluid, stim ulation of tu b u lar
sclerosis w ith in the dentine, and the p ro d u ctio n of reactionary d entine at the
p u lp o d e n tin a l interface. Sclerosis is d e p e n d e n t on the p resen ce of in tact
o d o n to b last cell bodies (Johnson et al., 1969), w hereas rep arativ e d en tin e is
th o u g h t to be form ed p rin cip ally by p u lp a l fibroblasts (T row bridge, 1981;
Tziafas, 1998). Thus it w ould appear that dentine perm eability is a key factor in
determ ining the response of the pulp to injury.

The relative com ponents of the pulp's response to injury is, in part, d ependent on
the nature of the stim ulus; sclerosis and reparative dentine form ation takes tim e
resulting, for instance, in a decrease in dentine perm eability of 60-80% w ithin the
first w eek follow ing cavity p rep aration (Pashley et al., 1983). H ow ever, som e
stim uli are of such a size that irreversible p u lp al dam age predom inates. For
exam ple, anim al m odels have show n that a tem perature rise of less th an 5.5°C
h ad no adverse affect on the pulp. H ow ever, above this tem p eratu re 15% of

13
p u lp s w ere found to necrose. This rose to alm ost 100% w ith an increase in
tem perature of 11°C (Zach & Cohen, 1965). It w ould appear therefore that pu lp
tissue is sensitive to changes in tem perature. This has bearing on the restoration
of teeth since it is essential that cavity preparation and m aterial setting reactions
do not result in tem perature changes in excess of 5.5°C.

2.3 Direct restorative materials

2.3.1 Introduction

O n com pletion of the cavity preparation, the tooth is restored. The principal
p u rp o ses of resto rin g a carious tooth are to restore the integrity of the tooth
surface, to prev en t further dam age from carious attack and to protect the pulp,
and to im prove function and aesthetics. To achieve this, the restoration m ust seal
the cavity herm etically ag ain st the oral environm ent. The ideal m aterial
therefore should:
• not irritate the dental pulp
• a d a p t w ell to the cavity w all w ith m inim al shrinkage d u rin g the setting
process
• not be adversely affected by m oisture
• not exhibit dim ensional change after placem ent in the cavity
• be resistant to attrition
• have the capacity to w ithstand the forces of m astication
• perm it m inim al tooth tissue rem oval for retention purposes

Properties of secondary im portance are the colour and aesthetics, low therm al
conductivity and ease of m anipulation. In short, the m aterial should duplicate
the physicochem ical properties of the virgin tooth. A m aterial that fulfils all
these criteria has yet to be created.

A range of restorative m aterials has been developed. In this study, tw o direct

resto rativ e m aterials w ere u sed and therefore the follow ing review w ill be
restricted to the consideration of current m aterials and d evelopm ents in this
group.

14
2.3.2 Dental amalgam

O ver the last forty years, there have been m ajor advances in the field of direct
restorative m aterials. H ow ever, despite this, dental am algam rem ains one of the
m ost w idely used of the available m aterials. It is tried an d tested, having been
u sed for m any years (M olin, 1992), an d p ro v id es the s ta n d a rd for several
param eters against w hich all direct filling m aterials are com pared.

A m algam is p ro d u ced at the chairside by m ixing liquid m ercury w ith am algam

alloy; a com bination of silver, tin, copper and som etim es zinc, p allad iu m ,
indium , and selenium . W hen freshly titurated it is reasonably easy to use; it has
a plasticity th at p erm its convenient packing into a cavity an d is not overly
technique-sensitive. W hen used u n d er the correct clinical conditions, am algam
restorations m aintain anatom ical form and have a reasonably adequate resistance
to m arginal fracture. In addition, they exhibit reduced m arginal leakage over
time because of the production of corrosion products (Pickard & G ayford, 1965)
an d exhibit reasonable longevity. F urtherm ore, w h en com pared w ith other
direct materials, the m aterial is inexpensive.

H ow ever, there are draw backs to dental am algam . It exhibits a brittleness and
toughness that are less than desirable. It is also subject to corrosion and galvanic
action: w hile corrosion initially reduces microleakage, prolonged corrosion will
resu lt in m arginal breakdow n. This is exacerbated by the lack of adhesion to
tooth structure. In the past, it was thought that galvanic action w as responsible
for the p o st-o p erativ e sensitivity experienced after th e placem ent of som e
am algam restorations, b u t this is now not considered an aetiological factor.
W hilst this has been of concern to the dental profession, the rep o rted cases of
am algam toxicity related to oral galvanism and corrosion have been of greater
public concern (Molin, 1992). The validity of the claim s relating to am algam
toxicity has been refuted. How ever, despite this several countries have placed
restrictions on the use of the m aterial. This, and the ever increasing p atien t
expectation for tooth-coloured fillings (Roulet, 1988), has ad d ed w eight to the
need for a strong aesthetic replacem ent for amalgam.

There are currently four categories of direct aesthetic filling m aterials on the
m arket; com posite resins, glass-ionom er cements, resin-m odified glass-ionom er

15
cem ents and polyacid-m odified resins. W hile the m aterials are considered here
as four separate m aterial types, on the basis of their setting reactions they can be
th o u g h t of as providing a continuum (Burgess et ah, 1996).

2.3.3 Composite resin materials

A 'com posite' is 'a com bination of tw o chem ically different m aterials w ith a
distinct interface separating the com ponents, and having properties w hich could
no t be achieved by any of the com ponents acting alone' (Bowen et al., 1972).
There are three m ain constituents in a com posite resin; the organic phase (the
resin matrix), the interfacial phase (the coupling agents), and the dispersed phase
(the reinforcing fillers). Clinical experience using the early com posite resins
show ed that, w hile they w ere an im provem ent over the original acrylic resins,
they h ad a num ber of significant disadvantages; m arginal leakage and staining,
inad eq u ate strength in high-stress areas, a lack of antibacterial action, porosity,
surface w ear and poor finishing. A ttem pts to im prove these deficiencies have
been m ade by ad d ressin g tw o areas, nam ely that of b o n d in g to enam el and
dentine and the com position of the resin m aterial itself.

C om posite resins do n o t b o n d directly to eith er enam el or d entine. The

d ev elo p m en t of b o n d in g agents has attem p ted to redress this deficit an d is
discussed further in Sections 2.7.2.1 and 2.7.2.2. M odifications to the three phases
of the resin has led to the developm ent of a w ide range of com m ercially available
m aterials and will be considered in the following three sections. As this study is
concerned w ith the microleakage of restorations, this review will focus m ainly on
the m aterial changes that have influenced this.

2.3.3.2 The organic phase: resin technology

The resin contributes the ability to be m oulded at am bient tem peratures coupled
w ith a setting by polym erisation achieved in a conveniently short time. W hile
analyses of proprietary composite resins on the m arket dem onstrate variations in
the com position of the m onom er (Ruyter, 1985), the m ajority of m aterials have
been based on the viscous liquid Bis-GMA m onom er. Bis-GMA is an acronym
for bisphenol-glycidyl m ethacrylate, its full nam e being 2,2-bis[p-(2-hydroxy-3
m ethacrylox y p ro p o x y )p h en y len e]-propane. It is form ed by the reaction of

16
b isp h e n o l A a n d g lycidyl m eth acry late an d is a b ifu n c tio n a l aro m a tic
d im ethacrylate w ith tw o phenyl groups to increase the rigidity of the molecule,
a n d h y d ro x y l g ro u p s w hich are th o u g h t to p ro v id e som e in term o lecu lar
h y d ro g en bonding. The large m olecular size and chemical structure of Bis-GMA
resu lts in the p ro d u ctio n of a resin w ith low er volatility an d p olym erisation
shrinkage, m ore rap id hardening and the production of a stronger, stiffer resin
w h en com pared to the earlier m aterials based on m ethylm ethacrylate. Blending
of the filler particles is difficult because of the viscosity of the m aterial and
therefore, a fluid d ilu en t m onom er such as triethylene glycol dim ethacrylate
(TEGMA) or ethylene glycol d im ethacrylate (EGMA) is u sed to red u ce the
viscosity. TEGMA is the m ost com m only used. H ow ever, because of its low er
m olecular w eight, it also increases the polym erisation sh rinkage (Davidson,
1986). A balance betw een the need for an increased filler content and im proved
h a n d lin g ch aracteristics, a g a in st the d e trim e n ta l effect of the in creased
contraction on curing is therefore necessary.

O ther m onom er system s have been used in w hich all, or p art of, the Bis-GMA
has been replaced by aliphatic or arom atic urethane dim ethacrylates. These have
a low er viscosity, low er w ater absorption, g reater to u g h n ess an d g reater
response to UV or visible light curing (Peutzfeldt, 1997).

The degree of polym erisation is crucial to the clinical perform ance of any resin
system and is d ep en d en t on the conversion percent of double b o nds an d the
netw ork form ation. This is influenced by tw o factors; the type of resin in the
organic m atrix and the m ode of curing.

The size of the Bis-GMA m onom er molecule coupled w ith the rap id increase in
viscosity m eans that reactive m ethacrylate groups find it increasingly difficult to
m igrate to the reaction site, w ith the result that a relatively high concentration of
acrylate or dim ethacrylate groups rem ain unreacted after setting. W hile this
reduces the contraction due to polym erisation, it also has a detrim ental effect on
the m echanical p roperties of the m aterial (A sm ussen, 1982). The ad d itio n of
carboxylic an hydrides (Peutzfeldt & A sm ussen, 1991), aldehydes (Peutzfeldt &
A sm ussen, 1992a) and ketones (Peutzfeldt & A sm ussen, 1992b), the use of heat
treatm ent (Bausch et a l, 1981) and spiro-orthocarbons w hich expand on curing

17
(Cook et a l, 1984) and curing u nder a continuous stream of argon (Rueggeberg &
M argeson, 1990) have all been found to increase the degree of polym erisation.

The conversion of the oligom ers or m onom ers to the polym er m atrix occurs by
free-radical ad d itio n polym erisation. In the early com posite resins, this w as
in itiated by chem ical or photochem ical m eans, the latter using light in the UV
ran g e (Craig, 1981). H ow ever, since the late 1970s, p o ly m erisatio n of the
m ajority of new com posite resins has been achieved w ith light in the visible
spectrum . In these m aterials the initiator com prises a m ixture of a diketone,
c o m m o n ly c a m p h o rq u in o n e , a n d an am in e re d u c in g a g e n t su ch as
d im eth y lam in o eth y l m ethacrylate or dim ethyl-p-toludine (Taira et al., 1988).
C am phoquinone rap id ly form s free radicals in the presence of the am ine and
light i n the blue region of 470 nm. M aterials are dispensed in pots, syringes or
com pules. The w avelength initiating polym erisation is in the spectrum w hich
has been im plicated in retinal dam age (400-500 nm) and there w as initial concern
th at this m ight pose a health risk to operators (Davidson, 1985; Ellingson et al.,
1986). H ow ever, M oseley et al (1987) found that an exposure of betw een 40 and
100 m in u tes p er d ay w as req u ired before the risk of visual d am ag e w as
significant. These light cured m aterials offered several advantages over those
that w ere chemically cured. A sum m ary of these is given in Table 2.2.

2.3.3.2 The dispersed phase: filler technology

The m ost significant changes in the com m ercial com posites have been m ade
th ro u g h alteratio n s in the filler com ponent. The filler co n trib u tes several
beneficial characteristics to the m echanical, therm al, and physical properties of
the polym er; rigidity, hardness, strength and m odulus of elasticity are increased
and the coefficient of therm al expansion and degree of polym erisation shrinkage
are reduced. In addition, a translucent filler enhances the optical properties of
the resin. These factors are controlled by the type, concentration, particle size
and distribution of the filler and to date six categories have been defined (Lutz &
Phillips, 1983; Bayne et a l, 1994). These are described in Table 2.3. The fillers
have generally been m ade from m ined m inerals or m elted glasses. H ow ever,
m ore recently, filler particles have been produced by a synthetic sol-gel process.
This process is one in which a m etal carboxylate and a m etal oxide sol are m ixed

18
 Table 2.2 Chemical versus light curing

Chemical curing Light curing

Advantages Uniform cure Single-paste formulation:
Uniform polymerisation shrinkage No mixing
No additional equipment Reduced porosity
Adequate working time:
Suitable for incremental packing:
Improved marginal adaptation
Optimal restoration of colour,
opacity, translucency and
morphology
Command set
More complete surface cure
Optimal physical properties
Improved wear resistance
Instant finishing possible
Good colour stability and
matching
Disadvantages Short working time Additional equipment necessary
Long setting time Technique sensitivity:
Poor colour stability and matching Limited depth of cure (dependant
on s h a d e and light-resin distance)
Delayed finishing
Polymerisation shrinkage towards
Mixing required
light source
Increased porosity
Premature setting with intense
Polymerisation inhibited by 0 2 operating light
Degree of polymerisation is m ass Polymerisation inhibited by 0 2
dependant:
Cost of material
thin margins may be not be cured
Potential retinal d am ag e
sufficiently,
large cavities are difficult and
time consuming

19
 Table 2.3 Filler types found in composite resin

Filler Preparation Shape Material Av. Dia. Advantages Lim itations

Traditional grinding or splinter quartz, 0 .1 - 6 0 -8 0 % filler poor wear

m acrofiller crushing glass, 100 pm loading resistance
borosilicate
or ceramic

M icrofiller hydrolysis & sphere Pyrogenic 0 .0 5 - good polishability resulting

precipitation silica 0.1 pm viscosity limits
filler loading

M icrofiller-based
com plexes
milling cured splinter Pyrogenic 1 -2 0 0 pm attain maximum filler loading has
Splintered pyrogenic silica/resin inorganic loading adverse
prepolym erised silica/resin with microfillers influence on
mixture aesthetic
properties

Spherical incorporating sphere Pyrogenic 1 -2 5 pm attain maximum filler loading has

polym er-based pyrogenic silica/resin inorganic loading adverse
silica into with microfillers influence on
partially aesthetic
cured properties
polymer
spheres

Agglom erated artificially sphere Pyrogenic 1 -2 5 pm attain maximum filler loading has
agglomerate silica inorganic loading adverse
d microfillers with microfillers influence on
aesthetic
properties

Nanofiller sol-gel sphere Pyrogenic 0 .0 0 5 - Permit filler levels To be evaluated

process silica 0.01 pm of 9 0 -9 5 % (by wt)

Fibre-fillers sphere glass (Max. improved fracture To be evaluated

ceramic Length: toughness and
300 pm) wear resistance

M egafiller sphere 8-quartz 0 .5 -2 mm minimise resin shrinkage at

glass volume, reduced insert/resin
polymerisation interface
shrinkage weakens
restoration

20
an d form a gel by deh y d ratio n . The gel is heat treated and th en g ro u n d to
produce fillers (Ferracane, 1995).

Several classifications of com posite resin have been described (Lutz & Phillips,
1983; W illems et a l, 1992; Bayne et a l, 1994), based on the filler particle size and
loading (Figure 2.1). The traditional (conventional) com posites w ere sim ply a
m ix tu re of trad itio n al m acrofiller particles and resin m onom ers. The early
m aterials contained filler particles in the range of 1-50 jim. H ow ever, as m illing
p ro ced u res have been refined, the range of sizes has increased to 0.1-100 j/m.
Q uartz w as po p u lar in these m aterials because of its chem ically inert nature and
its favourable index of refraction (Bowen, 1979). H ow ever, its h ard n ess m ade it
difficult to m ake fine particles and gave problem s in com posite polishing. This,
com bined w ith the rad io lu c en t n atu re of the m aterial and relativ ely high
coefficient of expansion (Bowen, 1979), led to the dem ise of quartz as a filler and
to the use of glass fillers. These contributed to the radiopacity of the restoration
an d , b ein g softer th a n q u a rtz, facilitated fine filler p ro d u c tio n . W hile
p o lym erisation shrinkage w as reduced, the sm ooth surface h y d ro ly sis of the
interfacial b o n d s an d w ear of the resin m atrix resu lted in p ro tru s io n an d
eventual loss of the filler (Lam brechts et a l, 1982) and thus the w ear resistance of
these m aterials posed a severe limitation.

Since the early m aterials, com posites have tended to w ard s a decrease in filler
size. The hom o g en o u s m icrofilled com posite w as in tro d u ce d in 1977, and
contained m icrofillers, extrem ely small diam eter silica particles (0.01 -0.1 jum).
The size of the particles, w hile giving a m aterial w hich could be polished to a
high lustre, lim ited the filler loading because of the increased viscosity of the
resin. To overcom e this, an indirect m ethod of filler blending w as introduced;
p rep o ly m erised blocks of resin containing a high filler lo ad in g of silica w ere
g ro u n d to pro d u ce filler particles of 5-30 jum diam eter (Willems et a l, 1992).
These w ere b len d e d w ith resin and m ore silica filler to p ro d u ce the final
heterogeneous m icrofilled resin (Soderholm, 1985). H ow ever, despite this, very
few of these m aterials attained a 50% loading (Willems et a l, 1992). The m aterials
h ad excellent aesthetics w ith good polishability. However, they exhibited poorer
physical pro p erties, in clu d in g a greater polym erisation shrinkage, th a n the
conventional com posites (Lutz & Phillips, 1983).

21
To com bine the physical properties of the macrofillers w ith the polishabililty of
the m icrofillers, h y b rid m aterials w ere developed. These contained a blend of
conventional barium or strontium glass particles, together w ith som e subm icron
particulate silica. The early hybrid m aterials used filler loadings of about 75% of
the m acrofiller particles (1-50 //m) an d 8% of the su b m icro n size (average
0.04 ^m), and in so doing, achieved a total filler of 83% or greater (McCabe, 1990).
M ore recently there has been a tendency tow ards sm aller conventional filler
particles of less than 1 jum diam eter (Willems et al., 1992). W hile the use of the
m icrofillers reduces the w ear difference betw een the conventional fillers an d the
m atrix, the surface of hybrid restorations is not as sm ooth nor as w ear resistant as
the heterogeneous microfilled m aterials (Lutz & Phillips, 1983).

C urrent m aterials are sophisticated form ulations w ith a broad range of particle
sizes and filler loadings. The new er m aterials contain a sm aller m ean particle
size and have fewer of the macrofillers than the com posites of a decade ago. The
m ajority of the current m aterials in commercial use are 'hybrid' m aterials of tw o
size ranges (Ferracane, 1995) and are classified as m id-w ay filled an d com pact-
filled w ith classifications of ultrafine and fine in each (Figure 2.1)(Willems et a l,
1992).

Overall, the tren d in fillers in com posite resins has been from relatively low to
high filler loadings, large to small particle size, and from hard to relatively soft
fillers. H ow ever, despite these changes, the problem of polym erisation shrinkage
still rem ains a concern. P roviding the increase in viscosity does not have an
adverse effect, an increase in filler loading reduces the polym erisation shrinkage.
H ow ever, Shen an d S arrett (1992) d em o n strated th a t w h en the degree of
polym erisation shrinkage was the same, the resin com posite w ith the low er filler
content w as able to delay microleakage longer than the m aterial w ith the higher
filler content.

In an attem p t to further reduce the degree of polym erisation shrinkage, recent

research has focused on the d evelopm ent of experim ental resins containing
nanofillers (Table 2.3). These fillers perm it overall filler levels of 90-95% by
w eight and as a result there is a significant reduction in polym erisation shrinkage
w h en com pared to other com posite resins (Bayne et a l, 1994). O ther recent

23
studies, in contrast to the trend of using fillers of decreasing size, have used glass
fibres as reinforcing fillers and have rep o rted im provem ents in the fracture
toughness and w ear resistance of the m aterial (Li et a l, 1993)

A n a lte rn a tiv e to c o n v e n tio n a l co m p o sites w h ic h re s u lts in re d u c e d

p o lym erisation shrinkage (Donly et a l, 1989; G eorge & R ichards, 1993) an d
re d u c e d m icro leak ag e (Bow en & Setz, 1986) has also b een d e v e lo p e d .
'M egafilled' com posite restorations are produced by filling the bulk of the cavity
w ith one of a num ber of shapes and sizes of beta-quartz glass inserts. The inserts
are su rro u n d e d by light cured com posite and bon d to the resin via a silane-
coupling agent.

2.3.3.3 The interfacial phase: coupling agents

The bond betw een the filler and resin m atrix is essential for m axim um physical,
m echanical and optical properties. Two m odes of b o n d in g have been used;
m icrom echanical and m ore com m only, chemical. In the form er, a porous filler
surface is p roduced by either etching w ith strong acid (Bowen & Reed, 1976) or
sin terin g the particles to g eth er (E hrnford, 1983). The m echanical b o n d is
achieved by resin flow into the porosities.

C hem ical b o n d in g involves the coating of the filler particle w ith a coupling
agent. The m ost com m only used agent is y-m ethacryloxypropyltrim ethoxy silane
(Soderholm , 1985). This is a bifunctional molecule; a m ethacylate group at one
end of the m olecule bonds covalently w ith the resin, and a silane g roup at the
other end is capable of bonding ionically w ith the filler. A bifunctional coupling
agent cannot be used for microfilled com posites because of the organic nature of
the filler. In these m aterials bonding occurs by polym erisation. H ow ever, there
is a ten d en cy for the b o n d stren gth to be poor because there are very few
m ethacylate m olecules available in the highly cured filler, and m icrom echanical
entanglem ent of m atrix into filler is lim ited because of the viscosity of the matrix.

2.3.4 G lass-ionom er cem ents

D erived from silicate cem ents and polycarboxylate m aterials, glass-ionom er

cem ent has been available since 1975 and, until recently, w as the only truly
chemically adhesive filling m aterial available in dentistry. It sets via an acid-base

24
reaction b etw een ion-leachable calcium alum inium fluorosilicate glass p o w d er
an d the p olym ers an d copolym ers of acrylic an d m aleic acid. The precise
m echanism of b o n d in g to enam el and dentine is unclear, b u t the m ost likely
theory is that it is achieved via ionic bonding of carboxylate groups in the cem ent
to apatite calcium ions, resulting in an ion-exchange layer betw een the cem ent
and the dentine. This m echanism w ould account for the greater bond strength
found w ith enam el (5 MPa) than w ith dentine (1-3 MPa). The bond form s in the
presence of w ater b u t is not stable and breaks dow n. H ow ever, it re-form s over
an d over again, thus providing a dynam ic bond betw een the tooth an d cem ent
(Ellis et al., 1990). A dditional bonding betw een the carboxylic acid groups of the
glass-ionom er cem ent and the reactive groups w ithin the dentine collagen, either
by h y d ro g en bon d in g or by m etallic ion bridging, has been suggested (Craig,
1997). The settin g reaction occurs in four stages; salt form ation, s o l/g e l
form ation, hardening (continuation of the so l/g el formation), and hydration w ith
w ater b o u n d to a salt, acid groups and a gel (W ilson & M cLean, 1988). This
reaction is d em o n strated by the presence of a clearly identified ion exchange
layer adjacent to the dentine in desiccated specimens.

The m aterial is dispensed as either a pow d er and liquid or in an encapsulated

form. In the earliest m aterials, the polym er acid was incorporated in the liquid,
an d the glass p o w d er m ade u p the pow der. M ore recently, the h an d lin g
p ro p erties have been im p ro v ed by b lending freeze-dried polym er acid and
tartaric acid w ith the glass pow der, which is then m ixed w ith water.

W hile the cem ents exhibit a degree of p o lym erisation shrin k ag e sim ilar to
com posite resins, it occurs over a longer period of time and is com pensated for
by flow. It is therefore of less significance than the contraction experienced by
the resins. This, plus their coefficient of therm al expansion (8 -1 6 ,10'6 “C '1) w hich
is sim ilar to that of tooth structure (8-11, 10'6 “C '1) has resulted in a m aterial that
exhibits little m icroleakage w hen com pared to the com posite resins (M ohanda &
Reddy, 1993). In addition, the cem ent m atrix contains significant quantities of
fluoride ions that readily diffuse to the surface of the restoration. The fluoride
ions are either w ashed aw ay by the saliva, or u n d erg o a reaction w ith the
su rro u n d in g tooth substance, thereby increasing the acid resistance of the tissue
(M ukai et al., 1993). The low incidence of leakage and the slow release of fluoride
w o uld suggest that glass-ionom er restorations were less likely to be subject to

25
caries. Indeed, several clinical investigations found that secondary caries rarely
d ev elo p ed adjacent to glass-ionom er m aterials (Knibbs, 1988; M ejare & Mjor,
1990). H ow ever, these studies w ere of sh o rt d u ratio n , an d m ore recently,
secondary caries has been rep o rted as the m ain reason for the replacem ent of
glass-ionom er restorations in general practice (Mjor, 1996; W ilson et a l, 1997).
N evertheless, the bonding to enam el and dentine and the low m icroleakage are
favourable properties. In spite of this, the clinical applications of glass-ionom er
cem ents are lim ited because of their p ro lo n g ed setting tim e w h ich d elay s
finishing and polishing for approxim ately 24 hours, their sensitivity to m oisture
d u rin g in itial h a rd e n in g , d e h y d ra tio n , th eir ro u g h su rface te x tu re a n d
opaqueness, and their inferior strength and w ear resistance.

2.3.5 Resin-modified glass-ionomer cements

The resin-m odified m aterials are a variant of the glass-ionom er m aterial an d

w ere d ev elo p ed to im prove the h an d lin g and w orking characteristics of the
original form ulation, w hile utilising som e of the ad v an tag eo u s p ro p erties of
com posite resin. They are fluoride-releasing, m ulti-cured m aterials and are m ore
aesthetic and less technique sensitive than the conventional glass-ionom ers. The
m aterials are p red o m in a n tly glass-ionom er, up to 80%, w ith 20% light-cured
resin and they are dispensed as tw o com ponent systems. The po w d er is sim ilar
to the p o w d e r in co n v en tio n al glass-ionom er system s, b u t the liq u id is
hy d ro x y eth y lm eth acry late (HEMA), w ater and a polyacid, w ith or w ith o u t
p en d an t m ethacrylate groups. The setting reaction occurs in tw o stages. The
first, an acid-base reaction, produces a gel th ro u g h polyvalent m etal-ion cross-
linking of the polyacid-sol. W hen placed on the tooth, free carboxylate groups
form a dynam ic bo n d w ith apatite. The second stage involves a photoinitiated
setting reaction betw een m ethacrylate m olecules grafted on to the polyacrylic
acid chain and the m ethacrylate g roups of the HEM A or polyH EM A . The
resu ltan t cross-linking causes rap id h ard en in g and increased stren g th to the
m aterial. In addition, some m aterials such as Vitrem er (3M D ental Products, St
Paul, MN, USA) exhibit a third setting reaction. This m aterial has an auto-cure
in itiator-catalyst system for resins w hich starts w hen the p o w d er an d liquid
in g re d ie n ts are m ixed to g eth er (C hristensen, 1997). In com m on w ith the

26
co n v en tio n al m aterials, d esiccated specim ens show a w ell d e lin e a te d ion
exchange layer at the dentine interface (Hallett & Garcia-Godoy, 1993).

Resin m odified glass-ionom er m aterials have significantly b etter m echanical

p ro p erties, lo w er w a te r so lu b ility an d m o istu re sen sitiv ity a n d re d u c e d
brittlen ess th an the conventional glass-ionom er m aterials. They also exhibit
com parable fluoride release (Forsten, 1995) an d im proved b o n d stren g th s to
dentine (Lin et al., 1992). H owever, one distinct disadvantage of these m aterials
is their lim ited light-curing depth. The m axim um d ep th of cure is 2 m m and
therefore renew ed m ixing m ay be necessary for m aterials dispensed as a pow der
and liquid w hen the m aterial is used in deeper layers.

2.3.6 Polyacid-modified composite resins

The polyacid-m odified com posite resins (com pom ers), introduced in 1991 as a
one-paste restorative m aterial avoided the necessity of renew ed m ixing for large
cavities. Like the resin-m odified glass-ionom er cements, com pom ers com bine
the favourable properties of the base m aterial, in these m aterials, com posite resin,
w ith those of the glass-ionom er cements. They are used in com bination w ith a
fifth generation dentine bonding agent, and therefore avoid the tim e-consum ing
techniques of the fourth generation agents.

T here has been co n sid erab le confusion in the p u b lish e d lite ra tu re over
n o m en clatu re, w ith resin -m o d ified glass-ionom er cem ents re fe rre d to as
com pom ers and vice versa. McLean et al (1994) distinguished the two m aterials
by their setting characteristics. They noted that w hile bo th h ad an acid-base
setting reaction, the reaction for the com pom ers w as not sufficient to allow
curing in the dark and therefore these m aterials relied on photopolym erisation to
achieve adeq u ate curing. M oreover, these m aterials lacked the ion-exchange
bonding m echanism seen w ith the resin-m odified glass-ionom er materials.

C ontaining approxim ately 30% glass-ionom er cement, com pom ers are prim arily
light-cured, low fluoride-releasing com posite resins w ith single com ponent
bonding system s. Bonding is achieved by the form ation of a hybrid layer w ith
m odification of the sm ear layer. In addition to this m icrom echanical retention,
adhesion via ionic bonds betw een phosphate groups in the prim er and calcium

27
ions in hydroxyapatite is also claimed for some m aterials, though it is not found
w ith the com pom er m aterial used in this stu d y The m aterials also have good
h andling characteristics and excellent colour m atching.

Burgess et al (1996) com pared the m echanical properties of the cu rren t direct
aesthetic m aterials. W hilst the com pom er m aterials h ad im p ro v ed m echanical
properties over the conventional glass-ionom er cem ents and the resin-m odified
m aterials, they exhibited g reater polym erisation shrinkage (% volum e). In
addition, the polym erisation shrinkage and w ear of the m aterial did not com pare
favourably to that of the com posite resin m aterials. Therefore, w ith the exception
of selected clinical situations in the p erm an en t dentition, these m aterials are
u su ally reco m m en d ed for the restoration of p rim ary teeth only. Use in the
p e rm a n e n t d e n titio n is restricted to resto ratio n s in lo w -stress areas an d
provisional Class I and Class II restorations. Furtherm ore, in com m on w ith the
com posite resins, the use of com pom ers is lim ited to areas w hich can be reached
by polym erising light.

2.3.7 The causes of restoration failure

The p u rp o se of restoring a carious tooth an d the ideal p ro p erties of direct

restorative m aterials were outlined in Section 2.3.1. In addition to these criteria,
it is essential that the restoration is durable. Studies investigating the reasons for
failed re sto ra tio n s hav e freq u e n tly reco rd ed d isco lo ratio n a n d m ate ria l
degradation. The incidence of these findings has decreased as the quality of the
m aterials has im proved (Kidd et a l, 1992). H ow ever, the m ost com m on reason
cited for the replacem ent of restorations ro u n d the w orld is secondary caries
(Kidd et ah, 1992; Mjor & Toffenetti, 1992; Mjor & Um, 1993; Friedl et al., 1995;
Mjor, 1996; W ilson et a l, 1997).

Histological exam ination of the secondary carious lesion reveals two regions; the
'outer lesion' in the surface enamel, form ed as a result of prim ary attack, and the
'wall lesion' form ed in the cavity wall (Hals & Nernaes, 1971). The w all lesion is
form ed as a result of the flow of bacteria, fluids, ions and molecules etc. betw een
the cavity w all and the restoration. This flow, k n o w n as m icroleakage, is
clinically undetectable. In ad d ition to the developm ent of secondary caries,
m icroleakage has also been im plicated in the d ev elo p m en t of d isco lo u red

28
m argins, pulp al changes, and post-operative sensitivity (Brannstrom & N yborg,
1972; Bauer & H enson, 1984; B rannstrom , 1986). It is essential therefore, that
m icroleakage is controlled if the long-term integrity of the restoration is to be
assured.

2.4 Microleakage

M icroleakage arises because of the presence of a m icrospace (m arginal gap) at the

cavity w a ll/re sto ra tio n interface (CRI). This gap is form ed as the resu lt of
dim ensional instability arising from polym erisation shrinkage, differences in the
coefficients of therm al expansion betw een the restorative m aterial and the tooth,
and the lack of com plete ad aptation and adherence of the m aterial to the cavity
w all (Brow ne & Tobias, 1986). Thus m aterial and cavity p rep aratio n factors
influence the degree of microleakage seen at the CRI.

In this study, m icroleakage is used to evaluate the influence cavity p rep aratio n
w ith the Erbium:YAG (Er:YAG) laser has on the seal of Class V com posite and
com pom er restorations. The literature covering m icroleakage is im m ense an d
therefore, unless otherw ise indicated, the follow ing review w ill be confined to
the assessm ent of com posite and com pom er restorations in Class V cavities, the
restorations u n d er investigation in this study.

2.5 Methods of assessing microleakage

2.5.1 Introduction

A test for m icroleakage should fulfil certain criteria: it sh o u ld be relatively

inexpensive, require m inim al specialist equipm ent and should be technique and
operator insensitive. In addition, the test should provide a m easure that is both
clinically relev an t an d rep resen tativ e of the cavity as a w hole. Finally,
lo n g itu d in al assessm ent should be possible. That the ideal test has yet to be
found is reflected in the w ide range of tests reported in the literature. To date,
the m arginal gap at the CRI has been assessed by m easuring the penetration of
tracer m olecules and bacteria, and the flow of fluids or an electric current along
the CRI, by visual exam ination of the CRI, or by sim ulation of the carious lesion.

29
All m eet certain of the criteria, b u t none provide the 'ideal' test. In this study,
m icroleakage w as assessed by m easuring the p en etratio n of an organic dye,
m ethylene blue, along the CRI. A detailed review of the other techniques is
beyond the scope of this thesis. H ow ever, a sum m ary of their advantages an d
disadvantages is given in Table 2.4.
2.5.2 Penetration of tracer molecules
Studies involving the use of tracer molecules are the m ost com m only reported in
the field of microleakage. Four types of tracer have been described; organic dyes,
radioactive isotopes, non-radioactive chemical tracers and neutron activated ions.
The latter is an expensive technique and is rarely used. The review of the
tech n iq u e has therefore been lim ited to the sum m ary of its ad v an tag es and
disadvantages found in Table 2.4.

V ariations in experim ental m ethodology have been reported for the other three
types of tracer, and there are also differences in the w ay in w hich the leakage is
assessed. H ow ever, by far the m ost recent reported studies have used an in vitro
im m ersion m ethod: following preparation, the restored tooth is sealed by wax or
nail varnish leaving a w indow su rrounding the restoration. It is then im m ersed
in the tracer solu tio n for a p red eterm in ed period, before being rin sed an d
assessed for m icroleakage. A variety of leakage 'scoring' m ethods have been
used. The m ost com m on m ethod of evaluating leakage for dye, and indeed the
m ethod used in this study, has been to m easure the tracer penetration along the
CRI in one plane of section. There are inherent errors in this w hich are com m on
to the three tracer techniques and it is therefore pertinent to consider these before
describing the individual techniques.

2.5.2 .1 Single section assessment of microleakage

Follow ing dye im m ersion, the tooth is sectioned through the m id-point of the
resto ratio n and each section is exam ined u n d er m agnification. The leakage is
either m easured w ith a m easuring ocular, or is assigned a num erical score w hich
increases w ith the degree of leakage. Several scoring system s have b een
described. Routinely, both sections are scored and the w orst score is taken for
each m argin.

30
 Table 2.4 A summary of the advantages and disadvantages of some
Technique
P enetration o f b acteria
a . C u lturin g tech n iqu e s
b. H is to b a cte rio lo g ica l
tech n iqu e s
Artificial c a r ie s
N eutron activation
a n a ly s is
Flow of flu id s or
e lectrica l current
a. A ir p re ssu re
b. L iq u id p re ssu re
c. E le ctro ch e m ica l
Visual exam in ation
a. L ig h t re fle cte d
m icro sco p y
b. S can n ing e lectron
m icro sco p y
microleakage tests
Advantages
O f s o m e clinical re le v a n c e
P u n c h s a m p lin g p e r m its a n a ly s is of s e v e r a l p o in ts
a lo n g t h e C R I of to o th s e c tio n s
T o o th s e c tio n in g is n o t re q u ir e d for all te c h n iq u e s
A s s e s s e s t h e viability of b a c te ria
In vivo m a tu rin g is p o s s ib le
O f s o m e clinical re le v a n c e
M e a s u r e s d e p th of p e n e tra tio n
In vivo m a tu rin g is p o s s ib le
C linically re le v a n t te s t
P ro v id e s a q u a n tita tiv e a n a ly s is for in vitro a n d in
vivo m a tu rin g s tu d ie s
L o n g itu d in a l a s s e s s m e n t p o s s ib le s in c e s p e c im e n
s a c rific e is u n n e c e s s a r y
Q u a n tita tiv e a n a ly s is .
L e s s v u ln e ra b le to p re p a ra tio n e r ro rs w h e n
c o m p a r e d to t r a c e r m e th o d s
l e a k a g e a s s e s s m e n t n o t lim ited to a p la n e of
s e c tio n
As above
As above
P o s s ib le to v is u a lis e le a k a g e with a d y e.
S im u la te s fluid sh ifts d u e to p e rm e a b ility of d e n tin e
fo u n d in vivo
As above
N o d ry in g effec t
O b s e r v e s a d a p ta tio n of re s to r a tiv e m a te ria l
L o n g itu d in a l a s s e s s m e n t is p o s s ib le if lim ited to
th e m a rg in a l g a p a t th e e n a m e l s u rf a c e only
P h o to g r a p h s p ro v id e a p e r m a n e n t re c o rd of g a p
s iz e
V is u a lis a tio n of g a p c a n b e e n h a n c e d by u s e of
flu o re s c e n t re sin
In vivo a n d in vitro a s s e s s m e n t of e x te rn a l s u rf a c e
of re s to r a tio n is p o s s ib le w ith th e u s e of re p lic a s
G r e a te r d e p th of fo c u s a n d re s o lu tio n th a n light
m ic ro s c o p y a n d is p o s s ib le to e x a m in e la rg e
s p e c im e n s th ro u g h e v e ry p o s s ib le a n g le
M icro g rap h p ro v id e s a p e r m a n e n t re c o rd
L o n g itu d in a l s tu d y in vivo a n d in vitro is p o s s ib le
u s in g re p lic a s
31
Disadvantages
R e q u ire s p e c ia lis e d te c h n iq u e s a n d e q u ip m e n t, a n d a tra in e d m ic ro b io lo g ist
Q u a lita tiv e m e a s u r e : th e p r e s e n c e o r a b s e n c e o f b a c te ria /c lo u d in g
o n ly a c c o u n t s fo r g a p s of > 0 .5 - 1 .0 pm
O rigin of b a c te r ia is n o t d e f in e d
S tr in g e n t sterility c o n d itio n s re q u ir e d
A n tib a c te ria l p ro p e rtie s of m a te r ia ls will in flu e n c e re s u lts
A s for cu ltu rin g t e c h n iq u e s , a n d :
S p e c im e n s a c rific e is n e c e s s a r y a n d s e ria l e x tr a c tio n s re q u ir e d
G ra m n e g a tiv e b a c te r ia m a y n o t b e re a d ily d e t e c t e d
M ay n o t d e te c t all ty p e s of o rg a n is m s
V iability of b a c te r ia is n o t a s s e s s e d
B a c te ria m a y b e lost d u rin g p r o c e s s in g
S u b je c tiv e m e a s u r e m e n t (d e p th of ca v ity )
S p e c im e n s a c rific e is m a n d a to r y a n d t h e r e f o r e lo n g itu d in a l a s s e s s m e n t is
n o t p o s s ib le
P r o c e s s Is tim e c o n s u m in g a n d re q u ir e s s p e c ia lis t e q u ip m e n t
L im ited u s e with a c id - e tc h e d r e s to r a tio n s ; m ild d e m in e r a lis a tio n s e e n w ith
a c id e tc h in g h a s a sim ilar m ic ro s c o p ic a p p e a r a n c e to a r e a s of
d e m in e r a lis a tio n s e e n in e a rly c a r io u s le s io n s r e s u lts in difficulties in
in te rp re ta tio n
T e c h n iq u e is c o stly , h a z a r d o u s a n d r e q u ir e s s p e c ia lis t e q u ip m e n t a n d
n u c le a r e n g i n e e r s
T h e a r e a of le a k a g e is n o t d e f in e d a n d a b s o r p tio n of t h e t r a c e r a t s i te s o th e r
th a n t h e r e s to r a tiv e m a rg in s c a n n o t b e d is tin g u is h e d
In vivo im m e rs io n re q u ir e d s i n g le -s ta n d in g te e th
D ire ctio n of le a k a g e is t h e r e v e r s e to th a t s e e n clinically a n d th e r e f o r e 'blind-
e n d in g ' l e a k a g e c h a n n e l s a r e n o t d e t e c t e d — m a y u n d e r - r e p r e s e n t
m ic ro le a k a g e
S p e c ia lis t e q u ip m e n t is re q u ir e d
In vivo in v e s tig a tio n is n o t p o s s ib le
p a s s a g e of air p r e v e n ts t h e s ta g n a tio n w hich m a y b e e x p e c t e d clinically
a lo n g t h e C R I a n d m a y h a v e a d ry in g e ffe c t o n t h e to o th a n d r e s to r a tio n .
M ay g e t le a k a g e of a ir th ro u g h clinically s o u n d to o th t is s u e . L e a k a g e is
difficult to lo c a lis e a n d p h o to g ra p h
V a ria tio n s in d e n tin e p e rm e a b ility b e c a u s e of a g e in g , follow ing c a v ity
p re p a ra tio n a n d in te r-to o th v a ria tio n s
E n a m e l, d e n tin e a n d m a te ria l c o n d u c t a n c e m a y in flu e n c e re s u lts
D o e s n o t d iffe re n tia te b e tw e e n c o n d u c t a n c e a t C R I a n d w ithin to o th
s u b s t a n c e a n d r e s to r a tiv e m a te r ia ls
In d ire ct m e a s u r e
A s s e s s m e n t of e x te rn a l s u r f a c e on ly g iv e s n o in d ic a tio n of d e p th of g a p
D e p th a s s e s s m e n t re q u ir e s s a m p le s a c rific e a n d p ro h ib its lo n g itu d in a l
asse ssm e n t
P o lis h in g of re s to r a tio n s a n d p re p a ra tio n of s p e c im e n m a y p r o d u c e a r te f a c ts
V ery lim ited d e p th of fo c u s a n d re s o lu tio n
L a tte r m a y b e im p ro v e d with u s e of m e ta l- s h a d o w e d re p lic a s
S m e a r p ro d u c e d d u rin g p o lish in g a n d s e c tio n in g m a y b lo ck g a p o r p r o d u c e
a r te fa c ts
E x p e n s iv e a n d s p e c ia lis e d e q u ip m e n t re q u ire d
A s s e s s m e n t of g a p d e p th n e c e s s i t a t e s s p e c im e n s a c rific e
A rte fa c ts m a y b e p ro d u c e d d u rin g s e c tio n in g o r a s a re s u lt of d ry in g d u rin g
p r o c e s s in g . T h e u s e of r e p lic a s o r ion e tc h in g r e d u c e t h e s e e r ro rs
As noted in Section 2.5.2, there are inherent lim itations and errors associated w ith
this m ethod of assessm ent: the sacrifice of the tooth precludes any longitudinal
assessm ent of m icroleakage for that particular specim en and the scoring, despite
being carried out by m ore than one exam iner is som ew hat subjective. Indeed, it
is im possible to obtain quantitative, objective m easurem ents w ith the scoring
system s described. H owever, a major problem , irrespective of the sophistication
of the m easurem ents and the statistical analysis em ployed, is the interpretation of
the resu lts from a tw o dim ensional im age into a th ree-d im en sio n al m odel.
Expressing the degree of leakage as a num bered score (Saunders et al., 1990), or a
calibrated m easurem ent (Pintado & Douglas, 1988; D ouglas et al., 1989) can be
affected by the position and angle of sectioning and is unlikely to provide a true
p a tte rn of leakage. The leakage found at one section is also not necessarily
re p resen tativ e of the w hole cavity (R oydhouse, 1968); M ixson et al (1991)
reported an increased leakage at the end-surfaces of the restorations. V ariation in
leakage is p articu larly likely w hen investigating dentine b o n d in g w here the
d istribution of organic and inorganic com ponents is not uniform , the bonding is
unlikely to be a continuous uniform attachm ent. In their pilot study, using a
non-radioactive chemical tracer m ethod, W enner et al (1988) scored six surfaces
of three sections and found that the probability of a false negative exceeded 33%
if only one random site was scored.

The use of the w orst score of both sectioned surfaces attem pts to reduce the effect
of these lim itations. H ow ever, other m ethods of scoring an d assessm ent have
b een described for each penetration technique. These will be described in the
relevant sections.

2.5.2.2 Organic dye penetration

In one of the earliest reported studies on the use of a dye, Fletcher (1895) (In
Blackwell, 1955) studied the shrinkage of am algam using an organic dye. Since
then the technique has seen several modifications. The early studies investigating
non-com posite m aterials, u sed roughened glass tubes to sim ulate the dental
tissue surface (Grossm an, 1939; M assler & Ostrovsky, 1954), b u t m ore recently,
extracted hum an or bovine teeth have been used.

32
The degree of dye penetration can be influenced by the experim ental conditions
an d p roperties of the tooth and dye. For instance, dye p en etratio n is red u ced
th ro u g h sclerotic and secondary dentine, w hereas, the penetration of dye along
the resto ratio n / tooth interface in studies investigating the leakage of root fillings,
w as fo u n d to increase w h en the e n trap p ed air w ith in the to o th /re s to ra tio n
system w as rem oved. This w as achieved by placing the resto red to o th in a
vacuum before im m ersion into the dye solution (G oldm an et al., 1989; Spanberg
e ta l, 1989)

P erh ap s of g reater significance is the choice of dye. D yes are p ro v id e d as

solutions or particle suspensions, and their behaviour is influenced by the size of
the m olecule or particle, polarity and type and concentration of the dye. The
penetration tim e of different concentrations of the sam e dye have been found to
vary b etw een five m inutes and one h o u r (C hristen & M itchell, 1966). A ny
in teractio n betw een the dye, restorative m aterial an d tooth tissues is also of
im portance. Some dyes have the propensity to bind to tooth substance or the
restorative m aterial. For exam ple, preparations of basic fuchsin solutions have
been show n to bind preferentially w ith carious dentine (Kidd et a l, 1989). While
valuable for the m anufacture of caries-disclosing agents, the use of tracers w ith
this property confounds microleakage assessment.

M ethylene blue is one of the m ost com m only used dyes. It penetrates the w ater
co m p artm en t of the tooth easily, and is readily detected u n d e r visible light.
H ow ever, a w ide variety of types and concentration of dye and im m ersion times
have been u sed w hich precludes direct com parisons b etw een m ost stu d ies
(Taylor & Lynch, 1992). In addition, colouration of the bonding layer m ay also
give false positive scores (Feilzer et a l, 1995b).

M odifications of the single section scoring system described in Section 2.5.2.1

have included the use of w eighted scores (Glyn Jones et a l, 1979), the evaluation
of the proportion of the cavity m argin at the tooth surface w hich is stained (Itoh
et a l, 1981) and the average of several sections (Dejou et a l, 1996). H ow ever,
these system s are all lim ited by their qualitative nature. Several w orkers have
recently evaluated the m icroleakage seen w ith com binations of different bonding
agents and com posite resins using a quantitative m ethod of dye p enetrations
analysis, the dye-recovery spectrophotom etric test (Rigsby et a l, 1990; Liu et al,

33
1993). In this m ethod, first described by D ouglas and Z akariasen in 1981, dye
p en etratin g the CRI is recovered by im m ersing a restored section of the tooth in
50% n itr ic a c id . T he dye c o n c e n tr a tio n is th e n d e te r m in e d
sp e c tro p h o to m e tric a lly an d the m icroleakage scored as V g of dye' p er
re sto ra tio n . T his m e th o d allo w s the d ire ct m e a s u re m e n t of leak ag e
volum etrically and is easily executed, giving m inim al h u m an error. H ow ever, it
does not differentiate betw een enam el and dentine leakage and there is also the
tendency for artificially high results because the recovered dye will include any
dye p en etratio n of the tooth tissue su rro u n d in g the restoration. Rigsby et al
(1990) com pared the quantitative leakage assessm ent, as evaluated by the dye-
recovery spectrophotom etric test, w ith a qualitative dye penetration technique
for three dentine b o n d in g /re sin restorative system s and found that, despite the
use of different dyes, the rank orders for m icroleakage were the sam e for the two
tests. O ne variation of the dye-recovery technique is the use of im age analysis
ap p aratu s linked to a stereom icroscope. This perm its quantification of both the
length of dye penetration at the resto ratio n /to o th interface (Fayyad & Ball, 1987)
and the percentage area of dye penetration in dentine (Glyn Jones et al., 1988).

A n alternative use of spectrophotom etry using a rhodam ine B dye tracer w as

described by H arashim a et al (1992). A restored 'plate' of tooth w as m ounted on a
jig w ith a therm ocycling Tine' on one side and a detection 'line' on the other. H ot
an d cold solutions of the dye w ere alternately cycled in the form er, and dye
leak ag e in the la tte r w as m e asu red at v ary in g tim e in te rv a ls u sin g a
spectrom eter. W hile there are obvious lim itations in the use of a tooth 'plate', this
technique perm itted a quantitative, longitudinal analysis.

A nother technique w hich does not require specimen sacrifice, has been described
by several w orkers an d has been used for longitudinal analysis; follow ing
exposure to the dye, the m argins of the restoration at the tooth surface w ere
exam ined to establish the p ro p o rtio n show ing staining (Tsuchiya et al., 1986).
W hilst this gave an indication of m arginal adaptation of the surface, it gave no
m easure of the extent of dye penetration tow ards the pulp. It does, how ever,
perm it in vivo m aturation and evaluation (Itoh et a l, 1981) w hich is in contrast to
all the other techniques described so far.

34
In sum m ary, allow ing for its lim itations, dye p enetration continues to be the
m ost com m only used test for m icroleakage. It is sim ple, inexpensive and, by
relying on a physical effect, does not require the success of a chem ical reaction or
the use of hazardous m aterials. The technique also allows for the placem ent of at
least tw o resto ratio n s in one tooth, thus p erm ittin g b o th control an d test
resto ratio n s to be placed in the sam e tooth. This reduces som e of the errors
incurred by inter-tooth variations in dentine and enamel.

2.52.3 Radioactive isotopes

Several w orkers have used au to radiography to dem onstrate isotope presence

w ith com posite restorations (Oritz et a l, 1979; H em bree, 1984; S aunders et al.,
1990;- H all et al., 1993). W ith this technique, penetration of radioactive tracers
along the CRI is detected on a radiograph. Accurate evaluation is d ep en d en t on
the experim en tal technique, the choice of isotope, and the reso lu tio n of the
autoradiograph: the d ep th of m arginal penetration of the isotope is influenced
by the ionic exchange and chemical reactivity of the ion, as w ell as the physical
and chem ical n ature of the filling m aterial (Going et al., 1960). Several isotopes
have been u sed, the m ost com m on being 45Ca as CaCl2 because it is easily
obtained and, as w eak beta em itter, produces clear autoradiographs. H ow ever,
ionic exchange w ith the calcium of apatite crystals can occur and will interfere
w ith the recognition of the true p attern of leakage. As an alternative, som e
w orkers have u sed isotopes w ith a very long half-life such as 14C-urea. This
allow s the rep eat p ro d u ctio n of au to rad io g rap h s w ith o u t loss of activity or
change in the darkening of the film .

The resolution of the autoradiograph is influenced by:

• the choice of isotope; the use of an isotope w ith low er energy gives greater
resolution.
• the to o th /em u lsio n distance; the smaller the distance, the better the resolution
• the length of exposure time of the film; longer exposure times result in poorer
resolution.
• the developm ent of the autoradiographs

The technique has several lim itations in its use as a detector of m icroleakage:
difficulties can arise in interpreting the films because the solubility of the tracer

35
solutions and the propensity for isotope absorption of m any restorative m aterials
can lead to contam ination of the specim en (Going et al., 1960). In addition, the
se p a ra tio n of the film from the tooth for processing m eans th a t the exact
relationship betw een the im age and the underlying tooth structure is lost. The
use of a strip-on film allow ing the tooth and film to rem ain in contact d u rin g
p ro cessin g an d assessm ent has gone som e w ay to a d d ress these p roblem s
(M artin, 1951). In com m on w ith dye penetration studies, the qualitative nature
of the assessm ent, and the variety of exposure tim es to the radioisotope solution
renders direct com parison betw een m any studies impossible.

In an attem pt to avoid the errors these, and the use of a single section technique,
incur, tw o q u a n tita tiv e techniques have been described; the radiochem ical
diffusion m ethod (Sorem ark & Bergman, 1961; C risp & W ilson, 1980) an d the
reverse radioactive absorption technique (Vasudev et al., 1981; H errin & Shen,
1985). A lthough not w ith o u t their ow n lim itations, both have the advantage of
allow ing longitudinal analysis of the specimen.

2.5.2A Non-radioactive chemical tracers

Relying u p o n the reaction of tw o or m ore chemicals, the use of non-radioactive

chem ical tracers is second only to dye p enetration studies in p o p u larity . In
recent studies, leakage has been detected by the sequential p en etratio n of tw o
colourless chemical tracers, a silver salt, com m only silver nitrate, and an organic
radiographic developer such as benzene 1,4-diol (hydroquinone), w hich react to
p ro d u ce an o p aq u e precipitate. Silver grains are d ep o sited w here the tw o
chemicals come into contact.

The technique is said to provide a severe test of m icroleakage because of the

sm all size of the silver ion (0.056 nm) (Douglas et al, 1989). H ow ever the extent
to w hich the silver is p recipitated is lim ited to the p en etratio n of the larger
developer molecule. N evertheless, this technique, in com bination w ith scanning
electron m icroscopy (SEM) has been used, m ore recently, to identify the exact
plane of leakage at the d en tin e/restoration interface (Sano et al., 1994).

M any of the characteristics of chemical tracer studies are in com m on w ith the dye
pen etratio n techniques (Section 2.5.2.2). H ow ever, the ready penetration of the

36
b lack silver stain along the d en tin al tubules of an intact d en tin e surface,
particularly w here the dentine tubules are parallel to the cavity m argin, can m ake
interpretation difficult (Pintado & Douglas, 1988; D ouglas et al., 1989).

Several m ethods have been used to reduce the lim itations of the single section
scoring system. Various m ultiple-surface scorings have been tested; the average
score (Swift & H ansen, 1989) and the highest score (W enner et al., 1988) of six
surfaces have been used. Two three-dim ensional techniques have also been
described, one em ploying a com puter reconstruction from digitised serial im ages
of parallel ab rad ed sections (G ale et al., 1994), an d the other u sin g a clearing
m ethod involving citric acid, alcohol and glycerol or m ethyl salicylate (M arinelli
& Eichmiller, 1993; Tay et al., 1995).

O ne final technique u tilising the chem ical pro p erties of a tracer m aterial is
w o rth y of note because of its potential as a longitudinal in vivo detection agent.
Leinfelder et al (1986) developed a technique w hereby the cavity w as lined w ith a
calcium hydroxide base, and the release and 'reverse' penetration of hydroxyl
radicals w as m easu red at the external surface of the resto ratio n w ith litm us
p aper. This technique, although providing only qualitative data, is reliable,
biologically com patible and sim ple to execute. H ow ever, the sensitivity of the
test has yet to be evaluated.

2.5.3 In v iv o versus in v itro m icroleakage

A m ajor lim iting com ponent of m any of the techniques available for investigating
m icroleakage is the in vitro nature of the test. M any w orkers have questioned the
clinical relevance of such tests and have m odified the technique to include a
period of in vivo m aturing of the restored teeth prior to extraction an d analysis.
The results of such tests, w hen com pared to those carried out com pletely in vitro,
have varied. Sw artz and Phillips (1961) found that the in vitro m icroleakage for a
n u m b er of restorative m aterials w as com parable to th at o btained w h en the
restorations h ad m atu red in vivo (Phillips et a l, 1961). H ow ever these results
differed from those of Going et al (1968) w ho found that the in vivo leakage w as
greater than the in vitro, and Barnes et al (1993) w ho found the reverse to be true.
Some of these discrepancies will be because of the differences in experim ental
m eth o d and the leakage test em ployed. H ow ever other factors such as the

37
influence of p u lp al h ydrostatic pressure, m echanical loading and tem p eratu re
change are also contributory. These will be considered briefly.

2.5.3.2 Pulpal hydrostatic pressure

Stuever et al (1971) investigated the effect of pulpal hydrostatic p ressu re on the

m icroleakage of com posite restorations. They found th at vital resto red teeth
w h ich h a d b een im m ersed in the tracer dye p rio r to ex tractio n exhibited
significantly low er leakage th an either vital teeth im m ersed post-extraction, or
root filled teeth im m ersed in vivo. Their results com pared favourably w ith a
sim ilar stu d y of am algam restorations and offered an explanation for the greater
in vitro leakage found by Going et al (1968) w hich w as referred to in the previous
paragraph.

2.5.3.2 Mechanical loading

The in vitro developm ent of both p erm anent and transitory gaps at the CRI of
am algam restorations in axially loaded teeth w as first dem onstrated in 1970 by
Jorgenson et a l . This gap form ation has since been associated w ith an increase in
b acterial p en e tra tio n at the m argins of Class V com posite re sto ra tio n s in
functional teeth in vivo (Qvist, 1983). This phenom enon, k now n as 'm echanical
percolation' is d u e to differences in the viscoelastic p ro p erties of resto rativ e
m aterials and enam el and dentine.

Several w orkers have investigated the influence of m echanical loading on the in

vitro m arginal ad ap tatio n of com posite resins w ith conflicting results. M argins
placed entirely in etched enam el or bonded dentine w ere found to be able to
w ith stan d m echanical stresses (Stewart et a l, 1986; M u n k sg aard & Irie, 1988).
H ow ever, w hen the restoration w as placed at the cervical m argin and subjected
to b o th th erm al and m echanical stresses, gap form ation w as not seen at the
e n a m e l/re sin interface, b u t there w as evidence of leakage at the d e n tin e /re sin
m argin (Rigsby et a l, 1992) These results suggest that therm al an d m echanical
cycling has a synergistic effect on microleakage at the resin /d en tin e interface.

38
2.5.3.3 Temperature change

The increase in m icroleakage seen w ith a change in tem p eratu re w hich w as

rep o rted by Rigsby et al (1992), was first described in 1952 w hen fluid w as seen at
the m argins of gold, am algam and acrylic restorations w hich h ad been w arm ed
b y the fingers (N elsen et al., 1952). This phenom enon, k n o w n as th erm al
p erco latio n , arises because of the difference in the coefficients of th erm a l
expansion of enamel, dentine and the restorative m aterial, and to a lesser degree,
on the effect of the expansion of the fluid occupying the m arginal gap at the CRI.

In an attem pt to m ake the investigations m ore clinically relevant, it is com m on to

include a therm al stress com ponent, therm ocycling, in tests of m icroleakage. A
w id e range of therm ocycling conditions have been reported: tem peratures have
ran g ed from 0-68°C, w hich approxim ate the m axim um range of tem peratures
to lerated in the m o u th (Barclay, 1998). Im m ersion tim es have v aried from
m inutes to several hours w ith betw een 1 and 5,000 cycles. H ow ever, as the teeth
are exposed to the extrem es of tem p eratu re for a m axim um of one second
(Youngson et a l, 1998) shorter dw ell times are now m ore com m only used.

D esp ite the c o n tin u ed use of therm ocycling in stu d ies in v e stig a tin g the
m icroleakage of com posite restorations, the effect of the therm al stressing has
yielded conflicting results. A longside Rigsby et al (1992) several w orkers have
found th at this com ponent resulted in increased leakage (Lee & Sw artz, 1976;
Crim & M attingly, 1981; Crim ef a l, 1985; Eakle, 1986), w hich occurred gradually
rather than in a step-wise m anner (Momoi et a l, 1990). H ow ever, other w orkers
have found that it had no significant effect (Kidd et a l, 1978; W endt et a l, 1992).
W hilst variations in experim ental technique m ust be taken into account w h en
com paring these results, the ap p arent contradiction in results reflect in h eren t
differences in the com posite resins, in p articu lar the effect of hygroscopic
expansion (Asm ussen, 1976; Kidd et a l, 1978; A rends et a l, 1984). This w ill be
discussed further in Section 2.7.1.

2.6 M icroleakage in com posite resin restorations

Of all the den tal m aterials ever developed, m arginal leakage is the g reatest
concern for com posite resins because they have no germ icidal or antibacterial

39
properties, and there is no increase in sealing w ith age. The m ain cause of gap
fo rm a tio n at the CRI is the sig n ifican t sh rin k a g e th a t o ccu rs d u rin g
polym erisation. This varies betw een, and w ithin, the different generations of
resins b u t has been sh o w n to be of the o rd er of 1.67-5.68 volum e p ercen t
(G oldm an, 1983). Polym erisation shrinkage has also been im plicated in crack
form ation at the enam el m argins (Asm ussen & Jorgensen, 1972; A sm ussen, 1975)
alth o u g h cavity p rep aratio n w ith a b u r has also been found to have a sim ilar
effect (Section 2.9.1).

D uring polym erisation, shrinkage of the m aterial occurs as the long m onovalent
bonds are converted into shorter, stronger covalent bonds. This results in the
b u ild u p of internal stresses w ithin the m aterial. In the initial stages of curing,
these'forces are balanced by adhesive forces betw een the m aterial an d the cavity
w all. H ow ever, as soon as the internal stresses exceed these forces, gap
form ation occurs. The degree of gap form ation is therefore d ep en d e n t on the
balance b etw een the forces of adhesion an d contraction. In ad d itio n , the
form ation of a gap in one area of the cavity reduces the tensile stresses w ithin the
m aterial and m ay perm it perfect adaptation at other areas of the cavity. The
contraction forces are also reduced by substantial shrinkage p erpendicular to the
free surface of the restoration resulting in a w all-to-w all contraction th at is less
than the volum etric contraction of a resin. Thus the m agnitude of the stresses
that develop in com posite resins d uring curing is d ep en d en t on the volum e of
shrinkage and on the ability of the m aterial to yield and therefore flow. To
m inim ise m icroleakage, these stresses m u st kept as sm all as possible an d
therefore it is essential that polym erisation shrinkage, is controlled.

2.7 The control of polymerisation shrinkage

Polym erisation shrinkage has been reduced by either altering the com position of
the m aterials so that certain properties can be controlled to advantage, or by
utilising certain restorative techniques. In essence they all achieve the desired
effect by either shifting the balance of the contraction /a d h e sio n forces in the
cu rin g m aterial (increasing the stren g th of ad h esio n to the cavity w all or
reducing the developm ent of tensile stresses) or by reducing the gap size after
polym erisation is complete.

40
2.7.1 The resin composition

The changes in resin and filler technology seen over the years w ere highlighted
in Section 2.3.3. A lterations to the com position of the resin can affect the
phy sico ch em ical p ro p e rtie s of the m aterial w hich in tu rn in flu en ces gap
fo rm a tio n at the CRI. Such m aterial p ro p e rtie s in clu d e th e d eg ree of
p o ly m erisatio n shrinkage and w ater absorption, an d b o th the coefficient of
therm al expansion and therm al diffusivity of the material.

2 .7 1 1 The degree of polymerisation shrinkage

The size of the polym erisation shrinkage for a given resin is influenced by the
type and volum e of both the m onom ers and fillers. This w as covered m ore fully
in Section 2.3.3, b u t a short precis is appropriate in this section: the Bis-GM A
m onom er m olecules exhibit less shrinkage on polym erisation th an the shorter
d ilu en t m onom ers such as TEGMA and therefore a volum etric increase in the
lo n g er m olecules w ill re su lt in a re d u c tio n in p o ly m e risa tio n sh rin k ag e
(A sm ussen, 1975). H ow ever, this will also incur an increase in the viscosity of
the m aterial, resu ltin g in a red u ction in the degree of com pensatory surface
shrinkage and m aterial flow. Furtherm ore, an increase in the p roportion of resin
filler reduces the volum etric contraction of the m aterial. H ow ever, it has no
effect on the w all-to-w all contraction and therefore on the size of the m arginal
gap seen at the CRI (Asm ussen, 1976). This is because the higher filler volum e
resu lts in an increase in viscosity. These factors account for the red u ced
shrinkage of the conventional m aterials over the microfilled.

Polym erisation shrinkage is also affected by the m ethod of polym erisation, light-
cured m aterials exhibiting significantly less polym erisation shrinkage than those
that are chem ically cured (Asmussen, 1975; Jacobsen, 1976; G oldm an, 1983). In
addition, variations in light intensity can also affect the integrity of the CRI;
lights of low er intensity slow the rate of polym erisation w ith the result that the
visco-elastic stage of curing is prolonged. Increased flow of the m aterial is
therefore possible w ith the resultant form ation of sm aller m arginal gaps (Uno &
A sm ussen, 1991; Feilzer et a l, 1995a; U nterbrink & M uessner, 1995). Prolonging
the curing time of the bonding agent has a similar affect (Crim & Abbott, 1988).

41
2.7.1.2 The degree of water absorption

A red u ctio n in m icroleakage is seen w hen com posite restorations are stored in
w ater prior to testing (A rends et a l, 1984) because w ater is absorbed by the resin
resulting in hygroscopic expansion. This can take u p to three m onths to reach
equilibrium (Braden et a l, 1976; Calais & Soderholm , 1988) and, if of a sufficient
size w ill re su lt in m arg in a l gap closure. H y g ro sco p ic e x p a n sio n v aries
considerably betw een m aterials, being d ependent on the m onom er com position
(Asm ussen, 1976) and the filler content (Calais & Soderholm, 1988). For instance,
the presence of hydroxyl radicals is im portant for the uptake of w ater. These are
p re se n t in Bis-G M A, b u t are ab sen t in m o n o m ers su ch as u re th a n e
dim ethacrylate w hose propensity for w ater absorption is lower.

The filler volum e has an indirect relationship w ith the degree of hygroscopic
expansion and therefore microfilled com posites show greater expansion than the
m acrofilled (Tortenson & Brannstrom , 1988). This is ad v an tag eo u s since the
g re a te r te n d e n c y for m icro filled co m p o sites to form g ap s b e c a u se of
p o ly m e risa tio n sh rin k ag e is co m p en sated to a d eg ree by the in c re a se d
hygroscopic expansion. H ow ever, w ater sorption also has an adverse effect on
the stren g th of the m aterial, p articularly those containing am o rp h o u s silica
spheres (Calais & Soderholm , 1988) and therefore the desire for g reater gap
reduction m ust be balanced by the need for optim al m echanical properties.

As noted in Section 2.5.3.3, the degree of hygroscopic expansion also influences

the effect tem perature has on com posite restorations. This is considered further
in the following section.

2.7.1.3 Coefficient of thermal expansion and thermal diffusivity

Com posite restorations contract to a greater degree than enam el and dentine for
the same change in tem perature because of differences in both the coefficient of
therm al expansion and the therm al diffusivity. The therm al expansion of the
restorative m aterial is affected by the filler type and volum e; an increase in filler
volum e reduces the effect of tem perature on the dim ensions of the m aterial. This
is p artic u la rly so for fused qu artz and the special glasses such as lith iu m
alum inium silicate which have zero or negative coefficients of therm al expansion.

42
H o w ev er, as n o ted in Section 2.5.3.3 stu d ies in v e stig a tin g the effect of
therm ocycling on m icroleakage have given conflicting resu lts for com posite
resins. This is due in p art to the influence of hygroscopic expansion. A change in
te m p e ra tu re w as fo u n d to have no effect on leakage of re sto ra tio n s w h en
therm ocycling w as carried out w ithin 24 hours of filling the cavity (Crim &
G arcia-G odoy, 1987). H ow ever, significant variations w ere fo u n d b etw een
m a te ria ls w h ic h h a d b een a llo w ed to e x p a n d h y g ro sc o p ic a lly b efo re
therm ocycling (Asmussen, 1976). These apparent discrepencies occur principally
because of differences in the degree of hygroscopic expansion th at occurred for
each m aterial. H ow ever, the interplay betw een polym erisation shrinkage, the
coefficient of therm al expansion, therm al conductivity, creep characteristics and
the elastic lim it of the m aterial w ere also im portant. In general, w h en cooling
from a high tem perature, elastic strains in the m aterial counteract any initial
change in gap size at the CRI for m aterials that have been hygroscopically
expanded. Once this strain is elim inated further cooling results in the form ation
of m arginal gaps (A sm ussen, 1974a). In contrast, som e m aterials exhibit an
increased gap size w h en the m axim um tem perature is increased. This occurs
p rim a rily becau se ex p o su re to the h ig h e r te m p e ra tu re re su lts in p lastic
d efo rm atio n of the m aterial (A sm ussen, 1974b). In ad d itio n , tem p e ra tu re
changes in the clinical range have also been found to reduce the yield strength
and elastic m odulus of sim ilar Bis-GMA resins (Draughn, 1981).

The app aren t conflict in the results of studies w hich have investigated the effect
of tem perature on m icroleakage has led some w orkers to question the validity of
incorporating a therm ocycling com ponent in the experim ental regim es of in vitro
studies (Kidd et a l, 1978). H ow ever, others have concluded th a t the use of
therm ocycling leakage experim ents to analyse the effect of the coefficient of
therm al expansion should be discontinued, b u t that therm ocycling sh ould be
incorporated into any experim ent that was investigating the effect of hygroscopic
expansion an d possible hydrolisation of the bond to dentine on m icroleakage
(W endt et a l, 1992).

43
2.7.2 R estorative tech n iq u es

A p lethora of specific restorative approaches have been reported, all p u rp o rtin g

to control polym erisation shrinkage. These are discussed in the follow ing five
sections.

2 .7 2 1 Increased bonding to enamel

The first rep o rted use of an acid conditioning agent to enhance the b o n d in g of
p olym ers to enam el w as by Buonocore in 1955. Since then, it has becom e a
stan d ard technique for the adhesion of com posite resin to enam el and there have
been m any studies reporting an im provem ent in bond strength (Oritz et al., 1979;
Crim & M attingly, 1980; Retief et al., 1982; Phair & Fuller, 1985). The increased
adhesion is the result of an interplay of factors. The effect of acid pre-treatm ent
on enam el w as described in Section 2.2.1. This selective rem oval of m ineral
increases the surface area, surface energy and w ettability of the co nditioned
surface, resu ltin g in increased resin flow an d tag fo rm atio n an d th erefo re
in creased m icrom echanical attachm ent. B onding is also en h an ced by the
form ation of secondary bonds betw een the resin and enam el. Their form ation
results in the net gain of therm odynam ic free energy w hich increases the flow of
the resin. This, com bined w ith the increased w ettability of the etched surface,
enhances tag form ation (Soetopo et al., 1978).

In his initial investigations, Buonocore used an 85% solution of phosphoric acid

for 60 seconds. H ow ever, a regim e of 35% phosphoric acid w ith a 15 second etch
has been found to be equally effective (Crim & Shay, 1987) w ith the additional
advantages of a reduction in both the restoration time and the loss of e n a m e l.

Buonocore also considered that dry, uncontam inated enam el w as im p o rtan t for
o p tim al b o n d stren g th , and ad v ised th at visual assessm ent of the frosted
appearance of the enam el was essential. However, the recent introduction of w et
bonding techniques (Section 2.7.22) has m eant that the enam el etch p attern is not
readily visualised. Some w orkers have found that drying the cavity surface to
ensure the adequacy of the enam el etch and then rew etting before applying the
dentine prim er has circum vented this problem w ithout jeopardising the bon d to
d en tin e (G w innett, 1994). H ow ever, there is evidence to su g g est th a t the

44
presence of m oisture m ay have an adverse affect on the enam el b o n d stren g th
(Swift & Triolo, 1992).

The degree of leakage reduction following acid pre-treatm ent is not uniform and
factors such as the location of the restoration have also been found to influence
the enam el bond. Leakage at the gingival enam el m argins of Class V cavities is
consistently w orse than that seen at the occlusal m argins (Eriksen & Buonocore,
1976; Crim & M attingly, 1980; Retief et al., 1982; M arzouk & Bhaiji, 1989). This is
because the enam el is thinner in the cervical area and therefore sm all enam el
fractures m ay occur d u rin g cavity preparation, polym erisation shrinkage, or
po lishing the resto ratio n (Buonocore & Sheykholeslani, 1973; A m sberry et a l,
1984). In addition, the u ltrastructure of the enam el in this area has an irregular
prism atic structure in w hich the surface layer is frequently prism less (G w innett,
1967) resulting in poorer bonding characteristics.

In addition, the efficacy of the com posite bond to enam el is d e p e n d a n t on the

ability of the bond to resist the tensile stresses w hich develop in the resin as a
resu lt of polym erisation contraction. A balance betw een the m aterial factors
outlined in Section 2.7.1 is therefore im portant (Shortall et al., 1985; Pow is et al.,
1988). In light of this, m odifications of the conventional acid-etch restorative
p ro ced u re have been developed w hich reduce the m ag n itu d e of th e tensile
stresses w ithin the restoration. These m odifications can be classified into four
principal types; the use of m aterials to provide dentine bonding, the use of high-
viscous com posite filling m aterials w ith non-com posite resins of low viscosity,
changes to the cavosurface angle of the restorations, an d m odification of the
restorative technique.

2.7.2.2 Increased bonding to dentine

The ideal restorative m aterial should bond to dentine. The favourable bonding
and leakage characteristics of the glass-ionom er cements (Section 2.3.4) have been
com bined w ith the positive w ear resistance and strength of the com posite resins
in the sandw ich technique (McLean et a l, 1985). W hen care w as taken w ith the
technique, the use of bo th conventional and resin -m o d ified glass-ionom er
cem ents as dentine replacem ents resulted in a reduction in m icroleakage (M ount
et al., 1992). O ther w orkers have also reported a reduction in m icroleakage, w hen

45
com pared to com posite resins, w ith resin-m odified glass-ionom er cem ents as the
sole m aterial (H allett & Garcia-Godoy, 1993; Sidhu, 1994).

W hile these stu d ies have given favourable results, significant resources have
been, and are still being invested into the developm ent of an agent th at provides
a d e q u a te d ire c t d e n tin e b o n d in g of co m p o sites w ith o u t a ffectin g the
en am el/co m p o site bond adversely.

D entine b o n d in g is m uch m ore com plex th an enam el b o n d in g because of the

high w ater an d protein content and the vital nature of the tissue (Section 2.2.2).
In addition, the lack of hom ogeneity seen in dentine w ithin and betw een teeth,
an d the changes seen w ith ageing, lead to a lack of uniform ity b o th in b o n d
strengths and in sealing capacity. W hilst m ost bonding system s have achieved
adequate bo n d in g to the dry, superficial dentine, m any of the earlier agents did
n o t b o n d w ell to the m o ister d eep er d en tin e (C auston, 1984). A n o th e r
confounding feature is the presence of the sm ear layer w hich covers the dentine
follow ing conventional cavity preparation. This is 1-5 jum thick and is a m oist,
plastic deform able layer of cutting or grinding debris. It contains hydroxyapatite
crystals an d partially d en atu red collagen arising m ainly from the u n d erly in g
d en tin e an d adheres to the calcified tissue w ith a stren g th of ap p ro x im ately
6 M pa (Ruse & Smith, 1991). A lthough it is partially porous, it dram atically
red u ces flu id flow from the u n d erly in g d en tin al tu b u les follow ing cavity
p rep aratio n (P ash ley et al., 1978). In addition, it serves as a cavity liner an d
dentinal tubule sealer. M ost of the reduction in dentine perm eability is because
of the presence of sm ear plugs w ithin the tubules. H ow ever, if left intact an d
unchanged, the sm ear layer above the plugs interferes w ith the close ad ap tatio n
of re sto ra tiv e m aterials an d p ro v id e s a su b stra te for the fo rm a tio n of
m icroleakage channels (Pashley et a l, 1989).

D entine bonding agents differ both in the w ay in w hich adhesion is achieved and
in the treatm ent of the sm ear layer. However, the basic structure of the adhesive
m olecule is the same for all m aterials; it is bifunctional and has a m ethacrylate
m olecule w hich bon d s to the polym er at one end and a functional g roup,
d esig n ed to react w ith, and bo n d to, the dentinal surface at the o th er end.
B onding m ay occur w ith either the inorganic com ponent of dentine, via the
calcium ion, or the organic part, via the am ino and hydroxyl groups. The dentine

46
b o n d should be of sufficient size to overcom e the tensile stresses th at develop
d u rin g polym erisation. The stresses generated by polym erisation shrinkage in a
b o x -sh ap ed cavity have been calculated to be of the o rd e r of 13-17 M Pa
(D avidson et al., 1984). It m ight be expected therefore that bonding agents which,
w h e n te sted , achieve g re a te r b o n d stre n g th s th a n th is w o u ld p re v e n t
microleakage. H ow ever, such studies invariably m easure bond strength on a flat
surface after 24 h o u rs storage in w ater. The tensile stresses of polym erisation
reach a m axim um in chem ically-cured m aterials w ithin 15 m inutes (H egdahl &
G jerdet, 1977) an d in light-cured m aterials im m ediately (H ansen & A sm ussen,
1985) an d it is the quality of the bond at these tim es w hich is im p o rtan t for
m arginal ad ap tatio n . Therefore the clinical relevance of m any of the stu d ies
reporting dentine bonding strengths m ust be questioned.

The com plexity of dentine bonding is reflected in the num ber of agents that have
been developed com m ercially over the last thirty years. D entine b o nding agents
h av e been arb itrarily assigned to one of five generations, d efin ed b y the
chem istry of the m aterials. Fourth and fifth generation m aterials w ere u sed in
this stu d y and therefore a detailed review of the earlier bonding agents is beyond
the scope of this thesis. A sum m ary of their salient characteristics is given in
Table 2.5.

In co n trast to the earlier m aterials, fo u rth generation b o n d in g ag en ts have

achieved d e n tin e /re sin bo n d strengths com parable to e n a m e l/re sin bonding.
They use total etch and m oist bonding techniques w hich enhance resin w etting
an d p en etra tio n (G w innett & Kanca III, 1992; Kanca III, 1992): acid-etched
dentine is hydrophobic and, unlike enamel, the surface energy of d entine does
not increase follow ing etching (Attal et al., 1994). In the fo u rth g en eratio n
m aterials, the w ettability of the acid-etched dentine is im proved by the use of
prim ers w ith both hydrophilic and hydrophobic groups. This in tu rn facilitates
the flow an d infiltratio n of the adhesive resin on the dentine. B onding is
achieved by hybridisation (Section 2.7.2.2.1) and, in ad d itio n to the im p ro v ed
b o n d stren g th s achieved, the m oist b o n d in g conditions req u ire d are m ore
favourable for the in vivo situation than the dry bonding conditions required by
earlier agents. Studies usin g these b o n d in g agents have sh o w n re d u c e d
m icroleakage at the dentine m argins (Linden & Swift, 1994) and greater retention
rates (Van M eerbeek et a l, 1994) com pared to their predecessors.

47
 Table 2.5 The five generations of dentine bonding agents

Generation Examples Characteristics Bond

1st C e rv id e n t B ip o la r m o le c u le s a t te m p te d to a c h ie v e c h e m ic a l b o n d in g to in o rg a n ic p h a s e of d e n tin e 2M Pa
a n d p o ly m er. V ery w e a k b o n d in g in vivo d u e to h y d ro ly s is of P 0 4- C a b o n d .
C o s m ic B o n d
Instability of a c tiv e a g e n t s in s o lu tio n
S e rv ito r
D ifficulties in o b ta in in g bulk p o ly m e ris a tio n
P a la v a v
R e te n tiv e ca v ity form r e c o m m e n d e d

P o s t- o p e ra tiv e sen sitiv ity c o m m o n

2nd H a lo ph o sph orou s e ste rs o f Ionic b o n d with re a c tiv e P O , g ro u p & C a w h ich c o - p o ly m e ris e s w ith p o ly m e r 4 -7 M Pa
B is -G M A
A tte m p te d to u s e s m e a r la y e r
S c o tc h b o n d
D e n tin e a n d e n a m e l b o n d in g c la im e d
D e n tin e b o n d in g A g e n t (J& S )
W e a k a d h e s iv e s a n d re q u ir e re te n tiv e ca v ity p r e p a r a tio n s
C re a tio n B o n d in g A g e n t
Instability of ionic b o n d in w a te r d u e to h y d ro ly s is a n d th e rm a l flu ctu a tio n .
P ris m a U n iv e rs a l B o n d
A p ro p o rtio n of d o u b le b o n d s of m e th a c ry la te g r o u p s w ithin t h e a g e n t n e u tr a lis e in
tim e , th e re b y limiting th e ir ability to form c o v a le n t b o n d s w ith re s in

P o s t- o p e ra tiv e sen sitiv ity e x p e r ie n c e d

P o lyure tha n es Is o c y a n a te g r o u p s b o n d to s u r f a c e b o u n d h y droxyl ra d ic a ls to from C 0 2 w h ich re s u lts 3 -6 M Pa

in i n c r e a s e d p o ro sity
D e n tin e A d h e sit
S lo w s e ttin g
D e n tin e B o n d in g A g e n t
A tte m p te d to u s e s m e a r la y e r

L im ited solubility in w a te r d o e s n o t a llo w fu rth e r re a c tio n w ith N H , in c o lla g e n

C o m p a tib le o n ly w ith c o m p o s ite r e s in s with a v a ila b le O H o r N H 2 for c o v a le n t b o n d in g

P o s t- o p e ra tiv e sen sitiv ity e x p e r ie n c e d

3rd G lu m a tw o -c o m p o n e n t p rim e r a n d a d h e s iv e s y s te m 10 M Pa

T en u re d e n tin e s u r f a c e m o d ified p rio r to re s in a p p lic a tio n

M irag e b o n d c o m p le te o r p artia l re m o v a l of s m e a r la y e r

A ll-B ond T h r e e b o n d in g a p p r o a c h e s : p rim ary c h e m ic a l, s e c o n d a r y c h e m ic a l, m e c h a n ic a l

(h y b rid isatio n )
S c o tc h b o n d II
M o re c o m p lic a te d a n d tim e c o n s u m in g th a n 1st a n d 2 n d a g e n t s , b u t re d u c e d n e e d for
re te n tiv e ca v ity form

R e d u c e d p o s t-o p e r a tiv e s e n sitiv ity , b u t p o o r re te n tio n a f te r 3 y e a r s

B o n d in g to m e ta ls p o s s ib le

4th G lu m a 2 0 0 0 S e v e r a l c o m p o n e n ts >15 M Pa

P e rta c B ond R e d u c e d te c h n iq u e se n sitiv ity a n d im p ro v e d p e r fo rm a n c e o n m o ist s u r f a c e s o r in high

hum idity
S c o tc h b o n d M u lti-p u rp o se
S p e e d of a p p lic a tio n m a y p o s e clinical difficulty
S y n ta c B o n d
S im ilar b o n d s tr e n g th s to e n a m e l a n d d e n tin e b o n d in g a c h ie v e d by h y b rid is a tio n
All B o n d II
T o tal e tc h a n d m o ist d e n tin a l b o n d in g u s e d
T en u re
R e d u c e d p o s t-o p e r a tiv e sen sitiv ity

5th P rim e & B o n d 2:1 S in g le c o m p o n e n t: prim ing a n d b o n d in g in o n e bottle > 15 M P a

S y n ta c S in g le c o m p o n e n t M oist b o n d in g
(C o m p o g la s s S C A )
N o m ixing
B ond 1
P o s t- o p e ra tiv e s e n sitiv ity e lim in a te d
O n e ste p
E tc h in g n o t m a n d a to r y for all m a te ria ls
T e n u r e Q u ick F

48
A dh esiv es in the fo u rth g en eratio n of m aterials are d istin g u ish e d by their
n u m e ro u s co m ponents an d the increased clinical com plexity of resto rativ e
p ro c ed u res. The p ercep tio n of com plexity has led m ore recen tly , to the
developm ent of the fifth generation, one com ponent, one bottle system s. K now n
as self-etching or self-prim ing systems, these agents use acidic prim ing solutions
w hich diffuse th ro u g h w ater-filled channels in the sm ear layer to the overlying
dentine. They enlarge the channels and dem ineralise the u p p e r surface of the
u n d erly in g dentine. As the prim er etches, the dem ineralised sm ear layer and
exposed collagen fibres of the dentine are sim ultaneously infiltrated w ith HEMA
an d an acidic co-m onom er w hich in tu rn co-polymerise to form the hy b rid layer.
In the earlier bonding agents, the sm ear layer w as a confounding factor in the
achievem ent of adequate bonds to dentine. However, the converse appears to be
tru e for the fifth g eneration agents because of the h y d ro p h ilic n a tu re of the
prim ers w hich incorporate both the conditioned sm ear layer and dentine into the
h y brid layer. The m aintenance of the sm ear layer and its inclusion in the hybrid
layer has three possible advantages. Firstly, the sm ear layer physically seals the
dentinal tubules. Secondly, there is not the increase in dentine perm eability and
dentinal fluid flow following conditioning that is seen w hen the layer is rem oved
w ith the fourth generation m aterials. The relevance of this is expanded further in
Section 2.7.2.2.1. Thirdly, d en tin e p en etratio n by the p rim er a n d resin is
shallow er th an that achieved by the earlier hybridising m aterials (0.5-2.0
com pared to 1-5 jum). Pashley and Carvalho (1997) speculated that this resulted
in a thinner, b u t m ore uniform hybrid layer w hich in tu rn w ould lead to a higher
quality of bond and reduced m icroleakage

2 .7 .2 .2 .1 H ybridisation

The prim ary site of bonding in all fourth and fifth generation agents is the hybrid
layer. This zone w as first d escribed by N ak ab ay ash i et al (1991): acid
conditioning by either the direct application of acids, or the indirect dissolution
by acidic com ponents in the prim er rem oves or modifies the sm ear layer before
decalcifying the dentine surface. The resulting conditioned dentine surface is
p rim a rily an u n s u p p o rte d n etw o rk of in ter- and in tra tu b u la r collagen.
D ecalcification of the h ighly calcified in tra tu b u la r d en tin e also p ro d u ces
funnelling of the dentinal tubules. H ydrophilic m onom ers penetrate the collagen

49
n etw o rk an d d entinal tubules to a d ep th of 1-5 and polym erise in situ to
create the h y b rid layer. The bon d strength to dentine is th o u g h t to correlate
better w ith the b o n d ed surface area rather than to the d ep th or volum e of the
resin penetration (Pashley & Carvalho, 1997), and therefore tubule concentration
has a significant influence on bonding.

This resin-reinforced zone is highly acid-resistant and rem ains intact even after
the d isso lu tio n of enam el and dentine in hydrochloric acid. In a d d itio n to
prov id in g m icrom echanical retention and to sealing the tubules, the hy b rid layer
effectively stops d entinal fluid flow and provides an effective b a rrie r against
bacteria, m olecules and com ponents of the overlying com posite resin (Leinfelder,
1993). The h y b rid layer also has a relatively low Young's M odulus of Elasticity
an d m ay p lay a role, albeit sm all, in stress relief d u rin g p o ly m e risa tio n
shrinkage.

W ater p lay s an im p o rta n t role in h y b rid isatio n . Excessive d ry in g of the

co n d itio n ed d en tin e surface, w hile possibly enhancing the b o n d to enam el
(Section 2.7.2.1) can lead to the collapse of the collagen netw ork. If it is n o t re ­
expanded by the application of w ater or aqueous prim ers, inadequate infiltration
of both the dem ineralised collagen and w idened tubules by the resin w ill result
in reduced bond strengths, an increased susceptibility of the exposed collagen
fibrils to slow hydrolytic degradation, and poor sealing of the tubules. All of
w hich incur an increased risk of m icroleakage and its sequelae of d en tin e
sensitivity and p u lpal irritation. The third and fourth generation agents, w here
the d en tin e surface is w ash ed and dried betw een co n d itio n in g a n d p rim e r
ap p licatio n , are at g reater risk of d e h y d ra tio n th a n the self-p rim in g fifth
generation m aterials. Effective hybridisation w ith the earlier hybridising agents,
therefore relies on the m aintenance of the collagen netw ork and the use of m oist
bonding and hydrophilic prim ers are essential com ponents of the procedure.

W hile the presence of w ater is im portant for the m aintenance of the collagen
n etw o rk , conversely, excessive w ater co n tam in atio n can h av e an ad v erse
influence on the form ation of the hybrid layer. This is because of the form ation
of blister-like spaces at the prim er-dentine interface w hich results in incom plete
sealing of the tubules (Tay et a l, 1996). In addition, the w ater also dilutes the
prim er m onom ers. The source of excess w ater can arise from either the rinsing of

50
the conditioner or, in vivo, from the increase in dentinal fluid flow as a direct
result of etching the dentinal tubules (Pashley et al., 1993). A gain, of the m ore
recent m aterials, it is the third and fourth generations of bonding agents th at are
m ore susceptible to excesses of w ater. It is clear therefore, th at the q u an tity of
w ater m ust be carefully controlled to ensure m axim um hybridisation.

W hen first introduced, the application of acid to the dentine w as of concern to

som e w o rk ers (Retief et a l, 1992). H ow ever, this arose from erro rs in the
interpretation of m icroleakage (Kanca, 1990) and m ore recently, total etching has
been accepted as a m ethod that does not increase the risk of dam age to the pulp.
H ow ever, if the acid is too aggressive, it m ay expose collagen fibrils below the
h y b rid layer, leaving a zone of w eak dentine that is susceptible to long term
degrad atio n . It is therefore essential that the m anufacturers' in stru ctio n s are
follow ed closely.

2.7.2.3 The use o f low viscosity resins: intermediate bonding and glazing

The use of a low viscosity b o nding resin, or an unfilled resin, p laced as an

interm ediate layer betw een the com posite resin and the cavity surface has been
p u rp o rted to reduce m icroleakage. While such a resin m ay im prove bonding, its
m ain functions are to act as a relatively flexible stress-absorbing layer betw een
the dentine and com posite resin during polym erisation shrinkage (Kemp-Scholte
& D avidson, 1990a; Kemp-Scholte & D avidson, 1990b) and to better transm it and
d istribute stresses induced by therm al changes, w ater absorption an d occlusal
forces across the interface (Van M eerbeek et al., 1993).

The results of studies investigating the effect of an interm ediate bonding layer on
m icroleakage have been conflicting (Chow, 1980; A m sberry et al., 1984; P revost et
al., 1984; S aunders et al, 1990). This is due to differences in the viscosity of the
m aterials used; in its unpolym erised state, a layer of m onom er in the liquid
phase is found on the resin surface. W ith less viscous com posite resins, this layer
behaves as an 'unfilled' resin. H ow ever for the more viscous m aterials resin flow
is red u ced and therefore the layer of m onom er is unable to pro v id e the sam e
degree of interm ediate bonding.

51
The results of the in vitro studies referenced in the above p arag rap h suggest that
an interm ediate bonding resin is unnecessary for some resins, b u t is of benefit for
others. H ow ever, there w as no evidence to suggest th at the use of such a
b o n d in g resin w as detrim ental to the sealing capabilities of the resin. In his in
vivo stu d y , Q vist (1985) rep o rted an im provem ent in m icroleakage w ith an
in term ed iate b o n d in g resin. A sim ilar finding w as rep o rted by C how (1980)
using a conventional resin and it m ay well be that bonding agents are of benefit
u n d er the less favourable circumstances experienced in vivo.

The use of an unfilled resin applied as a glaze to the surface of the restoration has
also been investigated as another m eans of reducing microleakage. H ow ever, as
w ith the in term ed iate b o n d in g resin, the results of these e x p erim en ts are
conflicting (A m sberry et a l, 1984; Qvist, 1985; Reid et al., 1991).

2.7.2.4 Altering the cavosurface angle o f the restorations

The cavosurface angle of a restoration can be changed by the p rep aratio n of a

bevel at the cavity m argins or by leaving excess filling m aterial finished to a
feather-edge over the surrounding tooth surface.

The concept of a 135° bevel at the enam el m arg in of c o n v en tio n al b u tt

p rep aratio n s has been p ro p o sed by several investigators (Welk, 1976). The
p ro p o sed ad v an tag es for the bevel include an increase in surface area, an d
therefore n u m b er of exposed enam el rods available for acid-etching, a larger
surface of the restoration available to com pensate for some of the w all-to-w all
poly m erisatio n , the d istrib u tio n of the forces gen erated by p o ly m erisatio n
contraction over a larger area thus reducing the likelihood of surface g razing
(Bowen et al., 1983), and the developm ent of stronger re sin /e n a m e l bo n d s w ith
etched transverse sections of enam el prism s than w ith lo n g itu d in al sections
(M unechika et a l, 1984).

In vitro studies have yielded conflicting results w ith several w orkers concluding
th at the presence of an enam el bevel does not influence the leakage p a tte rn if
etching of the enam el is effective (Retief et a l, 1982; Hem bree, 1984; Qvist, 1985).
W hile others have found a significant im provem ent in leakage w ith the bevelled
m arg in w h en com pared to the butt-joint (Crim & M attingly, 1980; G rieve &

52
G lynn Jones, 1980). As noted in Section 2.7.2.1, the degree of leakage found at
gingival enam el m argins of Class V cavities is consistently w orse than at occlusal
m argins. A gingival enam el bevel has been found to reduce m icroleakage w hen
co m p ared to a sim ilar p rep aratio n at the occlusal m argin (Crim & M attingly,
1980; H all et a l, 1993). From the results of these studies, it w as p roposed th at
occlusal b ev ellin g w as n o t ad v an tag eo u s, an d to o th stru c tu re s h o u ld be
conserved in this area, b u t that bevelling in gingival enam el sh o u ld be used
w here sufficient enam el w as available.

The difficulties en countered in achieving adequate b o n d in g to d en tin e w ere

referred to in Section 2.7.2.2. The influence of a bevel at the gingival m argin in
Class V restorations placed at the cervical m argin was investigated by Uno et al
(1988). They found that the bevel increased m icroleakage at the dentine m argin
w hile im p ro v in g the m arginal integrity at the enam el m argin. H ow ever, the
differences w ere not statistically significant.

In ad d itio n to the use of bevels, the influence of alternative cavosurface angles

and cavity shapes on the m icroleakage of composite resins has been investigated;
the use of a feather-edge finish w ith a butt-joint, a ro u n d ed b u tt m argin an d a
sau cer-sh ap ed cavity have been found to reduce m icroleakage considerably
w h en com pared to the conventional butt-joint restoration w ith a cavosurface
angle of 90° (Eriksen & Buonocore, 1976; M arzouk & Bhaiji, 1989).

2.7.2.5 Modification of the restorative technique

Polym erisation shrinkage has been controlled by changing the cavity shape, and
by controlling the direction of polym erisation and the volum e of polym erising
resin.

A sig n ifican t im p ro v e m en t in m arginal a d a p ta tio n has been fo u n d w ith

increasing w a ll/flo o r angles in dentine (H ansen, 1984) an d enam el cavities
(Eriksen & Buonocore, 1976) w ith the classic attrition-shaped cavity giving the
sm allest gap sizes and therefore reduced tensile stresses in the m aterial. This is
due to the increased area of the restoration free-surface com pensating for wall-to-
w all contraction. Feilzer et al (1987) describe such cavities as h aving a low
C -factor (configuration factor). The direction of polym erisation contraction can

53
also be controlled by the application of pressure to the restoration surface via a
m atrix strip (A m sberry et a l, 1984).

A n increase in cavity size results in increased m arginal gap size w h en com posite
resin is b o n d e d to enam el or d entine because of the in creased vo lu m e of
polym erising resin (Brannstrbm et a l, 1984; H ansen, 1984). Several m ethods have
been advocated for the control of volum e; increm ental packing (H ansen, 1986),
the use of a 'ball' of pre-cured polym er (W elbury & M urray, 1990) or a beta
quartz glass-ceram ic insert (Section 2.3.3.2), and the provision of an indirect resin
restoration (Douglas et a l, 1989).

Of these m ethods, increm ental packing is of greatest benefit for the direct Class V
re sto ratio n s u sed in this stu d y . W ith this technique, the p o ly m e risa tio n
shrinkage of each increm ent is directed tow ards the cavity w alls rath er th an to
the restoration surface. W hen com pared to bulk packing, this increases the free-
surface:volum e ratio and effectively low ers the size of the C -factor. D espite
im p ro v e m e n ts in the b o n d achieved w ith d e n tin e b o n d in g ag en ts, the
d e n tin e /re sin bond has continued to be the 'w eak link' in com posite restorations.
Several p attern s of packing have been investigated in an attem p t to reduce the
adverse influence of this and oblique increm ental packing has been fo u n d to
have the greatest positive influence on m icroleakage w h en com pared to bu lk
packing or horizontal increm ental packing (Hansen, 1986; S aunders et a l, 1991;
S aunders & M uirhead, 1992). This is particularly so w hen the first increm ent is
placed occlusally (Crim, 1991), presum ably because the early establishm ent of the
enam el bo n d ensures that the gingival bond is not d isru p ted . M ore recently
though, the results of studies using the new er dentine b o n d in g agents have
su ggested th at increm ental filling is not a critical consideration for adhesives
w hich achieve strong bonds to dentine (Linden & Swift, 1994).

This rev iew of m icroleakage has so far co n cen trated on th e co n tro l of

p o ly m erisatio n shrinkage of com posite resin m aterials. In this stu d y , tw o
m aterials w ere used; a h y b rid com posite resin, an d a p o ly acid -m o d ified
com posite resin, both w ith their respective bonding agents. M icroleakage in the
latter group of m aterials will also be considered.

54
2.8 Microleakage in polyacid-modified composite resins

Because of their recent introduction into clinical dentistry, the num ber of refereed
pap ers on this subject is naturally lim ited w hen com pared to those reporting the
incidence of m icroleakage w ith composite resin restorations.

As noted in Section 2.3.6, com pom ers w ere developed to enhance the favourable
pro p erties of com posite resins, nam ely their good aesthetics, strength and w ear
resistance, w ith those of the glass-ionom er cem ents i.e. low p o ly m erisatio n
shrinkage, bo n d in g to tooth structure and release of fluoride. It w o u ld not be
u n reaso n ab le, therefore, to expect th at these m aterials w o u ld exhibit less
m icroleakage than equivalent com posite m aterials and that m icroleakage at the
enam el an d dentine m argins w ould be com parable. H ow ever, several w orkers
h av e fo u n d a greater incidence of m icroleakage at bo th d en tin e an d enam el
m argins w ith com pom er m aterials w hen com pared to com posite resins (Uno et
al., 1997; O w ens et al., 1998). In contrast, at the dentine m argin, C hersoni et al
(1997) an d U no et al (1997) found no significant difference in leakage w ith
cavosurface angles of 135° and 90° respectively. Studies also vary in their results
w h en the m arginal integrity at the enam el and dentine m argins of the com pom er
restorations are com pared. Uno et al (1997) and Brackett et al (1998) found no
significant difference in leakage betw een the tw o m argins. H ow ever, other
w orkers have reported greater leakage at the dentine m argins (Cortes et al., 1998;
O w e n s et al., 1998). These a p p aren t contradictions reflect differences in the
com position and properties of the m aterials, b u t equally, restorative factors play
a role. As w ith the com posite resins (Section 2.7.2), the effect of d ifferent
restorative approaches on the m icroleakage of com pom er restorations has been
investigated.

As noted in Section 2.3.6, com pom er m aterials achieve m icrom echanical retention
to d e n tin e via the fo rm atio n of a resin -rein fo rced h y b rid lay er w ith the
app licatio n of fifth generation, single com ponent b o n d in g agents. T hus the
sm ear layer is m odified rather than being rem oved. The application of highly
dissociated acids such as phosphoric to dentine rem oves the sm ear layer and
results in an increase in the num ber and size of the resin tags (C hersoni et al.,
1997). Studies have show n that such dentine etching prior to prim er application
red u ces the incidence of m icroleakage at the c o m p o m e r/d e n tin e interface

55
(C hersoni et a l, 1997; Vichi et a l, 1997; Ferrari et al, 1998; O w ens et a l, 1998). The
sam e p attern of leakage w as found w ith the enam el m argin. H ow ever, Cortes et
al (1998) fo u n d no significant differences in leakage at either m argin betw een
etched and non-etched surfaces w ith the two com pom ers they tested.

In co n trast to com posite resins (Sections 2.7.2.4 and 2.7.2.5), increasing the
enam el cavosurface angle at the enam el and dentine m argins by increasing the
cavity w all /flo o r angles, or at the enam el m argin by bevelling, w as fo u n d to
have no significant effect on m icroleakage (Uno et a l, 1997). H ow ever, like the
com posite resins, the use of a dentine bevel at the gingival m argin influenced
m icroleakage at th at m arg in adversely, b u t resu lted in a re d u c tio n in the
m icroleakage at the bevelled enam el m argin (Owens et a l, 1998). Uno et al (1997)
also rep o rted an increase in the m icroleakage at enam el an d d en tin e m argins
w ith thermocycling.

2.8.1 Summary

From this brief review of the literature pertaining to both the com pom er and the
com posite resin m aterials (Section 2.6), it can be seen th a t p o ly m erisatio n
shrinkage is an im portant factor w hen considering m icroleakage in resin-based
m aterials. Ideally such resto ratio n s sh o u ld not exhibit m icroleakage an d
therefore to m inim ise this, it is essential that both the size and direction of the
stresses arising during polym erisation shrinkage are controlled. This is achieved
by changes to the com position of the restorative m aterial, b u t in addition, the
choice of restorative technique is im portant.

2.9 Cavity preparation

The cavity, m ateria l a n d resto rativ e factors in flu en c in g the c o n tro l of

m icroleakage w ere d iscu ssed in the p revious section. H ow ever, of equal
im portance for the ad ap tatio n of the m aterial is the m orphology of b o th the
cavity surface an d the su rro u n d in g enam el and dentine. This is, in part,
d ep en d en t on the m ethod used for cavity preparation. The m icroleakage studies
review ed to date have all u sed conventional m ethods of cavity p rep aratio n ,
principally the high-speed handpiece and diam ond bur w ith w ater coolant.

56
2.9.1 Conventional cavity preparation

Early caries rem oval revolved around enam el cleaning an d dentine excavation
w ith h an d instrum ents. H ow ever, the developm ent of the dental treadle engine
in 1875, in tro d u ced rotary instrum ents into clinical dentistry (Stephens, 1986).
M echanism s and handpieces w ere refined and the m odern slow, and high-speed
air turbine handpieces, w ith the use of carbide and diam ond burs to supplem ent
the early steel an d carb o ru n d u m instrum ents, have p ro v id ed an efficient, fast
an d reliable m eans of caries rem oval an d cavity p rep aratio n , w ith red u ced
discom fort and fatigue for both the patient and operator (Peyton & Arbor, 1955).

The m orphology of the resulting enam el and dentine surfaces is of interest w hen
considering the m icroleakage of restorations. Enamel is a brittle tissue (Section
2.2.1.3) an d therefore to o th p re p a ra tio n u sin g sh arp d ia m o n d s w o u ld be
expected to affect the surface. Xu et al (1997) investigated the appearance of the
enam el surface follow ing conventional cavity p reparation w ith a d iam o n d bur.
M icrographs of the cut surface show ed evidence of subsurface dam age in the
form of m ed ian -ty p e cracks an d m icrocracks w h ich ex te n d e d alo n g the
boundaries betw een the enam el rods. In addition, microcracks w ere seen w ithin
the in d iv id u a l enam el rods. The len g th of the m ed ia n -ty p e cracks w as
proportional to the diam ond particle size and also varied w ith the orientation of
the enam el rods, being longer w hen the cutting surface w as parallel to the long
axis of the rods. H ow ever, the rem oval rate and the force applied to the tissue
d u rin g cutting appeared to have no significant influence. These findings are of
p a rtic u la r im portance w h en considering the m arginal seal an d longevity of
restorations, since the presence of these cracks at the CRI m ay influence the
adaptability of the restorative material; in their discussion, Xu et al described the
cracked enam el surface as being dam aged, thereby im p ly in g th a t such an
appearance w as not desirable. They found that the dam age induced by the use
of coarse diam ond burs w as reduced effectively w hen finer diam ond b u rs were
used to finish cavity preparation, b ut etching w ith 33% phosphoric acid gel failed
to either rem ove or im prove the dam aged surface. As a result, the au th o rs
co n clu d ed th at these findings su p p o rte d the use of fine d iam o n d b u rs to
co m p lete cav ity p re p a ra tio n . H ow ever, the clinical significance of the
ap p earan ce of the cut surface on both the stren g th of the enam el a n d the
adaptabity of restorative m aterials needs further investigation.

57
The appearance of the dentine surface following conventional cavity p reparation
has also been investigated. W ith SEM analysis follow ing conventional caries
rem o v al an d cavity p re p a ra tio n at x50 m agnification, the d e n tin e surface
featured clear grooved m arks because of the rotary action of the b u rs (Aoki et a l,
1998). At h igher m agnification (x3000) the surface ap p eared flat an d a sm ear
lay er (Section 2.7.2.2) w as visible. W ithin the sam e experim ent, A oki et al
com pared this appearance w ith the dentine surface arising as a result of cavity
p rep aratio n w ith an Er:YAG laser. These findings are of relevance to this study
an d are described in Section 2.10.6.3.

In ad dition, to the m orphology of the cut enam el and dentine surfaces, use of
rotary instrum ents also produces frictional heat and vibration, giving rise to pain
a n d a h y p eraem ic increase in p u lp al blood flow (N a rh i et al ., 1982). H eat
prod u ctio n and its sequelae are lim ited w ith the use of w ater coolants (Stanley &
Sw erdlow , 1959). H ow ever, these side effects, com bined w ith the noise of the
m otor, m ay cause ap p reh en sio n for the p atien t and dam age to the p ulp. In
ad d itio n , the in stru m en ts are not selective in their tissue rem oval, a lth o u g h
tactile assessm en t w ith a slow speed b u r in p artic u la r does assist in the
d ifferen tiatio n of h ealth y and carious d en tin e and enam el. D esp ite these
lim itations, the use of high and slow speed handpieces in cavity p rep aratio n
rem ains the com m onest m ethod of caries rem oval and provides the stan d ard by
w hich all other m ethods are com pared.

H ow ever, as noted in Section 1.3. the dental drill is one of the com m onest fear-
p ro v o k in g stressors for the anxious patient. A lternatives to co n v en tio n al
m eth o d s of cavity p rep aratio n have been investigated in the attem p t to find a
technique that can prepare the cavity w ithin a reasonable length of tim e w ithout
causing pain or affecting the CRI adversely.

2.9.2 Alternative techniques for cavity preparation

To date, four altern ativ e techniques have been in v estig ated ; air abrasive
techniques, ultrasonic instrum ents, chem om echanical caries rem oval an d lasers.
All have been rep o rted to p rovide a m eans of cavity p re p a ra tio n or caries
rem oval w ith o u t pain or vibration for the patient (Black, 1955; O m an, 1955;
B rannstrom et a l, 1980; Keller & H ibst, 1997). H ow ever, the air abrasive

58
technique is lim ited to the teeth and surfaces in the direct vision of the operator
and conventional rotary instrum ents are required to com plete cavity preparation.
C onventional instrum ents are also required for the rem oval of h a rd caries and
the com pletion of cavity p rep aration w ith the chem om echanical an d ultrasonic
techniques (Oman, 1955; Brannstrom et al., 1980).

The success of lasers as a replacem ent for the conventional d rill has varied
d ep en d in g on the lasing m ed iu m em ployed. The Er:YAG laser is u sed in this
stu d y as an alternative to conventional cavity p rep aratio n and it is therefore
pertinent to consider this area in greater detail.

2.10 - Lasers in dentistry

2.10.1 Introduction

The w o rd 'Laser' is an acronym for Light A m plification by the S tim ulated

Em ission of R adiation. The light is p ro d u ced in a closed system an d is a
coherent, m onochrom atic, collim ated beam of photons. The beam m ay be
continuous, p u lsed or gated and the size of the focal p oint can be adjusted to
create a beam of electrom agnetic rad iatio n of trem en d o u s energy w hich is
significantly m ore intense th an conventional light sources. Lasers are nam ed
according to the laser m edium em ployed and to date, m ore th an 600 have been
identified, each operating at a different wavelength.

Since its conception by M aim an in 1960 , the laser has been considered for use in
m any areas of m edicine and surgery. Two m ain categories of laser have been
developed for use in these fields; 'soft' and 'hard' lasers. 'Soft' lasers provide low
energy at w avelengths w hich activate the circulation and cellular activity (M idda
& Renton-H arper, 1991; Miller & Truhe, 1993). They are used to prom ote healing
and to reduce the pain and oedem a produced by inflam m ation. 'H ard' lasers are
u sed w idely for surgical applications. All further references to lasers in this
thesis will refer to this latter type of laser.

Research into the application of lasers in dentistry has been ongoing over the last
30 years and is alm ost as old as the laser itself, a reflection of the in h eren t
difficulties of producing a clinical laser system that both interacts effectively w ith

59
the h ard dental tissues and is easy to use, while com plying w ith health and safety
req u irem en ts. Several h a rd an d soft tissue applications for h a rd lasers in
d entistry have been reported (Table 2.6). However, it is the ability of lasers to cut
enam el and dentine that is of interest in this study.

2.10.2 Lasers as optical 'drills'

W h en they w ere first developed, it w as h oped that lasers w o u ld p ro v id e an

altern ativ e to the dental drill (G oldm an et a l, 1964; G ordon, 1967; Stern et al.,
1972). The first rep o rt of the use of a laser on a vital tooth w as by G oldm an et al
(1965). Two pulses of a ruby laser were applied to a vital tooth. W ith sufficient
energy densities, the laser beam w as able to penetrate sound, norm al enam el,
an d the enam el surro u n d in g the im pact area show ed no m acroscopic evidence of
change. Furtherm ore, there w as no sensation of pain. As noted in Section 2.9.1,
the pain experienced d u ring conventional cavity preparation is usually caused by
the vib ratio n of the b u r an d the heat p ro d u ced from friction. It w as h o p ed
therefore that, in addition to cutting enam el and dentine, the use of a contactless
o p eratin g laser w ould p ro v id e a m ore accurate and painless m eans of tooth
p rep aratio n . In so doing, the need for local analgesia w o u ld be reduced an d
w o u ld p ro v id e a w elcom e altern ativ e for to o th p re p a ra tio n for an x io u s
individuals.

For the laser to replace or support, conventional m eans of cavity preparation, it

m u st fulfil certain criteria. Laser irradiation of the tooth surface should result in:
• the rem oval of enamel, dentine, caries and restorations w ithout dam age to the
surrounding hard tissues and pulp or to other oral tissues
• the production of m inim al tem perature change in the irradiated tissue
• a consistent and predictable effect on a defined area or tissue
• an ablation rate equivalent to the cutting rate of conventional handpieces
• the production of a cavity surface that does not influence the m arginal sealing
ability of restorative m aterials or the bonding of adhesive m aterials adversely.

In addition, desirable properties are that the tool should be selective for caries to
m inim ise h ard tissue rem oval and dam age, and should not cause pain sensation
d uring cavity preparation.

60
 Table 2.6 Potential soft and hard tissue applications of lasers in dentistry

Soft tissue applications

• incise, excise, remove or biopsy lesions such a s papillomas, fibromas, and epulides
• vaporise ex c ess tissues, for example, frenectomy, gingivoplasty and ginigivectomy
• rem ove or reduce hyperplastic tissue, for exam ple epanutin hyperplasia
• rem ove and control haem orrhaging of vascular lesions such a s haem angiom as, and in
patients with hem orrhagic disorders such a s haemophilia
• sym ptomatic pain relief of aphthous ulcers

Hard tissue applications

• vaporise carious lesions
• desen sitise exposed root surfaces
• endodontic: vaporise organic tissue, glaze canal wall surfaces and fuse an apical plug
with the potential to resist fluid leakage, root canal sterilisation
• roughen tooth surfaces in lieu of acid etching
• preventive effect on enam el: arrest demineralisation, prom ote remineralisation and
increase acid resistance
• debond ceram ic orthodontic brackets
• cure com posite resin (reduces polymerisation shrinkage)
• cut enam el and dentine
• scaling and root planing
• increase acid resistance of enam el

61
C ontrary to the high hopes arising as a result of the first reports, further studies
u sing the early lasers rep o rted th at the high energy densities req u ired to cut
th ro u g h the enam el and dentine led to overheating. This caused cracking and
shattering of the enam el surface w hich led to irreversible p u lp dam age (Stern et
a l, 1969; A d rian et a l, 1971). Furtherm ore, reflected energy p ro d u ced visible,
albeit less severe, changes in the enam el of adjacent teeth (Taylor et a l, 1965).
W hen used at low er energies to m inim ise these side effects, the lasers failed to
ablate enam el and dentine. These studies involved the use of continuous w ave
ruby, carbon dioxide and NdiYAG lasers.

The significant lim itations in the use of the early lasers for the 'cutting' of enam el
an d dentine led som e w orkers to conclude that they h ad no role in this area.
H ow ever, over the last thirty years, there have been continued technological
developm ents in the field. As this has happened, interest in the application of
lasers to d en tistry has been rek in d led to the extent that, at the end of the
tw entieth century, the clinician is faced w ith an array of laser types all of w hich
p u rp o rt to cut enam el and dentine. In order to und erstan d w hich of these m ay
satisfy the requirem ents of an optical drill, an understanding of the w ay in w hich
laser light interacts w ith enam el and dentine is necessary.

2.10.3 Mechanism of laser-tissue interactions

2.10.3.1 Introduction

O n im pinging a tissue surface, the laser light can be reflected, scattered, absorbed
a n d /o r transm itted. The absorbed light is responsible for the tissue effects of the
laser, and the quantity of light absorbed is influenced by the proportion in w hich
the oth er three effects occur. For instance, reflection lim its or reduces the
quantity of energy w hich enters the tissue and light that is reflected is dissipated
effectively resulting in very little dam age to the other oral tissues. Scattering
occurs w ith in the tissue and effectively distributes the energy over a larger
volum e of tissue than the laser beam entering the tissue. In so doing, it dissipates
th erm al energy. H ow ever, this m ay also resu lt in an increase in collateral
dam age w here the scattered radiation is absorbed. After a characteristic am ount
of scattering has occurred in the tissue, light energy is absorbed. T ransm ission

62
occurs w h en the light passes beyond a given tissue b o u n d ary and m ay result in
dam age to su rrounding tissues such as the pulp.

2.10.3.2 Interaction of absorbed light with the dental hard tissues

The interaction of the absorbed electrom agnetic radiation w ith tissues involves
the interaction of photons w ith the atom s or m olecules of the target tissue. These
interactions are follow ed by very complex reactions, m any of w hich are still not
u n d e rsto o d fully. Four m echanism s are currently recognised: photochem ical
interactions, therm al interactions, non-linear processes and therm om echanical
processes. The first of these, photochem ical processes, are not involved in the
reaction of laser light w ith the dental h ard tissues an d w ill therefore not be
considered further.

2.10.3.3 Thermal interactions

Therm al effects occur w hen the absorbed electrom agnetic radiation is converted
to heat energy; absorption leads to an increase in internal lattice vibrations w hich
in tu rn is converted to therm al energy. W hile vaporisation of the irrad iated
tissue m ay occur, several side effects in teeth have been noted. The direct effect
of excessive h ea t re su lts in the fo rm atio n of cracks, zones of necrosis,
carbonisation (charring) and m elting in enam el and dentine, and irreversible
dam age to the pulp. The ability of some ruby, carbon dioxide and Nd:YAG
lasers to m elt enam el has been proposed as a m eans to p revent carious attack
because of the increased acid-resistance seen in the tissue (Stern, 1972; Yam am oto
& Ooya, 1974; M eurm an et al., 1992). H ow ever, w ith this exception, these
therm al side effects are less than desirable, and the laser-induced alterations of
the tooth surface m ay have a deleterious affect on the successful b o n d in g of
restorative m aterials. In m ost clinical situations therefore, it is desirable to
m inim ise these therm al changes.

2.10.3.4 Non-linear processes

W hen pulse energies lie above a certain threshold, and the pulse d u ra tio n is
shorter than 1ms, the laser energy is used to break bonds non-therm ally. H eat
conduction can therefore be disregarded. In the rem oval of enam el and dentine,

63
tw o m ain types of non-therm al effects are known: photoablation by either m ulti­
p h oton stim ulation or direct electron dissociation, and photo-disruption.

2 .1 0 .3 .4 .1 P h o to a b la tio n

In contrast to the therm al effects, molecules can be directly dissociated w ith laser
light of high p h o to n energies (single photon dissociation), or w ith high energy
densities and short pulse d u ratio n (m ulti-photon processes). O nly the excim er
laser em its rad iatio n w ith p h o to n energies high en o u g h for d irect electron
dissociation. The m olecular bonds are broken w ith m inim al therm al side effects.
Photoablation is a tissue-specific process and prom otes selective caries rem oval.
In contrast to healthy dentine, the dem ineralised zones of a carious defect are
very easy to rem ove, resu ltin g in retentive areas in the enam el an d dentine
(Frentzen & Koort, 1990).

2 .1 0 .3 .4 .2 P h o to d isru p tio n

Very high energy and short pulsed laser light can ionise m aterial by building up
a plasm a, a sea of electrons and ions w ith tem peratures betw een 6,000-10,000 °C
w here the laser light focuses on the tooth. If this occurs, several effects m ay be
seen, d ep en d in g on w here the plasm a is generated. By absorbing som e of the
incident radiation, the presence of the plasm a m ay result in a reduction in laser
energy reaching the tooth surface. H ow ever, this is in p art com pensated for by
the direct action of the plasm a on the tooth surface; therm al energy is conducted
to the surface, w hich results in ablation and heating of the dental h ard tissues. If
uncontrolled, the form ation of a plasm a at the tooth surface m ay resu lt in an
unacceptable degree of therm al dam age. If the plasm a is generated beneath the
tooth surface, pressure builds u p and dissipates explosively inducing acoustic
shock w aves. These resu lt in the m echanical d etach m en t of v ario u s sized
particles of enam el and dentine. This effect of the plasm a is in d ep en d en t of
ab so rp tio n and is dictated in p art by the type of laser. For som e lasers, the
d ev elo p m en t of hig h p ressu re w aves has the potential to p ro d u ce cracks,
m icrocracks and zones of debris at the cavity surface. O thers, notably som e of
the later Nd:YAG lasers, attem pt to use the plasm a to cut enam el and dentine by
controlling the plasm a w ith a w ater coolant (Pick, 1993). This poses som e
concerns because the superhot plasm a can heat areas beyond the desired target

64
area, causing significant iatrogenic therm al dam age. In addition, the plasm a is
generally difficult to control, varying rapidly in intensity, w idth and location.

2.10.3.5 Thermomechanical processes

The m ajor absorption b an d of w ater is at 3.0 jum. Some of the new er infra-red
lasers that have w avelengths in this region, for exam ple, the Er:YAG laser, are
able to ablate the d en tal h a rd tissues via an in d irec t th erm o m ech an ical
m echanism : on im pinging the dental hard tissues, the incident laser energy is
absorbed by w ater in the tissues. The w ater heats to boiling producing w ater
v apour w hich in tu rn causes a build up in pressure resulting in a m icroexplosion
and the ablation of a small proportion of the tissue. The m ajority of the energy is
ex p en d e d in the process of ablation an d therefore only a sm all fraction is
available to heat the tissues, thus therm al changes are m inimal.

The laser-in d u ced effects seen on enam el an d d en tin e are the resu lt of a
com bination of one or m ore of the interactions described above. The balance
b etw een these is controlled by the characteristics of the laser radiation and the
irrad iated tissue. The laser param eters of concern are the w avelength, energy
density, w aveform and irradiation time, w hile the relevant tissue factors are its
optical, therm al and m echanical properties. These param eters will be considered
further in the following two sections.

2.10.3.6 Laser parameters

The d ep th of p enetration and absorption of radiation im pinging on a tissue is

d ictated by the balance th at occurs betw een the absorption, transm ission,
scattering, and reflection of the light. This balance is in tu rn d ependent on both
the w av elen g th of the radiation, and the optical pro p erties of the irrad iated
tissues. The latter are considered further in Section 2.10.3.7.

C onsidering the laser param eters further; in ad d itio n to the w avelength, the
energy density (fluence) of the laser light is im portant. This is defined as the
q u an tity of energy that is distrib uted over a surface area. The overall energy
deposited on the tissue surface depends also on the w aveform and the irradiation

65
tim e and this will influence the type of interaction that is seen. The w aveform is
the w ay in w hich the po w er o u tp u t varies w ith time i.e. continuous, g ated or
p u lsed . In general, long pulse d u ratio n s are not desirable because therm al
energy develops, thereby increasing the possibility of adverse therm al changes in
the irrad iated tissue. Pulse shortening, on the other hand, results in a reduced
volum e of tissue that is heated because of the reduced deposition time, and also a
decreased threshold energy for ablation (W ilder-Sm ith et al., 1997). The pulse
frequency is expressed in H ertz (Hz) and is also know n as the pulse repetition
rate (PRR) or the pulses per second (PPS).

2.10.3.7 Optical and tissue parameters

As w as seen in Section 2.2, teeth are m ark ed ly h e te ro g e n o u s stru ctu res.

A bsorption, the key to laser interaction is w avelength dependent, as indicated by
the absorption spectra of the tissue com ponents. It takes place at single atom s or
m olecules w hich have resonant absorption levels for the w avelength of the light
applied. As noted in Section 2.2.1, w ater and hydroxyapatite, com ponents of
both enam el and dentine, have strong absorption spectra at both UV and m id- to
far-IR w avelengths. Ruby and Nd:YAG laser radiations (visible an d near-IR
respectively) are therefore not absorbed w ell in either enam el or den tin e,
w hereas light from the carbon dioxide (far-IR) and Er:YAG (mid-IR) lasers are
well absorbed by both tissues.

H ow ever, absorption is not the only tissue factor dictating the characteristics of
the laser-tissu e interaction. The therm al p ro p erties an d the v a p o risa tio n
te m p e ra tu re s of the d e n ta l h a rd tissues also p lay an im p o rta n t role in
d eterm in in g the ability of a laser to ablate the tissue w ith m inim al ad verse
th erm al effects. Both enam el and dentine have low therm al coefficients of
therm al expansion (11.4,10'6/°C and 8.3,10'6/°C respectively) an d low therm al
conductivities and therefore any heat generated in the tissue, w hile creating
m inim al expansion, will diffuse slowly from the im pact p oint of the laser beam .
If of sufficient intensity, the resulting production and retention of therm al energy
will lead to dam age, the nature of w hich w as described in Section 2.10.3.3. In
addition, the vaporisation tem perature of enam el is of sufficient size that high
energy densities are necessary for ablation. For w avelengths that ablate enam el

66
an d d en tin e via therm al interactions, such an increase in energy d en sity w ill
increase the potential for therm al dam age.

Indirect irreversible p u lp al changes m ay be seen by the direct heating effect of

den tin e close to the pulp. H ow ever, in addition to this, the 'system ' of optical
fibres p ro v id ed by the dentinal tubules (Section 2.2.2.) perm its transm ission of
electrom agnetic energy to the pulp and direct pulpal dam age m ay arise from the
absorption of the transm itted light by the pulp tissue.

The influence of the tissue param eters on the laser-tissue interaction explains the
poor perform ance of the early dental lasers.

2.10.4 The early hard tissue dental lasers

These early lasers, carbon dioxide, ruby and Nd-YAG, w ere continuous-w ave or
pu lsed , w ith pulse d u ratio n s in the m icrosecond range, an d therm al changes
played an im portant role in their interaction w ith the dental hard tissues.

The carbon dioxide w avelength is well absorbed by h y d ro x y ap atite an d as a

result the early prototypes therm ally ablated enam el. H ow ever, because of the
shape of the laser beam (G aussian) w ith reduced intensity to w ard s the o u ter
lim its of the beam , the h eat g en erated in the tissue at the p e rip h e ry w as
insufficient to cause vaporisation. This led to the production of adverse therm al
changes (Stern et a l, 1972). Laser irradiation of dentine w ith the early carbon
dioxide laser had sim ilar effects.

In contrast, the w avelengths em itted by the ruby and Nd:YAG lasers are not well
absorbed by hydroxyapatite. From this it m ay be anticipated th at th erm al side
effects w ould not be seen following irradiation of enam el or dentine. H ow ever,
as noted in Section 2.10.2, this w as not the case and the early m odels exhibited
therm al change, w ith m inim al ablation (G oldm an et a l, 1964; Stern & Soggnaes,
1964; Yam am oto & Ooya, 1974). This w as because large energy densities w ere
used in an attem p t to increase absorption and resulted in a tw o fold effect; the
energy d ensity w as sufficient to cause therm al dam age of the enam el w ith
m inim al vaporisation, and the quantity of transm itted light increased, resulting
in increased direct pulp dam age. Enamel ablation w as increased follow ing the
ap p licatio n of a dye to the enam el surface (Yamom oto & Sato, 1980). This

67
ph en o m en o n (initiation) reflects the increased absorption of the Nd:YAG and
ru b y laser w av elen g th s in p ig m en ted tissue an d resu lte d also in g reater
ab sorption of these w avelengths for non-sclerotic dentine, sclerotic dentine and
caries (D ederich & Zakariasen, 1984). H ow ever, w hile enhancing the ablative
p roperties of the lasers, initiation also had adverse clinical im plications. D uring
ab latio n the b u lk of the energy w as still converted to heat, w hich in tu rn
p ro d u c e d ch arrin g of the d en tal h a rd tissues. This acted as an in itiato r,
increasing the absorption of the laser and resulted in the pro d u ctio n of a laser
beam w hich w as difficult to control (Dederich, 1991).

F urther developm ents in the field of lasers has led to the developm ent of laser
p aram eters w hich ablate via the non-therm al m echanism s outlined in sections
2.10.3.4 an d 2.10.3.5, th u s lim iting the d ev elo p m en t of ad v e rse th erm a l
interactions. This has led to a generation of h ard lasers w hich appear to have
great potential as optical drills.

2.10.5 The new generation of lasers

Experience g ain ed w ith the early 'h ard ' lasers has indicated th at there are
essentially tw o requirem ents for laser ablation of the dental h ard tissues: the
w avelength m ust be efficiently absorbed and the laser energy m ust be delivered
in sho rt bu rsts w ith high peak pow ers. The tw o trains of developm ent in the
m an u fa ctu re of lasers for ablating d en tal h a rd tissues have b een to use
w avelengths in either the UV or m id- to far-IR spectral regions, and to reduce the
pulse d u ratio n and size of the im pact point of the beam , thereby increasing the
p eak pow er density, although the overall energy reaching the tissue m ay be
relatively low. Table 2.7 lists some of the lasers used on the dental hard tissues to
date.

The new er laser system s have given prom ising results. A rim a and M atsum oto
(1993) dem onstrated that both sound and carious enam el and dentine could be
cut by the ArF:Excimer laser w ith a pulse duration of 10-12 nsec w ithout therm al
injury and w ith m inim um tem perature rise. H ow ever, the ablation rate (i.e.
ablated volum e per pulse) of this laser was very low. This, and the general risks
of UV rad iatio n to the patien t are m ajor disadvantages to its use in cavity
preparation. Furtherm ore, the high cost of these lasers limit their clinical use.

68
 Table 2.7 Hard lasers which ablate enamel and dentine

Laser type Waveband Wavelength Waveform Power

X (nm) (W)
Ar-F excim er UV 193 Pulsed 0-50
XeCI-excimer UV 308 Pulsed
Nd/YAG Near-IR 1,064 Pulsed/continuous 0-100
Ho/YAG Near-IR 2,100 Pulsed/continuous 0-100
Er/YAG Mid-IR 2,790 Pulsed/continuous 0-100
Er/Cr/YAG Near-IR 2,690 Pulsed
C 02 Far-IR 10,600 Pulsed/continuous 0-100

69
N iem z (1995) reported the rem oval of enam el and dentine by a picosecond laser
system , a solid-state Nd:YLF laser. Very precise cavities w ere obtained, w ithout
severe therm al or m echanical dam age, in the enam el and d entine of extracted
h u m a n m olar teeth, the quality of w hich w as superior to that achieved by other
laser system s. M oreover, the laser exhibited caries-selective properties; w h en
ap p lied to carious enam el, the ablation rate w as ten tim es higher th an th at for
sound enam el. H ow ever, these lasers are not yet com m ercially available and are
also likely to be com paratively expensive.

A nother laser w hich has show n great prom ise is the Er:YAG laser. Lasers of this
ty p e hav e been in clinical use in G erm any for a p p ro x im a te ly five years.
Furtherm ore, the C entauri Er:YAG laser (Prem ier Laser Systems) w as cleared for
m arketing in the U nited States of America by the Food and D rug A dm inistration
(FDA) on M ay 7 1997 for 'caries removal, cavity preparation, an d m odification of
dentine and enam el before acid etching for increased bond strength' (C ozean et
al., 1997). The laser used in this study w as an Er.YAG laser, the Tw inlight D ental
laser (Fotona, Ljublijana, Slovenia). T herefore this g ro u p of lasers w ill be
considered in greater detail in the following section.

2.10.6 The Erbium:YAG laser

2.10.6.1 Introduction

Erbium is a metallic elem ent in the rare-earth group. The Er:YAG laser is a solid
state, pulsed laser that has a m axim um em ission in the m id-infra-red region. At
2.94 /im, the w avelength of this laser coincides w ith the major absorption band of
w ater (-3.0 /im) and is therefore strongly absorbed in this region; the w ater
absorption coefficient for radiation produced by the Er:YAG laser is ten tim es
that of the radiation of the C O 2 laser. In addition , the w avelength is also w ell
absorbed by hydroxyapatite.

The first description of the effects of the Er:YAG laser on the dental h ard tissues
w as reported in 1988 and indicated that effective ablation of healthy and carious
tissue w as possible w ith o u t therm al injury and w ith m inim al te m p e ra tu re
changes to the su rro u n d in g h ard tissues (Hibst et a l, 1988; H ibst & Keller, 1989;

70
K eller & H ibst, 1989). The results of these studies led to the conclusion th at
ablation w as achieved via therm om echanical interactions (Section 2.10.3.5) and
that the m ajority of the incident radiation w as consum ed in the ablative process,
leaving very little resid u al energy for therm al interactions to occur. H ow ever, it
is w o rth noting that, w ith increasing pulse energies, small cracks su rro u n d in g the
crater w ere seen. These w ere th o u g h t to be artefacts arising d u rin g specim en
p rep a ra tio n rath er th an a direct effect of the incident radiation (Keller & Hibst,
1989).

The resu lts of these early reports suggested th at the Er:YAG laser h a d great
prom ise as a replacem ent for the dental drill, and since the late 1980's several
w orkers have investigated the use of the laser system in an attem pt to assess how
far it fulfils the properties of the ideal optical drill. A resum e of these criteria w as
given in Section 2.10.2.

Close in ter-stu d y com parisons are difficult because of the range of different laser
p a ram eters th a t have been chosen (Table 2.8). The follow ing review of the
literature attem pts to sum m arise the major findings reported.

2.10.6.2 Ablation

Early crater m easurem ents indicated that ablation depths of m ore than 30 jum per
pulse could be achieved for healthy enam el and dentine, w ith greater d e p th
m easurem ents being recorded for carious lesions (Keller & Hibst, 1995a). The
ab latio n th re sh o ld for enam el is higher th an that of dentine an d w h en the
th reshold is exceeded, m ass loss increases linearly w ith pulse energy (H ibst &
Keller, 1989) p ro v id in g the tissue does not become desiccated (Hoke et al., 1990).
C rater d ep th s an d w id th s increase w ith increasing pulse energies in both enam el
and dentine, those in dentine being larger than the craters found in enam el for
the sam e p u lse con d itio n s (H ibst & Keller, 1989). Keller an d H ibst (1995a)
calculated th at w ith a total pulse duration of 250 jus at 300 mj, 73 and 25 pulses
w ere req u ired to ablate 1 m m 3 area of enam el and dentine respectively and that
this w o u ld be achieved in 20 seconds w ith a repetition rate of 4 Hz.

The sp ee d in w h ich enam el an d dentine is rem oved is clearly of clinical

im portance. The ablation rate of the laser has been com pared to both high and

71
 Table 2.8 The range of Er:YAG laser parameters used in referenced reports

Report Energy Energy per Power Individual Pulse Total Pulse Pulse
density pulse (W) pulse repetition pulse cycle no.
(Jem 2) (mJ) duration rate duration time
(P S ) (Hz) (MS) (Ms)
Hibst & Keller, 1989 3 0 -3 6 0 1 1, single 250

Keller & Hibst, 1989 3 0 -3 6 0 1 1, single 250

Hoke et al, 1990 5 6 -1 1 8 2.5 250 14

Hibst & Keller, 1991 5 0 -3 5 0 1 300 10

Kayano etal, 1991 15.9 3 9 -5 0 0 200,000 1, 3,10 3 -1 0 0

Keller etal, 1991 100-300 1 -3 200 2 -1 0

Burkes etal, 1992 5 6 -9 5 2.5 250 14

Haller etal, 1992 250 2 3 0 0 -5 0 0

Keller etal, 1992 1 50-300 0 .5 -3 250 5 0 -2 5 0

Koort & Frentzen, 1 50-300 1.5, 5 200

1992

Li etal, 1992 2 5 -3 6 5 2, 5 200

Hofmann etal, 300/200 2

1992

Wigdor etal, 1993 500 3 250

Hibst & Keller, 1994 350 1.5

Keller & Hibst, 500 1.5-4 250

1995b

Wright etal, 1993 0 .2 -0 .3 2

Frentzen etal, 7 5 -2 0 0 1.5 200

1996

Visuri etal, 1996 up to ablation 2-10 230

110 threshold-400

Chao et al, 1996 0.5-2 3, 5, 10

Matsumoto et al, 2 5 0 -5 0 0 8
1996

Cozean etal, 1997 2 5 -1 2 0 5 -1 0

Keller & Hibst, 1997 150-350 2 250

Tanji etal, 1997 8 .6 4 - 6 0 -1 0 0

14.11

Aoki etal, 1998 180 10

Keller et al 1998 250-400, 2 -4 , 250

150-300 1 -3

72
slow speed bu rs in conventional dental handpieces (W igdor et a l, 1993; Chao et
a l, 1996; Keller et a l, 1998). For the laser param eters used (Table 2.8), the laser
ablated b o th enam el and dentine faster than the slow -speed bur, b u t w as less
efficient than the high-speed bur. Furtherm ore, the laser appeared to cause less
dam age to the pu lp and surrounding dental hard tissues than the slow speed bur
(W igdor et al, 1993), a property that is desirable in vivo.

H ib st an d K eller’s (1989) pro p o sal that therm om echanical interactions w ere

resp o n sib le for enam el an d den tine ablation w ere confirm ed in su b seq u en t
studies (Hoke et al, 1990; Li et al, 1992). To achieve ablation w hen the laser beam
is app lied over an area as opposed to a single spot and, or w hen, high energy
densities are used, w ater is required. In the absence of w ater, ablation occurs to a
lesser extent (Hoke et a l, 1990; Burkes et a l, 1992) an d the den tal h a rd tissues
becom e desiccated, exhibiting areas of charring, m elting and crack form ation.
The sim u ltan eo u s ap p licatio n of a w ater m ist d u rin g lasing p re v e n ts this.
H ow ever, there is evidence to suggest that the presence of excess w ater in deep
cavities can have an adverse affect on dentine ablation w h en laser energies
ap p ro a ch in g the th re sh o ld value for d en tin e are used. This is because a
significant proportion of the laser energy is absorbed by the excess w ater leaving
insufficient energy for dentine ablation (Visuri et al, 1996).

For clinical use, it is not only essential to be able to rem ove enam el, dentine and
caries w ith the laser, it is also necessary to rem ove restorative m aterials. H ibst
an d K eller (1991) found th at the ablation efficiency of p h o sp h a te cem ent,
carboxylate cem ent, glass-ionom er cem ent and com posites w as only slightly
low er than that for enam el and dentine for laser param eters of 10 pulses at 1 Hz
an d pulse energies of 50-350 mj. The ablation of silver am algam w as only
possible w ith energies exceeding 150 mj. H ow ever, high tem p eratu res w ere
gen erated d u rin g am algam ablation and, because of the high concentration of
m ercury in the plum e, Keller and Hibst (1995a) recom m ended that the EriYAG
laser should not be used for the rem oval of these restorations. This has obvious
im plications w hen considering the possibility of replacing the dental drill w ith a
laser.

73
2.10.6.3 M orphology

Several w orkers have investigated the m orphology of lased enam el and dentine
using light m icroscopic and SEM analysis (Keller & Hibst, 1989; H oke et al., 1990).
E xam ination of lased tooth sections u n d er light m icroscopy rev ealed slightly
ro u g h cavosurface angles in enam el, sm ooth d en tin al cavity w alls, an d an
irreg u lar to p o g rap h y of peaks and valleys on the p u lp al floor. SEM analysis
fo u n d th at enam el ablation p ro d u ced an irregular surface of grooves, flakes,
shelves and pits. In addition, at num erous sites on the enam el w all there w ere
c o n e-sh ap ed craters ex ten d in g irreg u larly into the surface. The surface
co n fig u ratio n of the den tin e w as sm oother and m ore ro u n d e d th an that of
enam el w ith sm aller pits and grooves. At high m agnifications (x3,000) the lased
d entine surface w as found to lack a sm ear layer and the dentinal tubules were
p ro m in en t because of selective ablation of the peritubular dentine. In addition,
the orifices of m any of the tubules w ere exposed, though some w ere occluded
w ith crystalline deposits (Aoki et al., 1998).

As no ted in Section 2.10.6.1, one early stu d y rep o rted the absence of therm al
dam age to the ablated surface and the su rro u n d in g hard dental tissue, despite
the presence of cracks in the su rro u n d in g enam el w ith high p u lse energies
(Keller & Hibst, 1989). In this study, a single spot w as lased w ith o u t additional
w ater. S u b sequent investigations using sim ilar laser p aram eters for cavity
p rep aratio n reported evidence of adverse therm al changes. This w as prevented
w ith the application of a w ater m ist during lasing (Hoke et al., 1990; Burkes et al.,
1992). H ow ever, ev en w ith the a d d itio n a l w ater, som e ch an g es in the
su rro u n d in g 10 jum of both enam el and dentine w ere noted; enam el exhibited
shelves w ith sm all flakes and grooves and the dentinal tubules w ere not intact
(Hoke et al., 1990). In a further study, evidence of acid resistance of lased enam el
w ith o u t crack form ation, and a thin m ineralising zone in the subsurface area of
lased dentine have been reported w ith pulse energies of 500 m j suggesting the
presence of some therm al change, albeit m inim al (Kayano et al., 1991).

H ow ever, in contrast to the lack of, or m inim al therm al change fo u n d in the

studies so far noted, other w orkers have reported evidence of crack form ation in
the d en tal h a rd tissues irrespective of the laser p aram eters u sed (K oort &
Frentzen, 1992; Frentzen et al., 1996). It w ould appear therefore th at w hile laser

74
p aram eters are im p o rtan t for successful ablation, the m orphology of the tooth
tissue is also significant (Frentzen et a l, 1996; V isuri et al, 1996). W hile the
com plete absence of therm al changes w ould appear to be unlikely, the Er:YAG
laser produces less dam age than com parable carbon dioxide , Nd:YAG, HorYAG,
Th:YAG and ArF excim er lasers (Keller & Hibst, 1989; Koort & Frentzen, 1992;
W igdor et al, 1993; Frentzen et al, 1996).

This resum e has focused on the m orphological effects of the laser rad iatio n on
the dental h ard tissues. Of equal im portance is the response of the pulpal tissues
to heat produced d u ring ablation of the dental hard tissues.

2.10.6.4 Temperature

The p u lp 's sensitivity to changes in tem perature were noted in Section 2.2.3. It is
therefore essential th at any changes in p u lp tem perature d u rin g lasing do not
exceed 5.5°C, since an increase beyond this is likely to produce irreversible pulpal
dam age (Zach & Cohen, 1965).

Reference has already been m ade to the effect of applying the Er:YAG laser beam
to an enam el surface w ith o u t w ater coolant (Section 2.10.6.3). T his w as
accom panied by an increase in tem perature of at least 20°C at the p u lpodentinal
junction. W hen a w ater m ist w as used sim ultaneously w ith the laser, the average
rise in tem p eratu re w as only 2.2°C (Hoke et al., 1990). This fin d in g is in
ag reem en t w ith other w orkers (Burkes et al., 1992; V isuri et al., 1996). The
m easu rem en ts w ere m ade in vitro w hich m ay be assu m ed to p ro v id e m ore
stringent conditions than in vivo w here blood flow accelerates the dissipation of
therm al energy. It can therefore be assum ed that the sim ultaneous application of
a w ater m ist w hile using the Er:YAG laser is sufficient to m ain tain the p u lp
tem p eratu re w ith in safe lim its for the laser param eters investigated. Indirect
confirm ation of this has been achieved w ith the use of a laser D oppler flow m eter
to m easure changes in the m icro-circulation of the pulp of vital teeth (Keller et al.,
1991).

To m inim ise the therm al effects on both the dental hard tissues (Section 2.10.3.3)
and the pulp, the use of m axim um energy densities of less than 80 and 74 Jem'2
for enam el and dentine respectively (Li et a l, 1992) w ith a w ater m ist for pulse

75
re p e titio n ra tes g re a te r th a n 2 H z (K eller & H ibst, 1995b) h av e b een
recom m ended.

2.10.6.5 Long-term pulp reaction

Keller et al (1992) investigated the effect of irradiation w ith the Er:YAG laser on
the h istology of the d en tal p u lp in dogs. The laser energies ra n g e d from
150-300 m j w ith pulse repetition rates of 0.5-3 Hz. No pulp reaction occurred for
any of the laser param eters w hen the cavity preparation stopped in enam el or in
dentine that did not approxim ate the pulp. For deep cavities, an increase in the
n um ber of blood vessels w as seen w ithin tw o weeks, and w h en the p u lp w as
exposed w ith the laser radiation, there w as evidence of necrosis near the lased
area. H ow ever, the odontoblasts adjacent to the laser defect w ere unchanged and
tw o w eeks later, a layer of secondary dentine w as seen in this region w hich
continued to increase in thickness over the next four weeks. These findings w ere
in agreem ent w ith su bsequent in vivo studies rep o rted by W igdor et al (1993)
using laser param eters w ithin the same range, and by C ozean et al (1997) using
energies of 25-120 m j w ith a PRR of 5-10 Hz. In the latter study, a group of lased
teeth w ere follow ed u p for u p to 36 m onths during w hich tim e radiographs and
routine sensitivity tests confirm ed the continued vitality of the pulps.

W hile these studies found a favourable pulpodentinal response to Er:YAG laser

irradiation, an inflam m atory reaction follow ed by necrosis has been rep o rted
w ith pulse energies of 500 m j for pulse repetition rates of m ore than 2 H z in the
absence of additional w ater (Keller & Hibst, 1995b).

Thus, these findings suggest that w ith the use of suitable laser param eters and a
w ater cooling system , irreversible pulp dam age can be avoided even w ith deep
cavity preparations.

2.10.6.6 Patient acceptance

The m echanical prep aratio n of a cavity w ith a b u r in both a slow- or high-speed

d en tal handpiece can result in pain because of vibration, pressure, heat an d
noise. For the p atien t's com fort, pain-free cavity p rep a ra tio n w ith o u t local
analgesia w o u ld be ideal. The absence of significant tem p eratu re an d p u lp al

76
changes noted in sections 2.10.6.4 and 2.10.6.5 led w orkers to suggest that this
m ay be possible for the Er:YAG laser.

In their in vivo study investigating the use of the Er:YAG laser for the preparation
of sm all to m oderate w edge-shaped defects, M atsum oto et al (1996) found that
80% (49) of patients felt no pain or discomfort. Overall, the clinical efficacy of the
laser, taking into account pain, p atient perception, and the results of sensibility
and radiographic investigations, w as felt to be good in 82% of cases. Two m ore
recent in vivo studies (Cozean et al., 1997; Keller & Hibst, 1997) rep o rted that
patien ts experienced m inim al pain d u rin g cavity p rep aratio n even w ith deep
cavities, and that less than 2% of the cavities required the adm inistration of local
analgesia for com pletion. In the latter study, laser p reparation w as found to be
com parable to the use of high-speed drill w hen pulpal changes w ere com pared.
H ow ever, the routine use of local analgesia for the control group of patients w as
inferred and therefore it w as not possible to com pare patient com fort for the two
p ro ced u res. In a later stu d y , 6% of patients u n d erg o in g laser p re p a ra tio n
re q u ire d local analgesia com pared to 11% of p atien ts w ith conventionally-
p rep ared cavities (Keller et al., 1998). This latter value is low er th an w o u ld be
expected from anecdotal clinical experience. For 80% of patients, the b u r w as
ju d g ed to be m ore uncom fortable, and 82% of patients stated a preference for
Er:YAG therapy in the future.

From this review , it can be seen that the Er:YAG laser has several advantageous
properties for cavity preparation. W ith the correct choice of laser param eters and
the use of a w ater coolant, ablation of both enam el and dentine is possible w ith
m inim al dam age to the h ard dental tissues and pulp and w ith very little pain for
the patient. H ow ever, in ad dition to these qualities, it is also essential that the
quality of the m arginal integrity of restorations is not affected adversely.

2.10.6.7 Microleakage

W hile the m orphological changes seen in enam el and dentine after irrad iatio n
w ith the Er:YAG laser have been extensively reported (Section 2.10.6.3), less
in fo rm atio n is available on the effect of the laser on m icroleakage. Some
assum ptions m ay be m ade by considering the ultrastru ctu ral features of lased
enam el and d entine. The rou g h ness of the lased surface, w hile increasing

77
porosity, m ay increase the w ettability of the surface and therefore have a positive
effect on m icrom echanical retention, effectively p ro d u cin g an 'etched surface'
w ith o u t the use of etchant. O n the other hand, the converse is possible an d the
ro u g h e r su rface m ay re su lt in in creased sp acin g a n d th e re fo re g re a te r
m icroleakage. In addition, other structural features m ay have an adverse effect
on m a rg in a l a d ap tab ility . A m o m en tary te m p e ra tu re rise in e n am el of
800-1,100 °C is sufficient for the fusing an d m elting of the ap atite crystals
(Featherstone & Nelson, 1987). As noted in Section 2.10.3.3, by sealing pits and
fissures an d red u cin g the p o tential for acid d em in eralisatio n of the enam el
surface, this p ro p erty has been used w ith carbon dioxide an d Nd:YAG lasers to
advantage in caries prevention (Yamamoto & Ooya, 1974; N am m our et al., 1992).
H ow ever, these structural changes serve to reduce the w ettability an d etchability
of the enam el surface and thus could have an adverse effect on the seal at the
CRI. In addition, the form ation of cracks m ay increase the perm eability of the
s u rro u n d in g tissue (Lobene & Ferreira, 1966; Koort & Frentzen, 1992). T hus
w hile the therm al side effects of the Er:YAG laser are m inim al, w h en they do
occur it m ay be assum ed that cracks and fusing of crystals m ay influence the CRI
adversely. These features are not lim ited to enam el: in a recent study, it w as
concluded th at the Er:YAG laser prom oted acid resistance of the rem ain in g
dentine, and that a pulse energy of 100 m j w ould p ro v id e a b etter p a tte rn of
m icrom echanical reten tio n w h en com pared w ith sm aller values (Tanji et al.,
1997).

Studies in vestigating the influence of the Er:YAG laser on the qu ality of the
m arginal seal of restorations have investigated three areas: cavity p rep aratio n
and enam el conditioning w ith the laser, cavity p rep aratio n w ith the laser and
conventional enam el etching w ith phosphoric acid, an d finally conventional
cavity preparation w ith a high-speed diam ond bur in an air-rotor handpiece and
laser conditioning. The apparent contradictions in the results of these studies is
p erh ap s a reflection of differences in the choice of laser param eters, restorative
m aterial an d cavity shape. This review w ill be lim ited to the stu d ies u sin g
com posite resins, glass-ionom er cem ents an d related m aterials in C lass V
cavities.

H ofm ann et al (1992) com pared the leakage of bevelled enam el m argins of box­
sh ap ed cavities p rep ared w ith the conventional h igh-speed d iam o n d b u r w ith

78
b o th bev elled an d non-bevelled cavities p re p a re d by the Er:YAG laser. In
addition, they also investigated the effect of om itting the acid-etching process in
the restoration of these three cavity types. Pulse energies of 300 m j and 200 m j
for enam el and dentine respectively, at a PRR of 2 Hz, w ere u sed for the lased
cavities. A fter seven d ays storage an d therm ocycling, the co n v en tio n ally -
p repared, bevelled and etched m argins exhibited significantly less leakage w hen
com pared to enam el m argins that had been p repared and bevelled w ith the laser
prior to acid-etching. W hen acid etching was om itted, an increase in leakage was
observed, th o u g h the differences w ere only significant for the conventionally-
p re p a re d cavities. This led the au th o rs to conclude th a t the acid etching
technique h ad very little influence on microleakage in the laser-prepared cavities,
w ith or w ith o u t a bevel. As w ou ld be predicted, of the lased cavities, those w ith
the higher C-factor (non-bevelled) exhibited the w orst leakage.

In a sim ilar stu d y using 350 m j at 1.5 Hz for cavity p rep aratio n , 120 m j for
bevelling, and an undefined storage period, H ibst and Keller (1994) investigated
the efficacy of the e n a m e l/c o m p o site b o n d using laser etch in g in ste a d of
conventional acid preparation, w ith and w ithout therm ocycling. Irrespective of
the m ethod of cavity preparation, therm ocycling resulted in a significant increase
in m icroleakage. After therm ocycling and im m ersion in fuchsin dye, they found
that bevelling and acid etching significantly reduced m icroleakage in the lased
cavities. Furtherm ore, for the laser-prepared m argins, w hen acid-etching w as
om itted, the box-shaped cavities exhibited significantly m ore m icroleakage than
those th at h ad been bevelled w ith the laser. This, and the influence of acid-
etching on m icroleakage w ere in contrast to the findings of H ofm ann et al (1992).
H ow ever, in agreem ent w ith H ofm ann et al (1992), w ith the exception of the
lased cavities w here bevelling h ad been achieved w ith the laser, the etched
cavities that had been conventionally p repared and bevelled exhibited the least
dye penetration. In addition, the sealing quality of laser-etched enam el m argins
im proved and approxim ated to that of acid-etched m argins, w hen, prior to laser
etching, the enam el w as ro u g h en ed by a defocused Er:YAG laser application.
H ibst and Keller (1994) suggested that this w as because cavity p rep aratio n w ith a
single laser energy led to a surface consisting of small, b u t sep arated craters
w h en com pared to the two stage procedure, and the relatively large area of
u n treated enam el led to a reduced m icrom echanical attachm ent. These findings

79
led them to suggest that etching w ith phosphoric acid could be replaced by laser
conditioning w ith conventionally-prepared bevelled enam el m argins.

W right et al (1993) com pared the efficacy of the en am el/com posite seal obtained
after acid-etching w ith th at achieved w ith laser etching. They re p o rte d no
significant difference in leakage after 90 days storage betw een conventionally-
p re p a re d cavities w ith enam el etching achieved by conventional p h o sp h o ric
acid-etching or laser-etching, an d lased cavity p rep aratio n w ith laser-etched
enam el m argins. H ow ever, very low pulse energies w ere u sed in this study;
300 ii] at 2 H z w ith a 200 juJ etch.

To sum m arise, from these studies, there w ould appear to be agreem ent that the
co n v entionally-prepared, bevelled and etched enam el m argins, on the whole,
produce a better com posite/enam el seal w hen com pared to m argins p rep ared by
the laser. H ow ever, w hile the leakage seen at the lased m argins w as influenced
by the m argin preparation, there did not appear to be any clear cut trends. It
w ould appear, therefore, that both the macro- and m icro-structure of the enam el
is im p o rtan t w hen considering m icroleakage (Hibst & Keller, 1994). In addition,
differences in experim ental protocol and m aterial variables m ay also contribute
to these a p p a re n t discrepancies. Investigations on the sealing q u ality of
com posite restorations in dentine has highlighted the im portance of the choice of
d e n tin e b o n d in g ag en t (H aller et al, 1993b). U sing the sam e m icrofilled
com posite resin, and laser param eters of 250 m j at 2 Hz, tw o of the seven dentine
b o n d in g agents exhibited significantly low er m icroleakage scores for lased
cavities w hen com pared to conventional preparation. A further tw o show ed no
difference an d the efficacy of the rem aining three agents, one of w hich w as
Scotchbond M ulti-Purpose, w as reduced w hen the cavities w ere p rep ared w ith
the Er:YAG laser. It w ou ld ap p ear therefore that in ad d itio n to the need for
optim al laser variables, the choice of com posite resin and dentine b o nding agent
is also essential.

In a d d itio n to investig atin g the efficacy of the to o th /c o m p o site resto ratio n

interface, H ofm ann et al (1992) and H aller et al (1993b) also fo u n d th a t the
m arg in al seal of glass-ionom er cem ent m aterials and resin -m o d ified glass-
ionom er cem ents w as su p erio r in the conventionally-prepared cavities w h en
com pared to those prepared w ith the laser.

80
2.11 General summary

This review of the literature has indicated that, of the lasers developed to date,
the Er:YAG laser show s prom ise as an optical drill and therefore m ay have a role
to play in the dental m anagem ent of anxious individuals. It is essential that the
use of the laser does not dam age the m arg in al in teg rity of the re su ltin g
restoration. H ow ever, w h en using the laser, the dentist is faced w ith a broad
range of operating param eters. W hile it is desirable to be able to rem ove caries,
enam el and dentine at rates that are at least com parable to the conventional high­
speed drill and bur, it is im portant that the selected operating conditions do not
ad v ersely affect m icroleakage at the d en tin e an d enam el m arg in s for the
restorative m aterial being used. This study seeks to address this issue for three
pulse'energies and tw o currently used direct adhesive m aterials.

2.12 Aims and objectives

The aim of this in vitro study was to investigate w hether cavity prep aratio n w ith
an Er:YAG laser influenced the seal of Class V com posite resin an d com pom er
restorations at the enam el and dentine m argins.

The objectives w ere to:

• evaluate the effect of three different laser energy densities on m icroleakage
• com pare the m icroleakage of cavities p rep ared w ith the Er:YAG laser w ith
those p rep ared conventionally w ith a diam ond bur in a high-speed air-rotor
handpiece
• com pare the m icroleakage of the two m aterials
• assess the influence of storage on com posite restorations

This w o rk tests the null hypothesis that the use of the Er:YAG laser in cavity
p rep aratio n does not have a deleterious effect on the m icroleakage of Class V
restorations w hen com pared to cavity preparation w ith a diam ond b u r u sed in a
conventional high-speed handpiece.

81
3 Materials and method

3.1 Materials

Tw o restorative system s, each w ith their respective bonding agents, w ere used in
this study. They were:

• Z100 MP (Z100) (3M D ental Products, St Paul, MN, USA) w ith Scotchbond
M ulti-Purpose (SMP) (Figure 3.1) and

• C o m p o g lass (V ivadent, Schaan, L eichtenstein) w ith C o m p o g lass Single

C om ponent A dhesive (SCA) (Figure 3.2).

3.1.1 Z100

Z100 is a dense, ultrafine com pact-filled hybrid com posite (W illems et al., 1993)
w ith an inorganic filler loading of 84.5% by w eight and 71% by volum e (3M,
1997) and is dispensed in pre-dosed com pules. The fillers are ro u n d ed zirconia
fillers produced by the sol-gel process (Ferracane, 1995) and have a m ean size of
0.6-1.0 jum. H ow ever, there is a w ide distribution of sizes u p to a m axim um of 4
ium w hich obviates the need for the addition of am orphous silica to im prove the
h a n d lin g properties. The m ajor com ponent of the resin is Bis-GMA w ith a
d iluent resin of TEGDMA. This organic phase com prises 15.5% by w eight of the
total m aterial (3M, 1997). The m aterial has good stren g th a n d h a n d lin g
properties, and the abrasion resistance and polishability are excellent, due in part
to the spherical nature of the fillers. The resin is also fast-setting an d relatively
rigid (de Gee & Pallav, 1994).

3.1.2 Scotchbond Multi-Purpose

SMP is a fo u rth generation dentine bonding agent and is com posed of three
com ponents: an acid, a prim er and an adhesive. The etchant in the original SMP
agent w as 10% maleic acid, and bond strengths to enam el and dentine of

82
 ufcdrtwntf
MuU. d"*"*"
sw» MW*“ S^ L * .

\V’V,vr' . .v .c,»v.i<W* ^ v ’

Figure 3.1 Z100 com posite resin and S cotchbond M ulti-P urpose b o n d in g agent

inw °

Figure 3.2 C om poglass com pom er resin an d C om poglass Single C om ponent

A dhesive

83
17.0 M Pa an d 21.8M Pa respectively w ere achieved (Swift & Triolo, 1992).
M oreover, these values increased w hen 35% phosphoric acid w as su b stitu ted as
the etchant w ith bond strengths of 24.5 M Pa (Swift & Cloe, 1993) an d 24.0 MPa
(3M, 1994) being reported for enam el and dentine respectively. The m ore recent
m aterials in the UK, and therefore in this stu d y have used a phosp h o ric acid
etchant.

The p rim er is com posed of the h y d ro p h ilic m onom er HEM A an d an acid

copolym er, w hile the adhesive is based on Bis-GM A an d HEM A an d also
contains an initiator. In com m on w ith other fourth generation m aterials, SMP
em ploys total etch and m oist bonding techniques. Successful m oist bonding is
d ep en d en t on the presence of the acid co-polymer (Gwinnett, 1992). Bonding is
achieved by the alteratio n of the sm ear layer and su b seq u en t h y b rid isatio n
(Section 2.7.2.2.1). In vitro m icroleakage does not appear to be affected adversely
w hen the dentine is left visibly m oist (Saunders & Saunders, 1996), an advantage
w hen bonding to deeper, highly perm eable dentine. The viscous adhesive results
in a relatively thick interm ediate resin layer w ith an identical stress-relaxation
buffer capacity as a low viscosity resin (Van M eerbeek et ah, 1994).

3.1.3 Compoglass

C om poglass is a single-com ponent, light-cured, fluoride-releasing com pom er

resin an d is d isp e n se d in p re-d o sed plastic com pules k n o w n as Cavifils.
C om posite resin m akes u p 70% of the m aterial, the rem ainder is glass-ionom er.
The resin is based on Bis-GMA and urethane dim ethacrylate in a ratio of 1:2.3 by
w eig h t, an d the m o n o m er has been m odified by a d d in g a cycloaliphatic
dicarboxylic acid dim ethacrylate (DCMA) (Vivadent, 1996). C om poglass has a
filler loading of 55.9% by w eight and 79% by volum e. The fillers, sialinised
barium fluorosilicate glass and ytterbium trifluoride fillers, have a m ean particle
size of 1.6 Jim and are responsible for the fluoride release of the resin.

The m anufacturers claim that the resin sets via radical polym erisation and that
an auxiliary acid-base setting reaction occurs w hen the m aterial is placed in
w ater. H ow ever, no increase in com pressive strength was found after storage in
w ater, and this secondary reaction has been questioned (Burgess et a l, 1996).

84
Bonding to enam el and dentine is purely reliant on m icrom echanical attachm ent
via a resin-reinforced h y b rid layer form ed by the application of C om poglass
SCA.

3.1.4 Compoglass Single Component Adhesive

C o m poglass SCA is a single-com ponent, light-curing, self-prim ing b o n d in g

agent. It consists of a m ethacrylate-m odified polyacrylic acid, HEM A, w ater,
m aleic acid, am m onium fluoride, photoinitiators and stabilisers. A cid-etching is
not req u ired and the m aterial bonds effectively to the dentinal sm ear layer via
the form ation of a hybrid layer. Bond strengths to enam el and dentine of 18 MPa
an d 19 M Pa respectively have been reported (Vivadent, 1996). In addition, the
presence of the fluoride ion results in fluoride release.

3.2 Method

3.2.1 Tooth selection

Caries- and restoration-free extracted perm anent hum an prem olar teeth, w hich
h a d been stored in 0.12% thym ol solution, w ere exam ined m acroscopically for
defects in the enam el and dentine. One h u n d red and eighty four w ere selected
an d cleaned of superficial debris w ith a scalpel. They w ere then lightly pum iced
before being random ly allocated to three equal sized groups, A, B and C.

3.2.2 Cavity preparation

A butt-joint Class V cavity w as prepared on both the buccal and lingual surfaces
of each tooth. Each tooth hosted a test and control cavity. The form er w as cut
w ith a p u lsed Er:YAG laser (Tw inlight D ental Laser, Fotona d.d, Ljublijana,
Slovenia) (Figure 3.3) and the control cavity was cut w ith a d iam ond fissure bur
(#FG108008, Horico, Berlin, G erm any) in a high-speed air-rotor handpiece. In
both cases an air / w ater coolant w as used and the tooth and handpiece w ere held
by h an d (Figure 3.4). The b u r w as changed after 20 cavities. A llocation of the
test and control surfaces w as random . The cavities were prepared at the cervical
m argin of the tooth (Figure 3.5), w ith the coronal and gingival m argins in cervical

85
 Figure 3.3 T he Erbium:YAG T w in lig h t D ental Laser

Figure 3.4 C avity p rep aratio n u sin g th e Erbium:YAG laser

86
Figure 3.5 Line draw ing show ing the position of the cavity at the cervical
m argin of the tooth; a) approxim al surface b) buccal surface

87
Figure 3.5 Line draw ing show ing the position of the cavity at the cervical
m argin of the tooth; a) approxim al surface b) buccal surface

87
enam el and den tin e or cem entum respectively. The cavity size w as m ade as
u nifo rm as possible, 1.5 m m deep, 3 m m in w idth and 2 m m in height, using
m etal strip tem plates (Figure 3.6). A two stage im pression of each cavity w as
then taken using Extrude addition cured silicone elastom eric im pression m aterial
(Kerr, Rom ulus, MI, USA) in a purpose-m ade tray. These w ere stored for SEM
analysis in another study. O n com pletion the teeth w ere retu rn ed to the thym ol
solution.

3.2.2.2 Laser parameters

Local laser protection guidelines w ere follow ed d u rin g lasing. The operating
param eters w ere selected on the control panel (Figure 3.7). A pulse repetition
rate of 5 H z w as used. This is know n to ablate enam el and dentine w ith m inim al
therm al dam age (Li et al., 1992). The teeth in each of the three groups (A, B and
C) w ere random ly divided into three subgroups, so enabling three different laser
energies to be tested on each group; one on each subgroup w ithin a group. The
three laser energies selected w ere 200 mj, 240 m j and 300 m j. C harring of the
dentine w as seen at the latter pulse energy (Figure 3.8) and therefore a 100 m j
dentine finish w as used for the 300 m j cavities only. For clarity, the subgroups
w ere iden tified u sin g the suffixes 200, 240 an d 300. The air p ressu re w as
m aintained at a constant 20 PSI, and the w ater m ist w as provided from a hand-
p u m p e d plastic container. The m axim um p ressure for this w as selected by
qualitative assessm ent of the resistance felt during hand-pum ping.

3.2.3 Cavity restoration

The teeth in groups A and B were restored w ith SMP and Z100 resin (shade A3.5)
according to the m anufacturer's instructions: each cavity w as lightly cleaned
w ith a pum ice and w ater slurry in a rubber cup. They w ere then w ashed and
dried w ith com pressed, oil-free w ater and air from a 3-in-l syringe. Total etching
w as perform ed w ith the 35% phosphoric acid gel for 15 seconds, then each cavity
w as w ashed copiously w ith w ater for 15 seconds before being dried gently w ith
com pressed air for 5 seconds. The prim ing agent w as applied an d w as lightly
d rie d im m ediately w ith air for 2 seconds. Follow ing this, the adhesive w as
applied w ith a brush and light-cured for 10 seconds w ith a visible light activating

88
 Figure 3.6 The metal templates used during cavity preparation

Figure 3.7 The control panel of the Erbium iYAG T w in lig h t D ental Laser
Figure 3.8 D en tin e charring d u rin g cavity prep aratio n w ith the 300 m j pulse
energy

90
u n it (Luxor, ICI M acclesfield, UK). The com posite resin w as ap p lied in three
increm ents. The first tw o w ere applied obliquely against the occlusal and the
gingival w alls respectively. The final increm ent w as placed flush w ith the
contour of the tooth and covered w ith a transparent cellulose acetate m atrix strip
to b o th assist in packing and contouring, and reduce oxygen inhibition d u rin g
polym erisation. Each increm ent w as light-cured for 40 seconds. Finishing w as
carried o u t im m ed iately after p olym erisation using g rad ed Soflex discs (3M
D ental Products, St Paul, MN, USA) according to the m anufacturer's instructions.

The initial stages of the protocol for the restoration of g roup C w as identical to
th at described for g roups A and B (i.e. cleaning w ith pum ice an d w ater slurry
and w ashing and drying w ith com pressed w ater and air). The cavities w ere then
restored w ith Com poglass SCA and Com poglass resin (shade A3.5) follow ing the
m anufacturer's instructions. The bonding agent w as applied to the cavity for 20
seconds, follow ing w hich it w as d istrib u ted w ith air an d lig h t-cu red for 20
seconds. A second layer of C om poglass SCA w as ap p lied and im m ediately
distrib u ted w ith blow n air before being light-cured for 20 seconds. The resin w as
applied increm entally and cured as for groups A and B and then the restoration
w as finished and polished w ith graded Soflex discs.

3.2.4 Storage and thermocycling

Following restoration, group A w as stored for 24 hours and groups B an d C w ere

stored for 3 m onths in 0.12% thym ol solution at a constant tem perature of 37 °C.
Each tooth w as then therm ocycled through w ater baths at 5 °C, 37 °C, 55 °C and
37 °C, w ith a 10 seconds dw ell tim e in each bath for 240 cycles (Figure 3.9) before
being retu rn ed to the thym ol solution at 37 °C for 12 hours. Care w as taken to
av o id d e h y d ra tio n at any stage of resto ratio n and d u rin g the su b seq u en t
prep aratio n for microleakage.

3.2.5 Microleakage assessment

M icroleakage w as assessed u sing a dye p en etratio n technique w ith in vitro

im m ersio n (Section 2.5.2). The teeth w ere dried, the root apices sealed w ith
sticky w ax an d coated w ith tw o layers of nail varnish (Max Factor D iam ond
H ard, Procter and Gamble, Surrey, UK) to w ithin 1 m m of the restoration. Once

91
Figure 3.9 The therm ocycling u n it

92
the nail varn ish w as dry, the teeth w ere retu rn ed to the thym ol so lu tio n for a
fu rth er 12 hours. Following this, each tooth w as placed in a 2% aqueous solution
of m ethylene blue, buffered to pH 7.00, for 24 hours at 37 °C. The teeth w ere then
rinsed thoroughly in tap w ater and the varnish rem oved w ith a w ax knife. Each
tooth w as sectioned longitudinally in a bucco-lingual plane th ro u g h the m id ­
p o in t of the restorations w ith a w ater-cooled diam ond disc on a m icrotom e,
L abcut (A gar Scientific Ltd, Stansted, UK) (Figure 3.10). M icroleakage w as
assessed by tw o calibrated exam iners w ho w ere unaw are of the groupings of the
teeth. Differences w ere reconciled by agreem ent. For each tooth, both sections
w ere exam ined u n d er x6 m agnification and the extent of the leakage w as scored
at b oth the enam el and dentine m argins using the follow ing rank o rd er system
(Saunders et al., 1991) (Figures 3.11-3.15).

0: no dye penetration;
1: dye penetration u p to one-third cavity depth;
2: dye penetration u p to tw o-thirds cavity depth;
3: dye penetration to full cavity depth;
4: extensive dye penetration to and into pulpal floor/axial wall.

The scores for both sections w ere com pared and the w orst score for each m argin
w as chosen to represent the specimen for statistical analysis.

3.2.6 Statistical analysis

The d ata w ere analysed on a PC using M initab (M initab inc. State College, PA,
USA). The effect on leakage of the type of restorative m aterial used w as assessed
by com paring the results for group B (Z100 restorative stored for 3 m onths) w ith
those for g ro u p C (Com poglass stored for 3 m onths). To assess the effect of
storage time on leakage the results from group B were com pared w ith those from
g ro u p A (Z100 stored for 24 hours). These com parisons w ere m ade for the
e n am el a n d d e n tin e m a rg in s sep a ra te ly . For b o th m a rg in ty p e s th e
conventionally-prepared and lased cavities w ere considered separately an d w ere
then com pared.

In addition, the extent of leakage in each of the subgroups (200, 240 an d 300)
w ithin each group (A, B and C) was com pared for both types of cavity

93
 Figure 3.10 The Labcut m icrotom e used for sectioning

Figure 3.11 M icroleakage scoring: enam el m argin = 0, dentine m argin = 0

94
Figure 3.12 M icroleakage scoring: enam el m argin = 1, d en tin e m argin = 3 w ith
extensive dye p en etratio n in the d entinal tu b u les

Figure 3.13 M icroleakage scoring: enam el m argin = 1, d en tin e m argin = 2 w ith

m inim al dye p en etratio n in the den tin al tu b u le s

95
Figure 3.14 M icroleakage scoring: enam el m argin = 2, d en tin e m argin = 4 w ith
m inim al dye p en etratio n in the den tin al tu b u les

Figure 3.15 M icroleakage scoring: enam el m argin = 2, d en tin e m argin = 4 w ith

extensive dye p en etratio n in the den tin al tu b u les

96
prep aratio n . Since these subgroup divisions w ere based on the different laser
energies used, no significant difference in m icroleakage w as expected for the
conventionally-prepared cavities i.e. the control cavities. Statistical com parison
of the su bgroup data for the conventionally-prepared cavities therefore p ro v id ed
a m eans of checking the integrity of the m ethodology used.

The K ruskal-W allis test w as used to determ ine the statistical difference am ong
the g ro u p s. The co m p ariso n of p aired g ro u p s w as m ad e u sin g the non-
param etric M ann-W hitney U-test. Both tests w ere corrected for ties an d a 0.05
level of significance w as applied.

97
4 Results

4.1 Introduction

There w as evidence of dye penetration, and therefore m icroleakage, to a greater

or lesser extent, in teeth from each of the groups (Table 4.1). As in d icated in
Section 3.2.6, ranking the degree of m icroleakage enabled the data to be analysed
statistically. The results of these analyses are reported below for the tw o m arg in
ty p es follow ing the fram ew ork described in Section 3.2.6. W here ap p ro p riate,
the resu lts have been illu strated using graphs an n o tated w ith the levels of
significance.

4.2 Enamel margins

4.2.1 Conventionally-prepared enamel margins

4.2.1.1 Within-group analyses

For the conventionally-prepared enam el m argins, the Kruskal-W allis test show ed
no significant difference in leakage at the 95% significance level b e tw e e n
su b g ro u p s 200, 240 and 300 for each of the three groups, A, B an d C (p = 0.21,
p = 0.53 and p = 0.86 respectively). As indicated in Section 3.2.6, this p ro v id ed an
in dication of the integrity of the m ethodology used. It also m eant th at these
su b g ro u p leakage scores could be com bined for further com parisons involving
only the conventionally-prepared cavities (i.e. the intergroup analysis in Section
4.2.1.2 and the enam el versus dentine analysis in Section 4.4).

4.2.1.2 Intergroup analyses

As discussed in Section 3.2.6, to assess the effect of storage tim e on the degree of
leakage, the group A scores w ere com pared to those from group B. The effect of
the restorative m aterial on the degree of leakage w as assessed by com paring the

98
 Table 4.1 Microleakage scores for all cavities

Restoration Group N Margin Conventionally- Lased scores

prepared scores

0 1 2 3 4 0 1 2 3 4

Group A A200 20 Enamel 3 13 3 1 0 3 11 6 0 0

Z100 and A200 20 Dentine 0 12 0 0 8 0 7 1 0 12

SMP stored A240 23 Enamel 3 7 11 1 1 4 1 16 2 0

for 24 hours A240 23 Dentine 4 11 3 0 5 1 4 4 2 12

-
A300 20 Enamel 5 6 6 2 1 4 5 9 1 1

A300 20 Dentine 1 8 5 1 5 0 7 6 1 6

Group B B200 20 Enamel 11 7 1 1 0 5 12 1 2 0

Z100 and B200 20 Dentine 2 4 6 2 6 0 1 1 2 16

SM P stored B240 20 Enamel 15 2 2 0 1 12 7 1 0 0

for 3 months B240 20 Dentine 1 4 3 2 10 0 1 0 0 19

B300 20 Enamel 11 7 2 0 0 13 6 1 0 0

B300 20 Dentine 8 1 4 0 7 3 3 1 1 12

Group C C200 20 Enamel 8 9 2 1 0 12 6 2 0 0

C om poglass C200 20 Dentine 7 4 7 1 1 6 7 7 0 0

and SCA C240 20 Enamel 8 8 4 0 0 18 2 0 0 0

stored C240 20 Dentine 5 7 6 1 1 9 5 3 2 1

for 3 months C300 21 Enamel 9 10 1 0 1 11 8 1 0 1

C300 21 Dentine 7 7 6 0 1 11 3 4 0 3

99
g ro u p B scores w ith those of group C. The results of these in terg ro u p analyses
are p resented in Figure 4.1. This show s that the enam el m argins of the teeth in
g roup B exhibited significantly less leakage than those in either group A or group
C (p < 0.001 and p = 0.04 respectively).

4.2.2 Lased enam el m argins

4.2.2 .1 Within-group analyses

Leakage w as observed at the lased enam el m argins in teeth from all three groups
(Figure 4.2a-c). H ow ever, the severest level of leakage (score 4) w as confined to
one specim en in each of the subgroups A300 and C300 w hich w as sim ilar to the
conventionally-prepared m argins (Section 4.2.1.1).

W ithin each group the difference in the extent of leakage w as com pared betw een
the subgroups (200, 240 and 300). In group A (Figure 4.2a) at least 80% (16) of
specim ens in each su b g ro u p exhibited som e degree of leakage. H ow ever, the
difference w as only significant betw een the A200 and A240 m argins (p = 0.02)
w ith the form er show ing less leakage.

C onversely, in g ro u p B (Figure 4.2b), the B200 m argins show ed significantly

m ore leakage th an those of B240 and B300 (p = 0.02 and p = 0.01 respectively).
The p attern s of leakage recorded for the B240 and B300 m argins w ere alm ost
identical (p = 0.77).

For g roup C (Figure 4.2c), there w as no leakage in 90% (18) of cavities in C240.
This w as significantly better than the degree of leakage observed in either the
C200 (p = 0.03) or C300 (p = 0.01) subgroups, w here only 60% (12) and 55% (11)
respectively of the enam el m argins w ere com pletely sealed. There w as no
sig n ifican t difference in leakage b etw een m argins in the C200 a n d C300
subgroups.

100
 40 t

37
111! A Enamel Conventional
llll B Enamel Conventional
II I ! C Enamel Conventional
Av B p < 0.001
Bv C p = 0.04

27
Number of teeth

49

2994

1 1
IIIIIII1 ■■■■■■■■mi
0 1 2 3 4 0 1 2 3 4 3 4
Microleakage scores

Figure 4.1 M icroleakage seen at the enam el m argins of conventionally-

p rep ared cavities

101
 Group A A200 E nam el Lased
A240 E nam el L ased
1 A300 E nam el L ased

A200 V A 240 p = 0.02

A200 V A 300 p = 0.27
A240 V A300 p = 0.37

Num ber of te e th

0 1 2 3
M icroleakage s c o r e s

G roup B I B200 Enam el Lased

B240 Enam el L ased
B300 Enam el L ased

B 200 V B 240 p = 0.02

B 200 V B 300 p = 0.01
B 240 V B 300 p = 0.77
Number of teeth

0
4 0 1 2 3 4
M icroleakage s c o r e s

G roup C j C 200 Enam el Lased

18
□ C240 Enam el Lased
BSa C300 Enam el Lased

C200 V C 240 p = 0.03

C200 V C 300 p = 0.67
C240 V C 300 p = 0.01
Number of teeth

0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
M icroleakage s c o r e s

Figure 4.2a-c Microleakage seen at the enamel margins of lased cavities in

groups A, B and C

102
42.2.2 Intergroup analyses

As w ith the conventionally-prepared cavities (Section 4.2.1.2), the g roup B results

w ere com pared w ith the leakage seen at the enam el m argins of teeth in groups A
(Figure 4.3) and C (Figure 4.4).

For all three su b g ro u p s (200, 240 and 300), the group B cavities exhibited less
extensive m icroleakage than those of group A. However, the difference w as only
significant for subgroups A240 com pared to B240 (p < 0.001) and A300 com pared
to B300 (p < 0.001). This p attern of leakage w as sim ilar to that rep o rted for the
conventionally-prepared m argins in enam el (Section 4.2.1.2).

C o m p ariso n of the results from g roup B w ith those from g ro u p C show ed

significantly less leakage at the enam el m argins in subgroups C200 (p = 0.04) and
C240 (p = 0.03) com pared to subgroups B200 and B240 respectively (Figure 4.4).
In contrast, the difference in leakage betw een su bgroups B300 an d C300 w as
insignificant (p = 0.39).

4.2.3 Conventionally-prepared versus lased enamel margins

The extent of dye p enetration at the conventionally-prepared enam el m argins

w as com pared to that at the enam el m argins p rep ared w ith the Er:YAG laser
(Figure 4.5a-c).

For g ro u p A (Figure 4.5a), the lased m argins in su b g ro u p s A200 an d A240

show ed evidence of greater leakage than those in the sam e conventionally-
p repared subgroups. However, the extent of leakage in the A300 lased m argins
w as less than that observed in the A300 conventionally-prepared m argins. N one
of the differences described above was significant (p > 0.05).

C om parison of the results from the group B lased m argins w ith those from the
group B conventionally-prepared m argins (Figure 4.5b) show ed a sim ilar pattern
to group A, i.e. greater leakage along the lased B200 and B240 m argins an d less
leak ag e alo n g the lased B300 m arg in s c o m p a re d to th e ir re sp e c tiv e
conventionally-prepared m argins. A gain the differences w ere not significant
(p > 0.05).

103
 A200 Enamel Lased
B200 Enamel Lased
A240 Enamel Lased
B240 Enamel Lased
18 A300 Enamel Lased
B300 Enamel Lased
16
16 A200 v B200 p = 0.32
A240 v B240 p < 0 .0 0 1
A300 v B300 p < 0 .0 0 1
14

12
12

0 0
0 1 b
0 1 2 3 4 4 0 1 2 3 4 0 1 2 3 4
Microleakage scores

Figure 4.4 Intergroup analysis of m icroleakage seen at the enam el m argins of

lased cavities in groups A an d B
B200 Enamel Lased
C200 Enamel Lased
B240 Enamel Lased
18 C240 Enamel Lased
B300 Enamel Lased
C300 Enamel Lased
16 B200 v C200 p = 0.04
B240 V C240 p = 0.03
B300 v C300 p = 0.39
14

12
£®
2 1o

4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
Microleakage scores

Figure 4.4 Intergroup analysis of microleakage seen at the enamel margins of

lased cavities in groups B and C

104
 Group A A200
A200
Enam el
Enam el
Lased
Conventional
A240 Enamel Lased
A240 Enam el C onventional
A300 Enamel Lased
A300 Enam el C onventional
A200 Lased v A200 C onventional p = 0.72
A240 Lased v A240 C onventional p = 0.40
A300 Lased v A300 C onventional p = 0 .7 3

Microleakage scores

B200 Enamel Lased

G roup B B200 Enamel C onventional
B240 Enamel Lased
B240 Enamel C onventional
B300 Enamel Lased
B300 Enamel Conventional

p = 0.08
p = 0.52
p = 0.48

D 0

0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
Microleakage s c o r e s

C200 Enamel Lased

G roup C 0200 Enamel C onventional
C240 Enamel Lased
^ C240 Enamel C onventional
rSyj C300 Enamel Lased
m 0 300 Enamel C onventional
C200 Lased v C2O0 C onventional p= 0.23
C240 Lased v C240 C on ventional p< 0.001
C300 Lased v C300 C onventional p= 0.61

t=K 3 4 0 1 2 3 4
Microleakage s c o r e s

Figure 4.5a-c A nalysis of the m icroleakage seen at the lased and

co n v entionally-prepared enam el m argins in groups A, B an d C

105
In co n trast to g ro u p s A and B, the gro u p C lased enam el m arg in s show ed
evidence of less leakage in subgroups C200 and C240 and m ore leakage in C300
than those p repared conventionally (Figure 4.5c). H ow ever, the differences w ere
only significant for the C240 subgroups (p < 0.001).

4.3 Dentine margins

4.3.1 Conventionally-prepared dentine margins

4.3.2.2 Within-group analyses

There w ere exam ples in all three groups of scores for m axim um leakage at the
d en tin e m arg in s (Figure 4.6). In g ro u p C this am o u n ted to 5% (3) of the
specim ens b u t rose to 29%(18) and 38% (23) for groups A and B respectively. The
K ruskal-W allis test again (see Section 3.2.6) fo u n d no statistical difference
betw een the subgroups in each of the three groups A, B and C (p = 0.37, p = 0.18
an d p = 0.76 respectively), and therefore the subgroup leakage scores w ere again
com bined for fu rth er statistical analyses involving only the conventionally-
p rep ared cavities.

4.3.1.2 Intergroup analyses

In contrast to the leakage seen at the enam el m argins (Section 4.2.1.2), the dentine
m argins in g roup C dem onstrated a significantly better seal than those of group
B ( p < 0.001; Figure 4.6). No significant difference w as seen betw een gro u p s A
and B at the dentine margin.

4.3.2 Lased dentine margins

4.3.2.1 Within-group analyses

The leakage observed at the dentine m argins in the three lased cavity groups is
com pared in Figure 4.7a-c. W ith the exception of C200, all su bgroups in each
g ro u p h ad at least one tooth w hich exhibited m axim um dye p en etratio n at the
dentine m argin. In group A, there was no significant difference in m icroleakage
betw een the three pulse energies (p > 0.05; Figure 4.7a).

106
 S A Dentine Conventional
S B Dentine Conventional
B B C Dentine Conventional
AV B p = 0.19
Bv C p < 0.001
155579999999
Number of teeth

19 19

3330

0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
Microleakage scores

Figure 4.6 M icroleakage seen at the conventionally-prepared d en tin e m argins

107
 Group A A200 D entine L ased
A240 D entine L ased
20 A300 D entine L ased

8 A200 v A240 p = 0.97

A200 V A300 p = 0.27
A240 V A300 p = 0.16
6

4
Numbor of tooth

0
8

6
4

0
0 1 2 3 4 0 1 2 3 4
Micro leak age sc o r e s

20
G roup B j___ 4 B 200 D en tin e L ased
! J B 240 D en tin e L ased
9 S S B 300 D entin e L ased

8 B 200 V B 240 p = 0.19

B 200 V B 300 p = 0.10
B 240 V B 300 p = 0.01
of tooth

0
Numtw

6
4

0 a
0 1 2 3 4 0 1 2 3 4
M icroleaksge s c o r e s

G roup C C 200 D entine L ased

C 240 D entin e L ased
C 300 D entin e L ased

C 200 v C240 p = 0.66

C 200 V C300 p = 0.54
C240 v C300 p = 0.89
Number of teeth

0 1 2 3 4
M icroieakage s c o r e s

Figure 4.7a-c Microleakage seen at the dentine margins of lased cavities in

groups A, B and C

108
There w as very close correlation betw een the degree of leakage exhibited at the
dentine m argins of the A200 and A240 subgroups (p = 0.97).

G roup B show ed sim ilar patterns of leakage to group A (Figure 4.7b). H ow ever,
the dye p en etratio n w as m ore severe across all subgroups. The B300 m argins
exhibited less m icroleakage than both the B200 and B240 dentine m argins b u t the
difference w as only significant for the latter (p = 0.01). A gain no significant
difference w as found in leakage betw een the B200 and B240 subgroups (p > 0.05).

C o m p ariso n of the d entine m argins w ithin the subgroups of g ro u p C (Figure

4.7c) show ed no statistical difference in leakage betw een the three pulse energies.

4:32.2 Intergroup analyses

Intergroup analysis betw een the subgroups of A and B (Figure 4.8) revealed that
the leakage at the den tin e m argins w as m ore severe for all su b g ro u p s of B
com pared to their respective subgroups in g roup A. This is in contrast to the
leakage found at the enam el m argins (Section 4.2.2.2). H ow ever, the difference
w as only significant betw een A240 and B240 (p = 0.003). This p attern of leakage
w as sim ilar to th at rep o rted for the conventionally-prepared dentine m argins
(Section 4.3.1.2).

C om parison of the results for groups B and C (Figure 4.9) show ed significantly
w orse leakage for B200, B240 and B300 com pared to the respective subgroups in
C (p < 0.001, p < 0.001 and p = 0.002 respectively).

4.3.3 C o nventionally-prepared versus lased dentine m argins

As for the enam el m argins, the extent of dye penetration in the conventionally-
prepared groups was com pared to that of the lased cavities (Figure 4.10a-c).

C om parison of the dentine m argins in group A (Figure 4.10a), indicated that the
extent of m icroleakage w as less for the conventionally-prepared cavities than it
w as for the lased cavities. H ow ever, the difference w as only significant for the
A240 subgroup (p = 0.005).

109
 A200 Dentine Lased
B200 Dentine Lased
20 A240 Dentine Lased
B240 Dentine Lased
A300 Dentine Lased
18 B300 Dentine Lased
16
16 A200 v B200 p = 0.09
A240 v B240 p = 0.003
A300 v B300 p = 0.28
14 --

12 12
f 12

I 10
ID
n
E
= 8

4 4

1 1
0 555 0 0
1------ f—
0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
Microieakage scores

Figure 4.8 In terg ro u p analysis of m icroieakage seen at the d en tin e m argins of

lased cavities in groups A and B
B200 Dentine Lased
C200 Dentine
20 B240 Dentine
19
Dentine
18 B300 Dentine Lased
C300 Dentine
16
16 B200 V C200 p < 0.001
B240 v C240 p < 0.001
B300 V C300 p = 0.002
14

Z 10
£
E
= 8 7 7

2
1 1
0 0 0„ o o
0 H
—ra — i—

0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
Microieakage score

Figure 4.9 Intergroup analysis of microieakage seen at the dentine margins of

lased cavities in groups B and C

110
 Group A A200
A200
D entine
D entine
Lased
Conventional
A240 D entine Laaed
A240 D entine C onventionai
A300 D entine Lased
A300 D entine Conventional

A200 Lased v A200 Conventional p = 0.16

A240 L ased v A240 C onventional p = 0.005
A3 00 L ased v A300 Conventional p = 0.51

0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
Microieakage scores

G roup B ( B200
B200
D entine Lased
D entine C onventional
I B240 D entine Lased
] B240 D entine C onventionai
j B300 D entine Lased
| B300 D entine C onventional

B 200 Lased v B 200 C onventional p = 04)1

B 240 Lased v B240 C onventional p = 04)03
B 300 Lased v B 300 Conventional p = 04)9

Microieakage scores

G roup C [
I
C200
C200
D entine
Dentine
Lased
Conventional
CW C240 D entine Lased
E g C240 Dentine C onventional
S C300 D entine Lased
S C300 Dentine Conventional
C200 Lased v C200 C onventional p = 0.69
C240 Lased v C240 C onventional p = 0 3 5
C300 Lased v C300 C onventional p = 0.59

Microieakage scores

Figure 4.10a-c A nalysis of the m icroieakage seen at the lased an d

co n v entionally-prepared d en tin e m argins in groups A, B an d C

111
A sim ilar p attern w as observed for the group B cavities w h ere the ex ten t of
leakage at the dentine m argins w as less for the conventionally-prepared cavities
com pared to the lased cavities for all three subgroups. H ow ever, the difference
w as only significant for the B200 and B240 subgroups (p = 0.01 and p = 0.003
respectively; Figure 4.10 b).

In contrast to groups A and B, in group C the lased m argins show ed less leakage
th an those th at had been conventionally prepared. H ow ever, the differences
w ere not significant for any of the three subgroups (p < 0.05; Figure 4.10c).

4.4 Enamel versus dentine

4.4.1 Conventionally-prepared margins

Because of the lack of statistical significance betw een the su b g ro u p s of each

g ro u p , the su b g ro u p leakage scores w ere com bined for the analysis of the
d ifferen ce b e tw e e n leakage at the enam el an d d e n tin e m a rg in s of the
conventionally-prepared cavities for groups A, B and C (see Section 4.2.1.1) In all
three g ro u ps (Figure 4.11), the enam el m argins dem onstrated less leakage than
the dentine m argins. H ow ever, despite 29% (18) of the dentine m argins in group
A scoring the m ax im u m of 4, the differences in m icroieakage w ere only
significant for groups B (p < 0.001) and C (p = 0.02).

4.4.2 Lased margins

Figure 4.12 illustrates the extent of m icroieakage observed in the lased cavities.
For all groups, the seal at the enam el m argins w as better than the dentine m argin
seal. Indeed, w ith the exception of the A300 subgroup, m ore th an h alf the
d en tin e m argins for g roups A (Figure 4.12a) and B (Figure 4.12b) exhibited
extensive dye penetration beyond the full cavity depth (i.e. score 4). This w as in
m arked contrast to group C w here leakage at the dentine m argin w as lim ited to
the outer third of the cavity dep th (i.e. score 0 or 1) in at least 65% (13) of the
sam ples, w ith m any show ing no leakage (Figure 4.12c). The difference in leakage
b etw een the enam el and den tin e m argins w as not significant for the A300
(p = 0.08) and C300 (p = 0.51) cavities. Analysis of the other subgroups revealed

112
 A Enamel Conventional
A Dentine Conventional
B Enamel Conventional
40
B Dentine Conventional
C Enamel Conventional
C Dentine Conventional
35 -
A Enamel v A Dentine p = 0.10
B Enamel v B Dentine p < 0.001
30 C Enamel v C Dentine p = 0.03

26
25
Number of teeth

20
20

15

11
10

IHUIdl
Figure 4.11 A nalysis of the m icroieakage seen at the enam el and d en tin e
m argins of conventionally-prepared cavities

113
 A200 Enamel Lased
Group A A200 Dentine Lased
A240 Enamel Lased
A240 Dentine Lased
A300 Enamel Lased
A300 Dentine Lased

A200 Enamel v A200 Dentine p = 0.002

A240 Enamel v A240 Dentine p = 0.005
Number of teeth A300 Enamel v A300 Dentine p = 0.10

Microieakage scores

G roup B B200
B200
Enamel Lased
Dentine Lased
B240 Enamel Lased
B240 Dentine Lased
B300 Enamel Lased
B300 Dentine Lased
B200 Enamel v B200 Dentine p < 0.001
B240 Enamel v B240 Dentine p < 0.001
B300 Enamel v B300 Dentine p < 0.001
Number of teeth

00
4 0 1 2 3 4
Microieakage sco res

C200 Enamel Lased

G roup C C200 Dentine Lased
C240 Enamel Lased
20
C240 Dentine Lased
C300 Enamel Lased
18 C300 Dentine Lased

C200 Enamel v C200 Dentine p = 0.03

16 - C240 Enamel v C240 Dentine p = 0.002
C300 Enamel v C300 Dentine p = 0.51
14
Number of teeth

0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
Microieakage sco r es

Figure 4.12a-c A nalysis of the m icroieakage seen at the enam el and d en tin e
m argins in th e lased cavities of groups A, B an d C

114
th at the dentine m argins exhibited significantly m ore leakage th an the equivalent
enam el m argins (p < 0.05).

4.5 S um m ary

Statistically significant differences in the extent of leakage observed betw een the
groups and subgroups are sum m arised below.

1. Enamel margins:
• conventionally-prepared enam el margins:
- A > B (p < 0.001);
- C > B (p = 0.04);
• lased enam el margins:
- A240 > A200 (p = 0.02);
- B200 > B240 (p = 0.02);
- B200 > B300 (p = 0.01);
- C200 > C240 (p = 0.03);
- C300 > C240 (p = 0.01);

- A240 > B240 (p < 0.001);

- A300 > B300 (p < 0.001);
- B200 > C200 (p = 0.04);
- B240 > C240 (p = 0.03);
• conventionally-prepared v lased enam el margins:
- C240 conventionally-prepared > C240 lased (p < 0.001);

2. D entine margins:
• conventionally-prepared dentine margins:
- B > C (p < 0.001);
• lased dentine margins:
- B240 > B300 (p = 0.01);

- B240 > A240 (p = 0.003);

- B200 > C200 (p < 0.001);
- B240 > C240 (p < 0.001);
- B300 > C300 (p = 0.002)

115
 • conventionally-prepared v lased dentine margins:
- A240 lased > A240 conventionally-prepared (p = 0.005);
- B200 lased > B200 conventionally-prepared (p = 0.01);
- B240 lased > B240 conventionally-prepared (p = 0.003).

3. Enamel v dentine m argins

• conventionally-prepared margins:
- B dentine > B enam el (p < 0.001);
- C dentine > C enam el (p = 0.03);
• lased margins:
- A200 dentine > A200 enam el (p = 0.002)
- A240 dentine > A240 enam el (p = 0.005)
- B200 dentine > B200 enam el (p < 0.001)
- B240 dentine > B240 enam el (p < 0.001)
- B300 dentine > B300 enam el (p < 0.001)
- C200 dentine > C200 enam el (p = 0.03)
- C240 dentine > C240 enam el (p = 0.002)

116
5 Discussion

5.1 In tro d u ctio n

The m ain p urposes of restoring carious cavities are to arrest the disease process,
and to restore the form and function of the teeth in such a w ay that the health of
the dental tissues is m aintained. A dequate m arginal integrity of a restoration is
therefore essential for the achievem ent of these goals. As n o ted in Section
2.10.6.7, failure of the seal m ay contribute to staining, post-operative sensitivity,
an inflam m atory p u lp al response and secondary caries, an d as a result, m ay
necessitate the replacem ent of the restoration.

The control of m icroieakage in com posite resins w as discussed in Section 2.7.

From this review of the literature, it was evident that, w hile factors integral to the
m aterial itself w ere of relevance, of equal im portance w ere the resto rativ e
techniques used, and the interplay betw een these and the choice of m aterial.
U nderlying these factors, is the im portance of good adaptation of the resin to the
cavity surface. For resin based m aterials, this is influenced by the surface
m orphology of the cavity follow ing preparation, and the quality of the p attern
achieved follow ing cavity etching or conditioning. The use of the Er:YAG laser
for cav ity p re p a ra tio n resu lts in a cavity w ith a sig n ifican tly d iffe re n t
m orphology to that achieved by conventional m eans (Aoki et al, 1998). Prior to
the introduction of the laser to routine clinical dentistry, it is essential to ensure
th at its use does not affect the efficacy of the cavity seal at the enam el and
dentine m argins adversely. This study therefore sought to clarify this situation
for three laser pulse energies.

5.2 M ethodology

The study w as carried out in vitro and therefore some aspects of the experim ental
w o rk varied from th at w hich w ould be expected clinically. N evertheless,

117
m ea su res w ere tak en to en su re as close a re p re se n ta tio n as possible w as
achieved.

The laser w as held by hand for the preparation of the cavities, and w hile care was
taken in positioning the handpiece so that the laser beam w as focused, this relied
on clinical judgem ent and w as m ore arbitrary than if the laser had been clam ped
in a fixed position. O ther aspects of the experim ental set u p w ere carefully
controlled. The w ater m ist w as provided u n d er pressure from a h an d -p u m p ed
plastic container. The effects of excess and insufficient w ater durin g the ablative
process w ere described in Section 2.10.6.4 and care was taken to ensure the w ater
pressure w as m onitored and adjusted at regular intervals. H ow ever, the lack of
standardisation of this m ay have introduced confounding factors.

As noted in Section 2.2.2, variables in the com position and structure of dentine
occur w ith tim e because of ageing and environm ental influences. In addition,
w ith in vitro studies, the storage perio d and m edia m ay influence d en tin e
p erm eab ility (G o o d is et al.f 1991), d entine b o n d in g (Sidhu et al., 1991) an d
m icro iea k ag e (H aller et al., 1993a). In this study, because of the m eth o d of
ran d o m allocation, no account w as taken of either the age of the tooth, or the
storage time, w hen the teeth w ere placed in their groupings. In an attem p t to
lim it any erro rs this m ay have in troduced, the teeth w ere stored in thym ol
solution. This is know n to have lim ited affect on m icroieakage w hen com pared
to teeth that are processed im m ediately post-extraction (Haller et al., 1993a).

The oral cavity p resents a rap id ly changing environm ent to any restoration.
T herm ocycling w as therefore included in the sam ple processing m eth o d to
p ro v id e a m easure of therm al challenge to the restorations. The tem peratures
u sed w ere w ithin the clinical range (Barclay, 1998) and the shortest dw ell time
possible for the therm ocycling unit was used.

The m arginal integrity at the CRI in enam el and dentine w as assessed by scoring
the d e p th of dye p e n etratio n of a single section in the m id-buccal plane,
perpendicular to the long axis of the tooth. This m ethod is one of the com m onest
u sed but, as w ith all in vitro tests, it does have its lim itations. These w ere
discussed fully in Section 2.5.2 and so will not be considered further, other than
to note that, w hilst this m ethod gives neither a direct m easu rem en t of the

118
likelihood, nor the degree of m icroieakage that could be expected clinically, it
does indicate a potential for leakage. Furtherm ore, as the significance of the
leakage seen in any one particular group can be related to the dye p enetration
seen in the other treatm ent groups of teeth valid conclusions can be draw n.

Since Buonocore (1955) first reported the use of acid etching to produce a suitable
enam el surface for the m echanical b o n d in g of com posite resin m aterials, a
succession of com posite m aterials and b o nding agents have been developed.
T hese h av e sh o w n an in creasin g im p ro v e m e n t in the seal at b o th the
en a m e l/ restoration and d en tin e/resto ratio n interfaces. A dequate sealing of the
enam el m arg in has been easier to achieve th an of dentine, an d historically,
m icroieakage has been greater at the dentine m argin than that found at enamel.

In this study, m icroieakage w as evident in some specim ens at the enam el a n d /o r

den tin e m argins in all g roups of teeth (Table 4.1). This is in agreem ent w ith
p revious studies reporting the m icroieakage of cavities restored w ith Z100 and
SMP (Vargas & Swift, 1994; Saunders & Saunders, 1996). H ow ever, the leakage
found at both the enam el and dentine m argins in this study w as greater than that
re p o rte d in th ese e arlie r stu d ies. R eports in the lite ra tu re d esc rib in g
m icroieakage in Class V cavities at the cervical m argin w hich w ere restored w ith
the original com position of Com poglass, the com pom er used in this study, are
lim ited. H ow ever, in agreem ent w ith this study, in vitro studies em ploying this
m aterial have reported leakage at both the dentine and enam el m argins (Cortes et
a l, 1998; Ferrari et al, 1998).

5.3 O u tlin e of discussion

The follow ing discussion will first consider the results of the en am el/resto ratio n
interface, looking in itially at the co n v en tio n ally -p rep ared m arg in s before
considering those p rep ared by the laser. Following this, the leakage seen at the
d en tin e/re sto ratio n interface is evaluated for both m ethods of cavity preparation.

119
5.4 The enamel/restoration interface

W hen considering the extent of dye penetration found at the enam el m argin, it is
p ertin e n t to note that, because of the w idth of the enam el in the cervical region
an d the criteria for scoring, a score of T is likely to indicate com plete failure of
the en am el/resto ratio n bond. Scores greater than this therefore represent failure
of both the en am el/resto ratio n and d en tin e/ restoration bonds. T hus the severity
of leakage seen at the enam el CRI is, in some part, due to dentine leakage. The
stresses at the dentine /re sto ra tio n bond at the coronal m argin are likely to have
differed to those at the cervical m argin because of the m ethod of increm ental
packing used. H ow ever, all other factors contributing tow ards m icroieakage will
have been sim ilar. Therefore, for clarity, discussion on the possible reasons for
the leakage seen at the coronal m argin is confined to the consideration of the
e n a m e l/re sto ra tio n interface only. Leakage at the cervical d en tin e m arg in is
discussed in Section 5.5 an d this section is confined to issues relatin g to the
e n am el/resto ratio n bond only.

5.4.1 Conventionally-prepared enamel margins

D espite the lack of uniform ity in the m orphology of enam el found at the cervical
m argin, co n v en tio n ally -p rep ared bevelled enam el m argins w h ich have been
etched w ith 35% phosphoric acid (Saunders & M uirhead, 1992; V argas & Swift,
1994) or p rim ed w ith an acidic prim er (Saunders et al, 1991) have resulted in an
absence of leakage. H ow ever, in this study, leakage was found at the enam el CRI
in all groups of teeth w ith conventionally-prepared enam el m argins (Figure 4.1).
Several factors m ay account for this ap p aren t reduction in the efficacy of the
enam el seal. A box-shaped cavity w as used in an attem pt to stan d ard ise cavity
shape, since a uniform bevel preparation w ith the laser could not be guaranteed
for all sam ples. H ow ever, such a cavity has a high C-factor (Feilzer et al ., 1987)
an d therefore it p ro v id e d an u n favourable cavity shape for the control of
m icroieakage. As noted in Section 2.7.2.2, the stress generated by polym erisation
contraction in a cavity of this shape has been calculated to be of the o rd er of
13-17 MPa (D avidson et a l, 1984). The enam el/S M P bond strength u sin g 35%
phosphoric acid as etchant is has been reported as being 24.5 M Pa (Swift & Cloe,
1993) and for Com poglass as 18.0 MPa (Vivadent, 1996). At first glance, it w ould
seem reaso n ab le to assu m e th a t these w ere of su fficien t size to resist

120
polym erisation stresses. H ow ever, these values w ere m easured on a flat surface
i.e. low C-factor, after 24 hours and are therefore higher than w ould be expected
at the tim e of curing in an unfavourable cavity shape. The d ev elo p m en t of
significant polym erisation stresses arising as a result of this factor m ay therefore
m ean th at the e n am el/co m p o site bond could not survive the poly m erisatio n
stresses. The use of increm ental packing, in reducing the C-factor, w ill have
red u ced the stresses th at developed d u rin g curing, b u t it is unlikely th a t this
w o u ld have com pletely com pensated for the effect of the 90° cavosurface angle
and the cavity shape for the m aterials tested.

M aterial factors m ay also have played a role in the leakage seen at the enam el
m argin. Looking first at the factors relating to Z100/SM P, the high filler content
of Z1€0 has resulted in a m aterial w ith a polym erisation shrinkage of 6% after
one h o u r (M cC onnell et a l, 1994). W hile this is an im provem ent on the earlier
m aterials, the resulting rigidity of the m aterial com bined w ith its rap id curing
reaction, results in a reduction in the com pensatory flow of the m aterial d u rin g
curing and will therefore influence the incidence of m icroieakage. The positive
effect of hygroscopic expansion on storage in reducing m icroieakage w as noted
in Section 2.7.1.2. an d w o u ld account for the significant im p ro v e m e n t in
m icroieakage seen at the enam el m argins in g roup B, after 3 m onths storage
com pared to group A.

In ad d itio n to the effect the com position of the Z100 resin m ay have h ad on
microieakage, three aspects of the application technique m ay have influenced the
results. Firstly, w hile the m anufacturer’s instructions w ere carefully follow ed,
S aunders and S aunders (1996) p o stulated th at the 'total etch' technique using
acids of eith er low er concentration, or of norm al concentration for sh o rter
p erio d s m ay resu lt in in ad eq u ate etching of the enam el. T raditionally, the
adequacy of the enam el etch has been assessed visually. H ow ever, this w as not
possible in this study because a w et-bonding technique w as used. M odification
of the m anufacturer's technique to perm it visual exam ination of the enam el prior
to re-w etting the surface to re-expand the decalcified dentine netw ork m ay have
served to im prove the enam el seal w ithout detrim en t to the dentine m arg in
(Gw innett, 1994). Secondly, the application of SMP prim er to enam el can have an
ad v erse influence on the b o n d w ith enam el etched w ith p h o sp h o ric acid
(Barkm eier & Erickson, 1994). The relationship of bond strength m easured on a

121
flat surface 24 h o u rs after polym erisation and m icroieakage has alread y been
discussed (Section 2.7.2.2). H ow ever, the effect on bond strength suggests that
the p rim er m ay influence the a d ap tatio n of the resin to the etch ed enam el
surface, and this, com bined w ith the am orphous structure of the cervical enam el,
w o u ld not have enhanced the enam el seal. Finally, it has been suggested th at the
b o n d to dentine using this com bination of bonding agent and com posite resin is
of such m agnitude to cause disruption of the enam el bond during polym erisation
(Saunders & Saunders, 1996). The likelihood of this being a significant factor in
this stu d y is questionable in view of the extensive leakage seen at the dentine
m argins. H ow ever, if it w ere, an im provem ent in the leakage fo u n d at the
enam el m argins w ould be expected by reversing the order in w hich the first tw o
increm ents w ere ap p lied i.e. placing and polym erising the cervical increm ent
before the occlusal.

M aterial factors are also relevant to the degree of leakage seen at the enam el
m argins resto red w ith the com pom er m aterial (Figure 4.1). C om poglass has a
high filler content and exhibits a polym erisation shrinkage of 2-3% on curing
(personal com m unication w ith V ivadent). It achieves m axim um hygroscopic
ex p an sio n w ith in one w eek. H ow ever, because of the p o o r p ro p e n sity of
u re th a n e d im e th a c ry la te for w ater, this does not fully c o m p e n sa te for
polym erisation shrinkage and will result in residual m arginal gaps, particularly
w ith the stringent cavity conditions used in this study.

As noted in Section 2.3.6, com pom ers w ere developed to provide a m aterial that
incorporated the positive qualities of com posite resins w ith those of the glass-
io n o m er cem ents. P olym erisation shrinkage w as one of the less desirab le
properties of com posites w hich w as hoped w ould be reduced w ith the ad d itio n
of glass-ionom er to the m aterial. It is therefore of interest to note th at there was
sig n ifican tly g re ate r leakage at the en am el m arg in s of the C o m p o g lass
restorations (G roup C) com pared to the Z100 stored for a sim ilar p eriod (G roup
B) (Figure 4.1). This trend is in agreem ent w ith the results of earlier studies (Uno
et a l, 1997; O w ens et al, 1998). In ad d itio n to the differences in hygroscopic
expansion, these differences can be accounted for by the m ethod of prim ing and
cavity p rep aratio n . The enam el seal is d ep en d e n t on the m icrom echanical
reten tio n achieved by the resin tags. C om poglass SCA is a fifth g en eratio n
b o nding agent and as such, etching is achieved by the acidic com ponents in the

122
p rim er (m ethacrylate-m odified polyacrylic and m aleic acids). These w eaker
acids p ro d u ce a shallow er etch p attern w hen com pared to p h o sp h o ric acid
(M eryon et al., 1987; Glasspoole & Erickson, 1994), and in addition the acid salts
p ro d u ced d u rin g etching are not w ashed away. These factors lead to a reduction
in resin tag form ation and w ould account for the increase in leakage fo u n d for
the drill m argins. The use of phosphoric acid, applied and w ashed away, prior to
p rim er application has been show n to im prove the m arginal sealing ability of
C om poglass restorations after tw o to three m onths storage (Vichi et al., 1997).
T his is p re su m a b ly becau se of the in creased w e tta b ility a n d a re a for
m icrom echanical retention afforded by the etched enam el surface and suggests
th a t the use of SCA alone, does not pro v id e the o p tim u m etch p a tte rn for
m icrom echanical reten tio n at conventionally-prepared enam el m argins. This
com bined w ith the m aterial factors could account for the greater incidence of dye
p en etratio n seen at the C o m p o g lass/en am el interface w h en com pared to the
enam el m argins in group B. The use of phosphoric acid prior to SCA application
in th is s tu d y m ay have im p ro v e d the m a rg in a l in te g rity of th e
C om poglass/enam el m argins.

T his d isc u ssio n has so far b een confined to the leak ag e seen a t the
conventionally-prepared enam el m argins. The factors discussed are of relevance
to the lased g roups also. H ow ever, the aim of this stu d y w as to evaluate the
in flu en c e th a t cav ity p re p a ra tio n u sin g the Er:YAG lase r h as on the
cav ity /re sto ra tio n interface. This will be considered for the enam el m argins in
the following section.

5.4.2 The influence of the Er:YAG laser on the enamel cavity/restoration

interface

Before considering the results in detail, it is pertinent to note that, because of the
experim ental design, it was likely that the enam el m argin in the 300 m j lased
g ro u p w o u ld have been influenced by the 100 m j d u rin g d en tin e finishing.
Enam el ablation is h ard er than dentine ablation for the sam e laser param eters
(Section 2.10.6.2) and therefore the 100 m j will not have affected the surface
m orphology to the same degree w hen com pared to dentine. H ow ever, it could
be sp eculated th at the resu ltan t crater p attern will have been shallow er and

123
possibly m ore regular than that seen w hen the enam el w as ablated w ith 300 m j
only.

Looking first at the results for the com posite/enam el interface (groups A and B),
there w as a tendency for the conventionally-prepared m argins to exhibit less
leakage th an those p rep ared w ith the laser. H ow ever, the differences w ere not
statistically significant. Thus it can be concluded that all the laser param eters
used in this stu d y produced an enam el surface that, w hen acid-etched, provided
b o n d in g c h a ra c te ristic s th a t w ere co m p arab le to th o se a c h ie v e d w ith
conventional p rep aratio n and etching. This finding is not in agreem ent w ith the
p rev io u s stu d ies usin g sim ilar pulse energies (H ofm ann et al., 1992; H ibst &
Keller, 1994) review ed in section 2.10.6.7. H ow ever, the stu d ies differ in the
choice of cavosurface angle and cavity position relative to cervical m argin, and in
the restorative m aterial and pulse repetition rate used. All these factors influence
the d istribution and size of the stresses that could be expected to develop w ithin
the resin m aterial d u rin g polym erisation and m ay account for the differences in
leakage perform ance.

The laser can be o p erated at one of a range of pulse energies, all of w hich
influence the m orphology of the cavity surface and the ablation rate. Clinically, a
fast ablation rate w ith o u t detrim ental effects on the h ard tissues an d p u lp is
desirable. In this study, three pulse energies w ere used to assess w h eth er the
choice of pulse energy influenced microieakage. While all three resulted in levels
of m icroieakage th at w ere com parable to co n v en tio n ally -p rep ared m argins,
statistical differences w ere seen betw een the different subgroups. A fter tw enty
four hours storage (group A; Figure 4.2a), the m arginal ad ap tatio n at the enam el
m argins p rep ared by the 200 m j energy w as better than both the 240 m j an d 300
m j. H ow ever, after three m onths storage (Figure 4.2b), the seal of the 200 m j
m argins had not im proved and, while the seal had not degraded, the m argins
exhibited significantly m ore m icroieakage than the other tw o laser subgroups. It
w o u ld therefore appear that the deeper crater patterns produced by the higher
pulse energies in com bination w ith acid-etching pro v id ed a m ore favourable
surface for long-term ad ap tatio n of this particular com bination of com posite
resin and bon d in g agent. The lack of im provem ent w ith the 200 m j sub g ro u p
after three m onths is difficult to explain on the basis of this theory.

124
For the C om poglass restorations (Figure 4.5c), laser preparation did not have an
ad v erse affect on m icroieakage w h en com pared to the seal p ro v id e d by
conventionally-prepared enam el m argins. H ow ever, in contrast to Z100 w here
th ere w as no sig n ifican t d ifference b etw een the tw o m e th o d s of cav ity
p re p ara tio n for any of the pulse energies used, the m argins p re p a re d by the
240 m j p u lse en erg y sh o w ed statistically less leakage th an the e q u iv a le n t
conventionally-prepared subgroup. The use of this laser energy also resu lted in
significantly less m icroieakage than the other two laser subgroups (Figure 4.4c).
Thus, of the param eters investigated, a pulse energy of 240 m j w ould ap p ear to
provide the best surface for sealing the enam el m argin w ith Com poglass.

W hen the m icroieakage at the conv en tio n ally -p rep ared enam el m arg in s in
g ro u p s B and C w as analysed (Figure 4.1), leakage w as greater for the m argins
resto red w ith C om poglass (group C) than those restored w ith Z100 (g roup B).
A n explanation for this difference was given in Section 5.4.1. H ow ever, w h en the
lased enam el m arg in s w ere considered the reverse w as fo u n d for m arg in s
p re p are d w ith the 200 m j or 240 m j pulse energies i.e. C om poglass exhibited
significantly less m icroieakage than Z100 for these energies b u t there w as no
statistically significant difference betw een the tw o m aterials w h en the 300 m j
energy w as used. These differences are difficult to explain an d perhaps m erely
reflect the poor perform ance of the enam el m argins prepared by the 200 m j laser
e n e rg y a n d re sto re d w ith Z100 a n d the low leak ag e seen w ith th e
C o m p o g lass/240 m j group.

In sum m ary, the use of the laser at the three pulse energies did not adversely
influence m icroieakage at the enam el m argin for either m aterial tested. Indeed,
the p erform ance of C om poglass w as im p ro v ed w ith the use of the laser at
240 mj. Furtherm ore, pulse energies of at least 240 m j enhanced the long-term
m arg in al seal of the com posite resin tested. These results suggest th a t laser
energies below 240 m j do not provide the optim um surface for ad a p ta tio n of
either m aterial to the enam el margin.

125
5.5 The dentine/restoration interface

The cavity and m aterial factors described for the enam el m argins (Section 5.4.1)
ap p ly equally w ell to the CRI in dentine an d therefore will not be discussed
fu rth er in this section.

5.5.1 Conventionally-prepared dentine margins

For the conventionally-prepared cavities, dye penetration w as m ore severe at the

d en tin e m arg in th an at the enam el m argin in all three g ro u p s (Figure 4.11).
H ow ever, these differences w ere only significant for the tw o groups stored for
three m onths, groups B and C. This is in agreem ent w ith previous studies using
Z100 and SMP (Vargas & Swift, 1994; S aunders & Saunders, 1996), b u t is in
contrast to the findings of Crim (1993). These ap p aren t discrepancies could be
because of m aterial and cavity factors outlined in Section 5.4.1.

C onsidering first the dentine leakage at m argins restored w ith Z100 and SMP
(groups A and B), the severity of the leakage seen in this study, w hen com pared
to sim ilar reports, is of concern. As noted in Section 2.7.2.2, dentine b o n ding
w ith SMP is achieved by the rem oval of the sm ear layer prior to the form ation of
both the resin-reinforced hybrid layer and the resin tags in the w idened dentinal
tubules. Leakage at the dentine CRI can occur in a variety of planes; below or
w ith in the h y b rid layer, betw een the hybrid layer and the com posite resin, or
w ith in the restorative m aterial itself. The dye p en etratio n and m agnification
techniques used in this study did not differentiate betw een the layers, or betw een
adhesive and cohesive failure and therefore it w as im possible to locate the exact
plane of leakage for the specim ens w ith m inim um leakage. The use of silver
n itrate staining techniques w ith SEM analysis described by Sano et al (1994)
w o u ld be necessary to achieve this level of resolution. H ow ever, w ith a
know ledge of the structure and function of the hybrid layer (Section 2.7.2.2.1)
som e assum ptions can be m ade by analysing the p attern of dye penetration seen
in the specim ens: w here leakage occurred, dye penetration w as seen along the
CRI, and in some cases this appeared to be confined to the CRI. Examples of this
can be seen at the dentine portion of the enam el m argins in Figures 3.14 and 3.15.
H ow ever, in a p ro portion of specimens, dye penetration appeared to follow the
p ath of the d entinal tubules. W here this occurred, there ap p eared to be tw o

126
p attern s of leakage. The distinction betw een the tw o w as in the p ro p o rtio n of
tu b u les involved. In 2% (1) an d 13% (8) of specim ens in g ro u p s A an d B
respectively, the area of tubule penetration did not correspond to the leakage at
the CRI (Figures 3.13 and 3.14). W hereas in 27% (17) of group A specim ens an d
58% (35) g ro u p B, tubule penetration appeared to m atch the extent of the dye
p enetration along the CRI (Figures 3.12 and 3.15). W here the dye w as confined to
the CRI, it can be assu m ed th at the d en tin al tubules h a d been a d eq u ately
occluded by the form ation of the resin-reinforced hybrid layer. The leakage seen
therefore rep resen ted cohesive failure w ithin the restoration, m ost likely at the
h y b rid la y e r/re s in interface. H ow ever, the presence of dye in the d en tin al
tubules w o u ld suggest that the hybrid layer w as not intact in these areas. The
tw o p attern s of tubule penetratio n indicating partial or com plete failure of the
h y b rid layer. This could arise because of inadequate form ation of a n d /o r, poor
stability of the h y b rid layer d u rin g storage. It is not possible to differentiate
b etw een the tw o m echanism s w ith the m ethodology used in this study, b u t the
prop o rtio n of specim ens exhibiting the two patterns of leakage in both groups A
and B w ou ld suggest that both were involved.

There are several factors w hich m ay have contributed to the m icroieakage and
failure of the hybrid layer seen at the dentine CRI: firstly, after phosphoric acid
conditioning, the dentine surface has been show n to be com pletely dem ineralised
w ith ex p o su re of the collagen fibrils to a d ep th of 4 jum (Prati et al, 1993).
Secondly, SEM exam ination of the hybrid layer form ed by SMP found that the
resin tags are conical in shape. This m ay be because of physical characteristics of
the bon d in g resin such as viscosity and surface tension w hich serve to reduce
penetration along the tubule before polym erisation. Thirdly, the hybrid layer has
been found to be m ore porous than several other dentine bonding agents (Sano et
a l, 1994). These factors suggest that physical properties of SMP m ay provide a
constraining influence on optim um w etting of the denatured dentine surface an d
subsequent m icrom echanical retention.

The role of w ater in h y bridisation w ith fourth generation b o nding agents w as

d iscu ssed in Section 2.7.2.2.1. The m anufacturers of SMP claim th a t it can
p roduce strong bonds to dentine under conditions of 95% hum id ity (3M, 1994).
O ptim um ad aptation of SMP to a dentine surface is seen w hen the surface is left
visibly m oist after the etch has been rinsed off (Swift & Triolo, 1992), presum ably

127
b ecau se the collagen n etw o rk is m a in tain ed in an e x p a n d e d state. The
m anufacturers of SMP state that, after the acid etch has been rinsed off the tooth
surface, the tooth should be either lightly d ried w ith com pressed air, or 'blot
dried', for 2 seconds. In this study, the form er technique w as used. A lthough
care w as taken to avoid excessive drying, the possibility of such an occurrence
cannot be ignored because of the drying m ethod em ployed. This w ould result in
in a d e q u a te resin in filtra tio n of the d em in eralised collagen an d increased
susceptibility to hydrolytic d egradation w ith poor sealing of the tubules. The
influence of excessive drying has been investigated in previous studies. Swift
an d Triolo (1992) rep o rted a reduction in bo n d strength to d ry dentine w hen
com pared to that achieved w hen the surface was left visibly m oist, although their
results w ere not statistically significant. H ow ever, other w orkers could detect no
significant difference in m icroieakage w hen the surface w as left w et or d ry
(S aunders & Saunders, 1996). These studies w ould suggest th at w ith SMP,
excessive drying w as not a risk factor for m icroieakage. H ow ever, in this study,
the strin g en t cavity factors m ay have increased the p o ly m erisatio n stresses
experienced w ithin the restoration resulting in disruption of a w eakened, porous
h y b rid layer. This sensitivity to w ater is p artly overcom e by the use of self­
prim ing agents such as Com poglass SCA. The use of an interm ediate bonding
resin w ith Z100/SM P has also been show n to reduce the m icroieakage at the
d e n tin e /re sto ra tio n interface (Swift et al., 1996) an d if used, m ay have served to
reduce the extent of dye penetration seen in this study.

Earlier work, using maleic acid conditioning, has show n that a storage period of
ninety days d id not affect the b o n d stren g th of SMP (M iears et al., 1995) or
m icroieakage (Crim, 1993) adversely. Indeed, as seen w ith the enam el m argins
(Section 5.4.1), it w ou ld be reasonable to expect hygroscopic expansion of the
resin to resu lt in a red u ctio n in m icroieakage w ith tim e. H ow ever, w here
inadequacies of the h ybrid layer are im plicated in m icroieakage, this increase
m ay be b alan ced by an increase in leakage over tim e because of fu rth er
hydro ly tic b reak d o w n of the layer. In this study, alth o u g h m ore specim ens
exhibited m axim um dye penetration in group B w hen com pared to group A, the
differences in leakage w ere not found to be significant at the conventionally-
p rep ared dentine m argins (Figure 4.8). This m ay purely be a reflection in the
high levels of leakage seen in group A. H ow ever, as noted earlier, the incidence

128
of tubule penetration by the dye w as higher in group B w hen com pared to group
A (72% and 29% respectively). This w ould suggest that there w as greater failure
of the hybrid layer in group B w hen com pared to group A. The role of hydrolytic
b reak d o w n has already been referred to in this context. C onversely hygroscopic
expansion m ay also have had an adverse effect on the hybrid layer: although this
has been rep o rted to com pensate, in part, for polym erisation shrinkage (Section
2.7.1.2), it is essential to rem em ber th at this does not occur im m ediately, b u t
rath er develops slow ly over a period. Furtherm ore, by the very process of w ater
sorption, the resin exposed to the oral cavity will absorb w ater in advance of the
bulk of the m aterial. This in itself adds new stresses to the restoration (D avidson
& Feilzer, 1997) w hich w ould result in greater strain on an already w eakened
h y b rid layer. Thus, w hile only speculation, several factors m ay account for the
lack of statistical difference three m onths storage a p p eared to have on the
dentine bond w hen com pared to that seen at the enam el m argin.

The application of SMP involves a num ber of sequential steps w hich is both time
consum ing and, from the results of this study, technique sensitive. The use of the
single p rim e r/b o n d in g system of Com poglass led to a significant im provem ent
in d entine leakage at conventionally-prepared m argins w h en com pared to the
m argins restored w ith Z100 and stored for a sim ilar period (group B; Figure 4.6).
In contrast to the leakage seen in group B, only 36% (22) exhibited evidence of
d ye p en e tratio n d o w n the tub u les and, of these, 64% (14) w ere sim ilar in
app earan ce to Figures 3.13 and 3.14 rath er th an Figures 3.12 an d 3.15. Fifth
generation bonding agents such as SCA incorporate a m odified sm ear layer into
the hybrid layer (Section 2.7.22). In addition, the application of the acidic prim er
p ro d u ces a d em in eralised surface to a d e p th of 5jum w ith p artially o pened
d en tin al tu b u les and a p orous collagen netw ork covering the surface of the
in tertu b u lar and p eritu b u lar dentine (N ortheast & Della Bonna, 1998). This is
sim ilar in appearance and depth to the hybrid layer form ed w ith SMP (Prati et al.,
1993). The incidence of m icroieakage and the pattern of dye penetration seen in
this stu d y w o u ld therefore suggest that the hybrid layer w ith SCA w as m ore
hom ogenous than that achieved w ith SMP.

The factors outlined in this section are also of relevance w hen considering the
lased dentine m argins.

129
5 .5 .2 The influence of the Er:YAG laser on the dentine cavity
restoration/interface

Looking first at the leakage seen w ith the different laser energies in groups A and
B, in the form er, Z 100/SM P stored for 24 hours, the absence of significant
differences in m icroieakage betw een the different laser energies (Figure 4.7a)
suggests that all three pulse energies produced surfaces that, w h en etched, w ere
com parable to each other. H ow ever, in group B, Z100/SM P stored for three
m onths, the use of 240 m j appeared to result in greater levels of m icroieakage,
although the differences w ere only significant w hen com pared w ith the 300 m j
group (Figure 4.7b). From these results, it w ould appear that, w hen considering
long-term perform ance, the use of laser param eters of 200 m j and, in particular,
300 m j w o uld be preferable to 240 mj. These findings w ere reinforced w hen the
re su lts of the in te rg ro u p co m p arisons w ere rev iew ed (Figure 4.8). The
differences can be explained by postulating on the shape of the crater patterns
that are likely to be produced by the different pulse energies. The crater patterns
in den tin e, w hile d eep er and w ider th an those found in enam el, w ill ten d
to w ard s a shallow er, less rough p attern w ith reducing laser energies (H ibst &
Keller, 1989). As n o ted in the previous p arag rap h , etching of the surface
increases the d ep th of the crater p attern significantly, because of the absence of
the sm ear layer. Thus w ith deeper crater patterns, the likelihood of incom plete
p en etratio n of the viscous SMP resin occurring will increase, resu ltin g in the
form ation of a poorer hybrid layer. This explains the slight trend in leakage seen
w ith the 200 m j and 240 m j energies in group B, althought the differences w ere
not statistically significant. As such, the 300 m j group w ould be expected to
exhibit the w orst levels of microieakage, but this was not seen. The 100 m j finish
w ith the 300 m j pulse energy was an im portant factor in this study. D entine
ablation using the 300 m j energy was com pleted w ith 100 m j to rem ove charred
tissue on the dentine surface. By doing this, the lower energy w ould have also
had the effect of 'sm oothing' the dentine surface and in so doing w ould provide a
surface th at allow ed closer ad ap tation of the resin than the h igher energy of
240 mj.

In this study, the perform ance of the laser in relation to that of the conventional
technique is of interest. W hen the com posite/dentine interface in groups A and
B are considered, the laser-prepared dentine m argins tended to exhibit m ore

130
m icroieakage th an those p rep ared conventionally. H ow ever, the differences
w ere only significant for the m argins p repared w ith a pulse energy of 240 m j in
g ro u p A and 200mJ and 240mJ in group B. This is in agreem ent w ith an earlier
re p o rt u sin g Scotchbond M ulti-P urpose an d pulse energies of 250 m j w ith a
storage tim e of 24 h o u rs (H aller et a l, 1993b). Therefore, in co n trast to the
findings at the en am el/com posite m argin, it w ould appear that the perform ance
of the laser is not satisfactory for all the pulse energies investigated in this study.
Speculation as to the reason for this can be m ade by considering the m orphology
of the d e n tin a l surface p ro d u ced by lasing. This w as described in Section
2.10.6.3. In ad d itio n to the scaly, cratered surface, SEM analysis of the dentine
surface follow ing laser p rep aratio n w ith pulse energies of 100 m j and 180 m j
found it to be devoid of a sm ear layer, the dentine tubules w ere p ro tru d in g and
the tubule orifices w ere exposed (Tanji et a l, 1997; Aoki et a l, 1998). W ith the
h ig h er pu lse energies u sed in this study, sim ilar appearances of the d en tin e
surface w ould be expected, b u t w ith deeper crater patterns. The absence of the
sm ear lay er m ay re su lt in excessive d em in eralisatio n of the d e n tin e an d
w idening of the tubules following the application of phosphoric acid in the total
etch procedure. C onsidering the viscous nature of the SMP bonding resin noted
in the p rev io u s section, this p a tte rn of d em in eralisatio n co u ld re su lt in
inad eq u ate infiltration of the dem ineralised tissue and therefore a m ore porous
h y b rid layer. This m ay account for the increase in m icroieakage seen w ith the
laser and, if true, w ould suggest that conditioning w ith either a less dissociated
acid, or the laser only m ay be indicated for this m aterial w ith cavity p rep aratio n
by the laser. SEM analysis of the m orphology of the lased surface before and
after application of the phosphoric acid is required to support these conclusions.

Thus w hile both the 200 m j and 300 m j w ith 100 m j finish appeared to give the
m ore favourable long-term m icroieakage results w hen com pared to a 240 mj
pulse energy, of the three energies tested, the 300 m j lased dentine m argins in
g ro u p B w ere the only su bgroup that did not exhibit significantly w orse dye
penetration than the equivalent conventional m argins.

In g ro u p C (Com poglass), the d entine m argins p rep ared by the th ree laser
energies p erform ed equally w ell (Figure 4.7c). Furtherm ore, all three pulse
energies appeared to provide favourable surfaces for w etting and penetration of
C om poglass SCA w hen com pared to conventionally-prepared m argins (Figure

131
4.10c). Thus it w ould appear that the hybrid layer form ed w ith C om poglass SCA
is of a sim ilar quality irrespective of the presence of the sm ear layer for the three
pulse energies. From this, it can be postulated that dentine conditioning w ith the
w eak o rg a n ic a c id s in C o m p o g lass SCA d o es not cau se e x cessiv e
d em ineralisation in the absence of a sm ear layer. In addition, it w o u ld ap p ear
that the penetration and adapatability of Com poglass SCA w as not influenced by
the different surface m orphologies produced by the three pulse energies.

These factors are of relevance w h en the perform ance of the tw o m aterials is

com pared. Like the conventionally-prepared cavities, C om poglass gave a better
long-term seal at the dentine m argins than Z100. This difference w as significant
for all three pulse energies (Figure 4.9). As noted in section 5.5.1, it w ould appear
th at C om poglass SCA resulted in a m ore hom ogenous hybrid layer th an SMP,
w ith or w ith o u t the presence of the sm ear layer. W ettability an d adaptability
characteristics of the tw o m aterials and the cavity surface are of relevance here.
Furtherm ore, w hen applied to lased dentine surfaces, it is unlikely that the w eak
o rg a n ic a c id s fo u n d in C o m p o g lass w o u ld p ro d u c e th e e x te n t of
dem ineralisation seen w ith m ore dissociated acids such as phosphoric.

In sum m ary, laser ablation of dentine had a varied effect on m icroieakage w hen
Z 100/SM P w ere u sed to restore the cavities, w ith the 300 m j energy w ith a
100 m j finish p ro v id in g the m ore favourable results. H ow ever, all three laser
param eters were equally effective for Compoglass.

5.6 Conclusions

The effects the acid-etching of dentine has on the pulp have been controversial
(Kanca, 1990; Retief et a l, 1992) th ough recent consensus has agreed th a t the
procedure is biologically safe w here adequate dentine hybridisation is achieved.
Indeed, it has been suggested that the current hybridisation adhesive system s
could replace conventional liners and bases for pulp protection (Cox & Suzuki,
1994). H ow ever, in this study, sealing of the dentine tubules w as not guaranteed
w ith either m aterial, b u t particularly so w ith the com bination of SM P/Z100. This
is of concern, especially in situations w here the adhesive system is the only

132
m eans of p u lp protection. O n the basis of the results of this stu d y it is concluded
that further m easures are necessary if pulp protection is to be guaranteed.

In conclusion, the results of this study suggest that for the laser p aram eters used,
the Er:YAG laser can vary in its effect on the efficacy of the m arginal seal at both
the enam el and dentine m argins. It w ould appear that, w ithin the lim itations of
the range of param eters investigated in this study, o p tim u m cavity sealing is
ach iev ed w ith d ifferen t laser energies for d en tin e and enam el. For b o th
Z100/SM P and C om poglass/SC A , laser energies of at least 240 m j are preferable
to low er ones for enam el ablation. W hile low er energies of 200 m j or m ore
particularly, higher b u t w ith a lower energy for finishing (300 m j-100 mj), appear
to p ro v id e a better long-term m arginal seal for dentine w ith Z 100/SM P. All
th re e lase r energies are equally effective at the dentine m argin for Com poglass.

T hus it w ould appear that w ith care in the choice of laser param eters, tailored to
the choice of restorative m aterial, the Er:YAG laser does not have an adverse
effect on m icroieakage at enam el and dentine m argins and therefore this could be
considered as a p otential tool to replace the use of the conventional d rill for
anxious in d iv id u als. W ithin the constraints of this stu d y , an d for the tw o
m aterials used, the null hypothesis w as therefore found to be tru e for certain
pulse energies.

133
6 Future research
This stu d y has concentrated on one aspect of the use of the Er:YAG laser, nam ely
th at of m icroleakage. As w ith all studies, the results of this stu d y have led to
fu rth er questions w hich should be answ ered before the laser can be accepted for
routine use in the UK.

A s n o te d in Section 2.11, the clinician is faced w ith a b ro a d choice of

com binations of operating variables w hen using the Er:YAG laser. W hile this
stu d y investigated the influence on m icroleakage of three pulse energies at the
sam e pulse rep etitio n rate, it m ay be that a higher energy or a different pulse
repetition rate w o uld result in at least as good a seal w ith the additional benefit
of operating at a faster ablation rate. Further w ork is necessary in this area. In
add itio n , the results of this stu d y have indicated that satisfactory enam el and
dentine ablation m ay require different laser param eters, and that this m ay further
be d ep en d en t on the restorative m aterial to be used.

In add itio n to finding the optim um com bination of laser param eters for ablation
w ith respect to m icroleakage, it is essential that the choice gives a clinically
acceptable ablation rate w ith m inim al therm al dam age to the dental h ard tissues
or pulp. These areas need further evaluation. In this study, im pressions of the
cavities w ere taken prior to restoring the teeth. SEM exam ination of these is to be
carried o u t to evaluate the resulting surface m orphology for all three laser
energies. Such exam ination will give an indication as to the incidence of therm al
changes that occurred during the lasing process. In addition, com parison of the
m o rp h o lo g y w ith the leakage p atterns will give inform ation on the adhesion
ch aracteristics of the surface for o p tim u m sealing for the tw o m aterials
investigated. This, and the extent of the leakage seen, particularly at the dentine
m arg in s w ith Z100 also raises the qu estio n as to w h eth er, for the correct
com bination of variables, laser etching and conditioning m ay obviate the need
for acid etching and conditioning.

134
Satisfactory ablation w ith the Er:YAG laser requires an adequate w ater supply.
In the in vitro conditions of this study, this w as obtained from the w ater m ist
p ro d u ce d by the laser and from residual m oisture in the tooth from storage.
H ow ever, in vivo, cavity preparation results in an increased outflow of dentinal
flu id from the o p en ed d en tin al tubules. Theoretically, this, an d the m oist
environm ent of the oral cavity should reduce the potential for tissue desiccation
d u rin g lasing an d m ay also influence m icroleakage. As w ith all new techniques,
the accep tab ility of the use of the Er:YAG laser req u ires fu rth e r in vivo
assessm ent.

Finally, clinical acceptability of the laser for the optim al param eters should be
assessed. Lasers are expensive item s of equipm ent and it is therefore essential
th a t th e y are fully ev alu a ted from b o th the p a tie n t's an d the clin ician 's
perspective. To date, in vivo studies to assess patient com fort d u rin g cavity
p re p ara tio n w ith the laser have reported favourable results, particularly w hen
com pared to conventional preparation (Section 2.10.6.6) H ow ever, in their in vivo
assessm en t of an Er:YAG laser, Evans et al (1998) found th at the clinicians
them selves preferred conventional rotary handpieces. The reasons for this w ere
not evaluated, b u t can be speculated from recent w ork by Aoki et al (1998) and
the experience gained during this in vitro study. The Erbium:YAG laser operates
at a w avelength w hich is readily reflected by the intra-oral m irrors in current
clinical use and if absorbed by the eye, perm anent dam age m ay ensue. To lim it
the possibility of this, the use of intra-oral m irrors is contra-indicated and the
clinician m u st w ear tinted protective glasses, specific for this w avelength. Both
affect visibility in the oral cavity, although a high intensity operating light w ould
be of help in m inim ising this effect. Intra-oral access can also be problem atic; the
anterior teeth, and buccal surfaces of the posterior teeth are readily accessible to
the laser, b u t lasing other surfaces can be difficult. This has im plications w hen
considering the laser as an alternative to the conventional handpiece an d b u r
w hen m anaging the anxious individual.

Finally, ablation w ith the Er:YAG laser is not tissue specific and thus m ay result
in excessive tissue rem oval during cavity preparation. W hen using conventional
m eth o d s of cavity p rep aratio n , the experienced clinician relies on tactile
sensation an d visual exam ination, often w ith reflected or transillum inated light
to assess the cavity. As noted in the previous paragraph, the use of reflected or

135
tra n sillu m in ated light w hile lasing is contra-indicated. In addition, the lack of
tactile sensation associated w ith a non-contact laser such as the one used in this
s tu d y could be perceived as a d isadvantage to the experienced clinician. The
in tro d u c tio n of all new techniques into clinical dentistry requires a p erio d of
tra in in g an d adjustm ent. The in tro d u ctio n of the Er:YAG laser in to clinical
practice is no exception. Experienced operators of the Er:YAG laser rep o rt a
difference in the quality of the sound produced w hen ablating dentine, enam el or
caries an d suggest that this is a useful aid for cavity preparation. Furtherm ore,
there are reports in the literature of the use of Er:YAG lasers th at operate in the
contact m ode (Chao et al., 1996; Aoki et a l, 1998). This w o u ld be expected to
p ro v id e a m easure of tactile sensation. H ow ever, Aoki et al rep o rted that there
w as insufficient feedback w ith the contact laser to enable differentiation to be
m ad e betw een enam el, dentine and caries. They relied on tactile exam ination
w ith the probe and caries disclosing procedures to assess the caries-status of the
cavity. The latter w as not w ithout its difficulties; because of staining differences
b etw een the lased and conventionally-prepared surfaces, the clinician w as not
able to judge com plete caries rem oval w ith laser treatm ent. It w ould therefore
ap p ea r th at cavity assessm ent m ay be problem atic and should be considered
further.

In conclusion, w hile there are an increasing num ber of reports being published
on the effectiveness of the Erbium:YAG laser as an optical drill, the advantages
an d lim itations of the laser for clinical treatm ent have yet to be fully evaluated.
A reliable p rocedure for the clinical use of the laser m ust be established. To
achieve this, the further studies outlined above should be com pleted.

136
Bibliography
3M (1994) 3M Scotchbond™ M ulti-Purpose Plus D ental A dhesive System . 3M
D ental Products Laboratory, St. Paul, pp. 1-40.
3M (1997) 3M restorative™ Z100 MP; Product inform ation. 3M D ental P roducts
Laboratory, St. Paul, pp. 1-7.
A drian, J. C , Bernier, J. L. and Sprague, W. G. (1971) Laser and the d en tal pulp.
Journal of The American Dental Association , 83:113-117.
A m sberry, W., von Fraunhofer, J. A., Hoots, J. and Rogers, H. (1984) M arginal
leakage of several acid-etch com posite resin restorative system s. Journal of
Prosthetic D entistry , 525:647-653.
Aoki, A., Ishikawa, I., Yamada, T., Otsuki, M., W atanabe, H., Tagami, J., Ando, Y.
a n d Y am om oto, H. (1998) C o m p ariso n b e tw e e n Er:YAG la se r an d
co n v en tio n al technique for root caries in vitro. Journal o f D ental Research,
77:1404-1414.
A ren d s, J., V an d er Veen, G., Van G roeningen, G. an d Schuthof, J. (1984)
Q u a n tifie d m a rg in a l leak ag e of co m p o sites in vitro. Journal o f Oral
Rehabilitation , 12:229-234.
A rim a, M. and M atsum oto, K. (1993) Effects of ArF:Excimer laser irrad iatio n on
h u m an enam el and dentine. Lasers in Surgery and Medicine, 13:97-105.
A sm ussen, E. (1975) Com posite restorative resins: com position versus w all-to-
wall polym erization contraction. Acta Odontologica Scandinavia, 33:337-344.
A sm ussen, E. (1976) M arginal ad ap tatio n of restorative resins in acid etched
cavities. Acta Odontologica Scandinavia, 35:125-134.
A sm ussen, E. (1982) Restorative resins: hardness and strength vs. q u an tity of
rem aining bonds. Scandinavian Journal of Dental Research, 90:484-489.
A sm ussen, E. an d Jorgensen, K. D. (1972) A m icroscopic in v estig atio n of the
a d a p ta tio n of som e plastic filling m aterials to den tal cavity w alls. A c ta
Odontologica Scandinavia, 30:3-21.
A sm ussen, E. R. (1974a) The effect of tem perature changes on the a d ap tatio n of
resin fillings. I. Acta Odontologica Scandinavia, 32:161-171.
A sm ussen, E. R. (1974b) The effect of tem perature changes on the a d ap tatio n of
resin fillings. II. Acta Odontologica Scandinavia, 32:292-297.

137
A ttal, J. P., A sm ussen, G. and Derange, M. (1994) Effects of surface treatm ent on
the free surface of dentine. Dental Materials, 10:259-264.
Barclay, C. W. (1998) Therm ocycling: an unrealistic technique for sim ulating
clinical conditions? Journal of Dental Research, 77:901 (abstr 2155).
Barkm eier, W. W. and Erickson, R. L. (1994) Shear bond strength of com posite to
en am el a n d d en tin u sin g Scotchbond M ulti-P urpose. Am erican Journal o f
D entistry, 7:175-179.
Barnes, D. M., T hom pson, V. P., Blank, L. W. and M cD onald, N. J. (1993)
M icroleakage in Class V in vivo, and in vitro com posite resin restorations.
Journal o f Dental Research, 86:114 (abstr 186).
Bauer, J. G. and H enson, J. C. (1984) Microleakage; a m easure of the perform ance
of direct filling m aterials. Operative Dentistry, 9:2-9.
B ausch, J. R., De Lange, C. an d D avidson, C. L. (1981) The influence of
tem perature on some physical properties of dental com posites. Journal o f Oral
Rehabilitation, 8:309-317.
Bayne, S. C., H eym ann, H. O. and Swift, E. J. (1994) U pdate on dental com posite
restorations. Journal of the American Dental Association, 125:687-701.
B erggren, U. a n d M eynart, G. (1988) D ental fear an d avoidance; causes,
sy m p to m s an d consequences. Journal o f The American Dental Association,
116:641-647.
Bernstein, D. A., Kleinknecht, R. A. and Alexander, L. D. (1979) A ntecedents of
dental fear. Journal of Public Health in Dentistry, 34:113-124.
Black, R. B. (1955) A pplication and revaluation of air abrasive technic. Journal of
The American Dental Association, 50:408-414.
Blackwell, R. E. (1955) Caries of the teeth: Etiology. In Black's Operative D entistry
Vol I: Pathlogy of the Hard Tissues of the Teeth, Oral Diagnosis, E dico-D ental
Publishing Co., London, pp. 181-219.
Bowen, R. L. (1979) Com patability of various m aterials w ith oral tissues. I: The
com ponents in com posite resins. Journal of Dental Research, 58:1493-1503.
Bowen, R. L., Barton, J. A. J. and M ullineaux, A. L. (1972) C om posite restorative
m aterials. In Dental Materials Research. Nat But Stand Special Publ 354, N ational
Bureau of Standards, Gaithersburg, Md, pp. 93-100.
Bowen, R. L., Nem oto, K. and Rapson, J. E. (1983) A dhesive bonding of various
m aterials to h ard tooth tissues: forces developing in com posite m aterials
d u rin g hardening. Journal of The American Dental Association, 106:475-477.

138
Bowen, R. L. and Reed, R. E. (1976) Sem i-porous reinforcing fillers for com posite
resins. II: H eat treatm en t an d etching characteristics. Journal o f D ental
Research, 55:748-756.
Bowen, R. L. an d Setz, L. E. (1986) Posterior com posite restorations w ith novel
stucture. Journal of Dental Education, 65:797 (abstr 642).
B raden, M., C austen, E. E. an d Clarke, R. L. (1976) D iffusion of w ater in
com posite filling m aterials. Journal o f Dental Research, 55:730-732.
B rannstrom , M. (1986) The cause of postoperative sensitivity an d its prevention.
Journal of Endodontics, 12:475-481.
B rannstrom , M., Johnson, G. and Friskopp, J. (1980) M icroscopic observations of
the dentin u n d er carious lesions excavated w ith the GK-101 technique. Journal
o f D entistry for Children, 47:46^9.
B ran n stro m , M. an d N yborg, H. (1972) P ulp reactio n to com posite resin
restoration. Journal of Prosthetic Dentistry, 27:181-189.
B rannstrom , M., Tortenson, B. and N ordenvall, K. J. (1984) The initial gap around
large com posite restorations in vitro: the effect of etching enam el w alls.
Journal o f Dental Research, 63:681-684.
Bratthall, D., H ansel Petersson, G. and Sundberg, H. (1996) Reasons for the caries
decline: w h a t do the experts believe? European Journal o f Oral Science,
104:416-422.
Brow ne, R. M. an d Tobias, R. S. (1986) M icrobial m icroleakage an d p u lp al
inflam m ation: A review. Endodontics and Dental Traumatology, 2:177-183.
Buonocore, M. G. (1955) A sim ple m ethod of increasing the adhesion of acrylic
filling m aterials to enam el surfaces. Journal of Dental Research, 346:849-853.
B uonocore, M. G. an d Sheykholeslani, Z. (1973) E v alu atio n of an enam el
adhesive to prev en t m arginal leakage: An in vitro study. Journal o f D entistry
for Children, 40:119-124.
Burgess, J. O., N orling, B. K., Rawls, H. R. and Ong, J. L. (1996) D irectly placed
esthetic restorative m aterials—The continuum . Com pendium o f C ontinuing
Education in Dentistry, 17:731-746.
Burkes, E. J., Hoke, J., Gomes, E. and W olbarsht, M. (1992) W et versus dry
enam el ablation by Er:YAG laser. Journal of Prosthetic Dentistry, 67:847-851.
Calais, J. G. and Soderholm , K.-J. M. (1988) Influence of filler type and w ater
exposure on flexural strength of experim ental com posite resins. Journal of
Dental Research, 67:836-840.

139
C auston, B. E. (1984) Im proved bonding of com posite restoratives to dentin: A
stu d y in vitro of the use of com m ercial halogenated p h o sp h ate ester. British
Dental Journal, 156:93-95.
Chao, W. S., Shen, B. I. and W hite, J. M. (1996) A blation of d en tin an d enam el
utilizing contact Er:YAG. Journal o f Dental Research, 75:91 (abstr 587).
C hersoni, S., Lorenzi, R., Ferrieri, P. and Prati, C. (1997) Laboratory evaluation of
com pom ers in Class V restorations. American Journal o f D entistry, 10:147-151.
Chiego, D. J. (1994) H istology of pulp. In Oral Development and Histology, (Ed,
Avery, J. K.) Thieme M edical Publishers, Inc., pp. 262-281.
Chow , M. H. (1980) Effects of sealants placed over com posite resin restorations.
Journal of Prosthetic Dentistry, 44:531-535.
C h risten , A. G. an d M itchell, D. F. (1966) A fluorescent dye m eth o d for
dem o n stratin g leakage around dental restorations. Journal o f Dental Research,
45:1485-1492.
C hristensen, G. J. (1997) Com pom ers vs. resin-reinforced glass ionom ers. Journal
o f the American Dental Association, 128:479-480.
Cook, W. D., Beech, D. R. an d Tyas, M. J. (1984) Resin b ased resto rativ e
m aterials—a review. Australian Dental Journal, 29:291-295.
Cortes, O., Garcia, C., Perez, L. and Perez, D. (1998) M arginal m icroleakage
aro u n d enam el and cem entum surfaces of two com pom ers. Journal o f Clinical
Pediatric Dentistry, 22:307-310.
Cox, C. F. an d Suzuki, S. (1994) R e-evaluating p u lp p ro tectio n : calcium
h y d ro x id e liners vs cohesive hybridization. Journal o f the Am erican Dental
Association, 125.
Cozean, C., Arcoria, C. J., Pelagalli, J. and Powell, G. L. (1997) D entistry for the
21st century? Erbium:YAG laser for teeth. Journal o f the Am erican Dental
Association, 128:1080-1087.
Craig, R. E. (1997) Direct Esthetic R estorative m aterials. In Restorative Dental
Materials, Mosby-Year Book, inc., pp. 244-280.
Craig, R. G. (1981) Com position and properties of composite resins. Dental Clinics
of North America, 25:219-239.
Crim, G. A. (1991) M icroleakage of three resin placem ent techniques. American
Journal of Dentistry, 4:69-72.
Crim , G. A. (1993) Effect of aging on m icroleakage of resto rativ e system s.
American Journal of Dentistry, 6:192-194.

140
Crim , G. A. and Abbott, L. J. (1988) Effect of curing tim e on m arginal sealing by
four d entin bonding agents. American Journal o f Dentistry, 1:12-14.
Crim , G. A. and Garcia-Godoy, F. (1987) Microleakage: the effect of storage and
cycling duration. Journal of Prosthetic Dentistry, 37:574-576.
Crim , G. A. an d M attingly, S. L. (1980) M icroleakage an d the ClassV com posite
cavosurface. Journal of Dentistry for Children, 47:333-336.
Crim , G. A. and M attingly, S. L. (1981) Evaluation of tw o m ethods for assessing
m arginal leakage. Journal of Prosthetic Dentistry, 45:160-163.
Crim , G. A. and Shay, J. S. (1987) Effect of etchant tim e on m icroleakage. Journal
o f D entistry for Children, 545:339-340.
C rim , G. A., Sw artz, M. L. and Philips, R. W. (1985) C o m p ariso n of four
therm ocycling techniques. Journal of Prosthetic Dentistry, 53:50-53.
Crisp, S. an d W ilson, A. D. (1980) Radioactive tracer technique for m onitoring of
m icroleakage: A n interim report. Journal o f Biomedical M aterials Research,
14:373-382.
D avidson, C. L. (1985) Conflicting interests w ith p o sterio r use of com posite
m aterials. In International sym posium on Posterior Composite Resin Dental
Restorative Materials, (Eds, Vanherle, G. and Smith, D. C.) Peter Szulc, Utrecht,
pp. 61-66.
D avidson, C. L. (1986) Resisting the curing contraction w ith adhesive com posites.
Journal of Prosthetic Dentistry, 55:446-447.
D avidson, C. L., de Gee, A. }. and Feilzer, A. (1984) The com petition betw een the
com posite-dentin bo n d stren g th and the polym erization contraction stress.
Journal of Dental Research, 63:1396-1399.
D av id so n , C. L. an d Feilzer, A. J. (1997) P o ly m erizatio n sh rin k ag e an d
p o ly m eriza tio n shrinkage stress in polym er-based restoratives. Journal o f
Dentistry, 25:435-440.
de Gee, A. J. and Pallav, P. (1994) Occlusal w ear sim ulation w ith the ACTA w ear
m achine. Journal of Dentistry, 22:S21-27.
Dederich, D. N. (1991) Laser tissue interaction. A O Vol 84 Scientific, :33-36.
D ederich, D. N. an d Zakariasen, T. J. (1984) Scanning electron m icroscope
analysis of canal w all d en tin follow ing n eo d y m iu m :y ttriu m -alu m in iu m -
garnet laser irradiation. Journal of Endodontics, 10:428-431.
Dejou, J., Sindres, V. and Camps, J. (1996) Influence of criteria on the results of in
vitro evaluation of microleakage. Dental Materials, 12:342-349.

141
D only, K. J., W ild, T. W., Bowen, R. L. an d Jensen, M. E. (1989) A n in vitro
in v estigation of the effects of glass inserts on the effective com posite resin
polym erisation shrinkage. Journal o f Dental Research, 68:1234-1237.
D ouglas, W. H., Fields, R. P. and Fundlingsland, J. (1989) A com parison betw een
the m icroleakage of direct and indirect com posite restorative system s. Journal
of Dentistry, 17:184-188.
D ouglas, W. H. an d Zakariassen, K. L. (1981) V olum etric assessm ent of apical
leakage utilising a spectrophotom etric, dye recovery m ethod. Journal o f Dental
Research, 60:438 (abstr 512).
D ow ner, M. C. (1994) Caries prevalence in the U nited K ingdom . International
Dental Journal, 44:365-370.
D rau g h n , R. A. (1981) Effects of tem p eratu re on m echanical p ro p erties of
com posite dental restorative m aterials. Journal o f Biomedical Materials Research,
15:489-495.
Eakle, W. S. (1986) Effect of th erm al cycling on fractu re s tre n g th an d
m icroleakage on teeth resto red w ith a b o n d ed com posite resin. D en ta l
Materials, 2:114-117.
E hrnford, L. (1983) D ental com posites reinforced w ith m icroporous sintered
glassfiber netw orks. Swedish Dental Journal (Supplement), 18:1-45.
Ellingson, O. L., Landry, R. L. and Bostram, R. G. (1986) A n evaluation of optical
rad iatio n em issions from dental visible polym erisation devices. Journal o f the
American Dental Association, 112.
Ellis, J., Jackson, A. M., Scott, R. P. and W ilson, A. D. (1990) A d hesion of
carboxylate cem ents to hydroxyapatite. Ill A bsorption of poly(alkenoic acids).
Biomaterials, 11:379-384.
Eriksen, FI. M. an d Buonocore, M. G. (1976) M arginal leakage w ith different
com posite restorative m aterials in vitro: Effect of cavity design. Journal o f Oral
Rehabilitation, 3:315-322.
Evans, D. J., M athew s, S., Pitts, N. B., N ugent, Z. and Longbottom , C. (1998) A
clinical evaluation of an Erbium:YAG laser for cavity preparation. Journal of
Dental Research, 77:955 (abstr 2591).
Fayyad, M. A. an d Ball, P. C. (1987) Bacterial p en etratio n a ro u n d am algam
restorations. Journal of Prosthetic Dentistry, 575:571-574.
Featherstone, J. D. B. and Nelson, G. G. A. (1987) Laser effects on dental h ard
tissues. Advances in Dental Research, 1:21-26.

142
Feilzer, A. J., de Gee, A. J. and Davidson, C. L. (1987) Setting stress in com posite
resin in relatio n to the configuration of the restoration. Journal o f D ental
Research, 66:1636-1639.
Feilzer, A. J., De Gee, A. J. and Davidson, C. L. (1995a) Influence of light intensity
on p o ly m erisatio n shrinkage and integrity of restoration-cavity interface.
European Journal of Oral Sciences, 103:322-326.
Feilzer, A. J., D ooren, L. H., de Gee, A. J., Verhey, J. C. and D avidson, C. L.
(1995b) D ifferences b etw een tw o test m eth o d s for e v a lu a tin g m arg in a l
integrity. Journal o f Dental Research, 74:930 (abstr 1154).
Ferracane, J. L. (1995) C urrent trends in dental composites. Critical Reviews in Oral
Biology and Medicine, 6:302-318.
Ferrari, M., Vichi, A., Mannocci, F. and D avidson, C. L. (1998) Sealing ability of
tw o "com pom ers" applied w ith and w ithout phosphoric acid treatm en t for
Class V restorations in vivo. Journal o f Prosthetic Dentistry, 79:131-135.
Forsten, L. (1995) Resin-m odified glass ionom er cements: F luoride release an d
uptake. Acta Odontologica Scandinavia, 53:222-225.
Fosse, G., Saele, P. K. and Eide, R. (1992) N um erical density an d d istrib u tio n al
p attern of dentin tubules. Acta Odontologica Scandinavia, 50:201-210.
Frentzen, M. and Koort, H. J. (1990) Lasers in dentistry: new possibilities w ith
advancing laser technology? International Dental Journal, 40:323-332.
F rentzen, M., W inkelstrater, C., van Benthem , H. and Koort, H.-J. (1996) The
effects of p ulsed ultraviolet and infra-red lasers on dental enam el. European
Journal o f Prosthodontics and Restorative Dentistry, 4:99-104.
Friedl, K. H., Hiller, K. A. and Schmalz, G. (1995) Placem ent and replacem ent of
com posite restorations in Germany. Operative Dentistry, 20:34-38.
G ale, M. S., D arvell, B. W. and C heung, G. S. (1994) T h ree-d im en sio n al
reconstruction of microleakage pattern using a sequential grinding technique.
Journal of Dentistry, 22:370-375.
George, L. A. and Richards, N. D. (1993) Polym erisation shrinkage in a com posite
restoration involving a glass-ceramic insert. Journal o f Dental Research, 72:351
(abstr 1979).
Glasspoole, E. A. and Erickson, R. L. (1994) The effect of various acid treatem ents
on enam el: D em ineralization, SEM and bon d strength. Journal o f D ental
Research, 73:387 (abstr 2281).

143
G ly n Jones, J. C., G rieve, A. R. an d H arrington, E. (1979) A m ach in e for
therm ocycling in the investigation of m arginal leakage. British Dental Journal,
146:207-211.
G lyn Jones, J. C., G rieve, A. R. an d Youngson, C. C. (1988) M arginal leakage
asso ciated w ith three po sterio r restorative m aterials. Journal o f D entistry,
16:130-134.
G oing, R., M assler, M. and Dute, H. L. (1960) M arginal p en etratio n of dental
resto ratio n s by differen t radioactive isotopes. Journal o f Dental Research,
39:273-284.
G oing, R. E., M yers, H. M. and Prussin, S. G. (1968) Q uantitative m eth o d s for
s tu d y in g m icroleakage in vivo a n d in vitro. Journal o f D ental Research,
47:1128-1132.
G oldm an, L., Gray, J. A., Goldm an, J., Goldm an, B. and M eyer, R. (1965) Effect of
lase r b eam im p acts on teeth. Journal o f the Am erican D ental Association,
70:601-606.
G oldm an, L., H ornby, P., Meyer, R. and G oldm an, B. (1964) Im pact of the laser
on dental caries. Nature, 203:417.
G o ld m an , M. (1983) P o ly m erizatio n sh rin k ag e of resin -b ased re sto ra tiv e
m aterials. Australian Dental Journal, 28:156-161.
G o ld m an , M., Sim m onds, S. an d Rush, R. (1989) The u sefu ln ess of dye-
p e n e tra tio n stu d ies re-exam ined. Oral Surgery, Oral M edicine and Oral
Pathology, 67:327-332.
G oodis, H. E., M arshall, G. W., Jr. and W hite, J. M. (1991) The effects of storage
after extraction of the teeth on hum an dentine perm eability in vitro. Archives of
Oral Biology, 36:561-566.
G ordon, T. E. (1967) Single surface cutting of norm al tooth w ith a ru b y laser.
Journal of the American Dental Association, 74:398^02.
G rieve, A. R. and G lynn Jones, J. C. (1980) An in vitro stu d y of m arginal leakage
associated w ith com posite restorations using acidified agar technique. Journal
o f Oral Rehabilitation, 7:215-223.
G rossm an, L. I. (1939) A study of tem porary fillings as herm etic sealing agents.
Journal of Dental Research, 18:67-71.
G w innett, A. J. (1967) The u ltrastructure of the prism less enam el of p erm an en t
h u m an teeth. Archives of Oral Biology, 12:381-387.

144
G w innett, A. J. (1984) Sm ear layer: M orphological considerations. O perative
D entistry, 3:2-12.
G w innett, A. J. (1992) M oist versus dry dentin: Its effect on shear bon d strength.
American Journal of Dentistry, 5:127-129.
G w innett, A. J. (1994) D entin bo n d stren g th after air d ry in g an d rew etting.
American Journal of Dentistry, 7:144-148.
G w innett, A. J. and Kanca III, J. (1992) M icrom orphological relationship betw een
resin and dentin in vivo and in vitro. American Journal o f D entistry, 5:19-23.
Hall, L. H. S., Cochran, M. A. and Swartz, M. L. (1993) Class 5 com posite resin
restorations: m argin configurations and the distance from the CEJ. Operative
D entistry, 18:246-250.
H aller, B., H ofm ann, N., Klaiber, B. and Bloching, U. (1993a) Effect of storage
m ed ia on m icroleakage of five d en tin b o n d in g agents. D ental M aterials,
9:191-19 7.
H a ller, B., H o fm an n , N., K lem en, J. an d K laiber, B. (1993b) Er.YAG-
L aserp rap aratio n u n d K om posit-D entinhaftung in vitro. D eutsch Zahnarztl,
48:707-712.
H allett, K. B. and Garcia-Godoy, F. (1993) M icroleakage of resin-m odified glass
ionom er cem ent restorations: an in vitro study. Dental Materials, 9:306-311.
H als, E. an d N ernaes, A . (1971) H istopathology of in vitro caries developing
around silver am algam fillings. Caries Research, 5:58-77.
H ansen, E. K. (1984) Effect of Scotchbond d ependent on cavity cleaning, cavity
diam eter and cavosurface angle. Scandinavian Journal o f D ental Research,
92:141-147.
H ansen, E. K. (1986) Effect of cavity depth and application technique on m arginal
ad aptation of resins in dentin cavities. Journal o f Dental Research, 65:1319-1321.
H ansen, E. K. and Asm ussen, E. (1985) C om parative study of d en tin adhesives.
Scandinavian Journal of Dental Research, 93:280-287.
H arashim a, I., Takashi, U. and H irasawa, T. (1992) A new m ethod for assessm ent
of m arginal sealability of dental restorations. Dental Materials, 11:150-156.
H ardw ick, J. L. (1960) The incidence and distribution of caries th ro u g h o u t the
ages in relation to the Englishm an's diet. British Dental Journal, 108:9-17.
H egdahl, T. and Gjerdet, N. R. (1977) C ontraction stresses of com posite resin
filling m aterials. Acta Odontologica Scandinavia, 35:191-195.

145
H em bree, J. H. (1984) M icroleakage of m icrofilled com posite resin restorations
w ith different cavosurface designs. Journal o f Prosthetic D entistry, 52:653-656.
H errin , H. K. an d Shen, C. (1985) M icroleakage of root caries restorations.
Gerodontics, 1:156-159.
H ibst, R. an d Keller, U. (1989) Experim ental studies of the ap p licatio n of the
Er:YAG laser on dental h ard substances: I. M easurem ent of the ablation rate.
Lasers in Surgery and Medicine, 9:338-344.
H ibst, R. an d Keller, U. (1991) Rem oval of dental filling m aterials by Er.YAG
laser radiation. Lasers in orthopedic, Dental and Veterinary Medicine. Proc SPIE,
1424:120-126.
H ibst, R. an d Keller, U. (1994) Sealing quality of com posites after Er:YAG laser
enam el conditioning. In Lasers Surgery: Advanced Characterization, Therapeutics
and System s IV. Proceedings o f Biomedical Optics Conference, Vol. 2128 (Eds,
A nderson, R. R. and Katzir, A.) Los Angeles, pp. 260-266.
H ibst, R., Keller, U. an d Steiner, R. (1988) The effect of p u lsed Er:YAG laser
radiation on dental tissues. Lasers in Medicine and Surgery, 4:163-165.
H ofm ann, N., H aller, B., Klaiber, B. and Kasdorf, A. (1992) Fiillungsrandschlufi
nach laserpraparation. Deutsch Zahndrztl, 47:711-713.
H oke, J. A., Burkes, E., Gomes, E. D. and W olbarsht, M. L. (1990) ErbiumiYAG
(294 jum) laser effects on dental tissues. Journal o f Laser Applications, 2:62-65.
Itoh, K., Iw aku, M. and Fusayam a, T. (1981) Effectiveness of glazing com posite
resin restorations. Journal of Prosthetic Dentistry, 45:606-613.
Jacobsen, P. H. (1976) W orking time of polym eric restorative m aterials. Journal of
Dental Research, 55:244-251.
Johnson, N. W., Taylor, B. R. and Berman, D. S. (1969) The response of deciduous
d entine to caries studied by correlated light and electron m icroscopy. Caries
Research, 3:348-368.
Jorgensen, K. D., M atono, R. and Shimokobe, H. (1976) D eform ation of cavities
an d resin fillings in loaded teeth. Scandinavian Journal o f D ental Research,
84:46-50.
K anca III, J. (1992) Resin b o n d in g to w et substrate. I. B onding to dentin.
Quintessence International, 23:39-41.
Kanca, J. (1990) A n alternative hypothesis to the cause of pulpal inflam m ation in
teeth treated w ith phosphoric acid on the dentin. Quintessence International,
21:83-86.

146
Kayano, T., Ochiai, S., Kiyono, K., Yamamoto, H., Nakajima, S. and M ochizuki, T.
(1991) Effect of Er:YAG laser irradiation on hum an extracted teeth. Journal of
Clinical Laser Medicine and Surgery, 9:147-150.
Keller, U. an d H ibst, R. (1989) Experim ental studies on the ap p licatio n of the
Er:YAG laser on den tal h ard substances: II. Light m icroscopic an d SEM
investigations. Lasers in Surgery and Medicine, 9:345-351.
Keller, U. and Hibst, R. (1995a) Er:YAG laser effects on oral h ard and soft tssues.
In Lasers in dentistry, (Eds, M iserendino, L. J. and Pick, R. M.) Q uintessence
Publishing Co. Inc, Carol Stream, pp. 161-172.
Keller, U. an d H ibst, R. (1995b) H istological findings of p u lp al changes after
Er.'YAG irradiation. Journal of Dental Research, 74:545 (abstr 1159).
Keller, U. and H ibst, R. (1997) Effects of Er:YAG laser in caries treatm ent: A
clinical pilot study. Lasers in Surgery and Medicine, 20:32-38.
Keller, U., H ibst, R., G eursten, W., Schilke, R., H eidem ann, D., Klaiber, B. and
Raab, W. H. M. (1998) Erbium:YAG laser app licatio n in caries th erap y .
E v alu atio n of p a tie n t p ercep tio n an d acceptance. Journal o f D en tistry,
26:649-656.
Keller, U., H ibst, R. an d M ohr, W. (1992) H istologische U n tersu ch u n g en der
P ulpareaktion nach Er:YAG-Laserbestrahlung. Deutsch Zahnaerztl, 47:222-224.
Keller, U., Raab, W. H. and Hibst, R. (1991) Die P u lp areak tio n w a h re n d der
B estrahlung von Z ahn h artsu b stanzen m it dem Erbium-YAG-Laser. D eutsch
Zahnarztl, 46:158-160.
Kem p-Scholte, C. M. and D avidson, C. L. (1990a) C om plete m arginal seal of
ClassV resin com posite restorations effected by increased flexiblity. Journal of
Dental Research, 69:1240-1243.
Kem p-Scholte, C. M. and D avidson, C. L. (1990b) M arginal integrity related to
b o n d stren g th and strain capacity of com posite resin restorative system s.
Journal of Prosthetic Dentistry, 64:658-664.
Keyes, P. H. (1960) The infectious and transm issible n atu re of experim ental
caries: Findings and implications. Archives o f Oral Biology, 1:304-320.
Kidd, E. A. M., H arrington, E. and Grieve, A. R. (1978) The cavity sealing ability
of co m p o site resto ra tio n s subjected to th erm al stress. Journal o f Oral
Rehabilitation, 5:279-286.

147
K idd, E. A. M. an d Joyston-Bechal, S. (1997) F luoride S u p p lem en tatio n . In
Essentials o f Dental Caries : The disease and its management, Vol. 2 O xford
U niversity Press, Oxford, pp. 83-102.
Kidd, E. A. M., Joyston-Bechal, S., Smith, M. M., Allan, R., Howe, L. and Smith, S.
R. (1989) The use of a caries detector dye in cavity preparation. British Dental
Journal, 167:132-134.
K idd, E. A. M., Toffenetti, F. and Mjor, I. A. (1992) Secondary caries. International
Dental Journal, 42:127-138.
K leinknecht, R. A., Klepac, R. K. and A lexander, L. D. (1973) O rig in s an d
characteristics of fear of dentisrty. Journal o f the American Dental Association,
86:842-848.
Knibbs, P. J. (1988) Glass ionom er cement: 10 years of clinical use. Journal of Oral
Rehabilitation, 15:103-115.
Koort, H. J. an d Frentzen, M. (1992) YAG-lasers in resto rativ e dentistry: A
histological investigation. Laser Surgery SPIE, 1643:403-411.
Lam brechts, P., Jochum, P. and Hiibner, H.-J. (1982) O bservation and com parison
of polished com posite surfaces w ith the aid of SEM and profilom eter. Journal
o f Oral Rehabilitation, 9:169-182.
Lee, H. L. an d Sw artz, M. L. (1976) Scanning electron m icroscope stu d y of
com posite restorative materials. Journal of Dental Research, 491:149-158.
Leinfelder, K. F. (1993) C urrent developm ents in dentin bonding system s. Journal
o f the American Dental Association, 124:40-42.
Leinfelder, K. F., O 'N eal, S. J. and M ueninghoff, L. A. (1986) Use of Ca(O H )2 for
m easuring m icroleakage. Dental Materials, 2:121-124.
Li, X., E dw ards, K. and Yee, A. F. (1993) R educing cure stress and im proving
w ear resistance in dental composites. Journal o f Dental Research, 72:113 (abstr
179).
Li, Z., Code, J. E., Willem, P. and Van De M erwe, P. (1992) Er:YAG laser ablation
of enam el an d d en tin of h u m an teeth: D eterm ination of ablation rates at
various fluences and pulse repetition rates. Lasers in Surgery and Medicine,
12:625-630.
Lin, A., M cIntyre, S. and Davidson, R. D. (1992) Studies on the adhesion of glass-
ionom er cem ents to dentine. Journal of Dental Research, 71:1836-1841.
Linden, J. J. and Swift, E. J. (1994) M icroleakage of tw o new d en tin adhesives.
American Journal of Dentistry, 7:31-34.

148
Liu, H., Retief, D. H., Salza, M. H. and Russell, C. M. (1993) Shear b o n d strengths
an d q u an titativ e m icroleakage of Prism a U niversal Bond 3 /A P H . Journal o f
Dental Research, 72:115 (abstr 189).
Lobene, R. R. an d Ferreira, S. (1966) Interaction of laser ra d ia tio n w ith oral
tissues. Journal of Prosthetic D entistry , 16:589-597.
Lutz, F. an d Phillips, R. W. (1983) A classification and evaluation of com posite
resin system s. Journal of Prosthetic Dentistry , 504:480-488.
M aim an, T. M. (1960) Stim ulated optical radiation in ruby. Nature, 187:493-494.
M arinelli, S. M. and Eichmiller, F. (1993) C om paring three D im ensional vs. tw o
dim ensional evaluation of m icroleakage in com posite restorations. Journal o f
Dental Research, 72:197 (abstr 748).
M artin, S. D. (1951) The perm eability of D entin to P32 u sin g the direct tissue
rad io a u to g ra p h y technique. Oral Surgery, Oral M edicine and Oral Pathololgy,
4:1461-1464.
M arzouk, M. A. and Bhaiji, A. H. F. (1989) Influence of enam el cavosurface
configuration on m arginal leakage in Class V com posite resin restorations.
American Journal o f Dentistry, 2:165-169.
M assler, M. and Ostrovsky, A. (1954) Sealing qualities of various filling m aterials.
Journal of D entistry for Children, 21:228-234.
McCabe, J. F. (1990) Silicate filling m aterials (Silicate cem ents). In Aplied Dental
Materials, Blackwell Scientific Productions, Oxford, pp. 141-144.
M cConnell, R. J., Johnson, L., Corazza, L. and Gratton, D. R. (1994) D im ensional
change d u rin g setting of com posite resins. Journal o f Dental Research, 7 3:126
(abstract 196).
McLean, J. W., Nicholson, J. W. and Wilson, A. D. (1994) P roposed nom enclature
for g lass-io n o m er d e n ta l cem ents an d related m ate ria ls. Quintessence
International, 25:587-589.
M cLean, J. W., Powis, G. R., Prosser, H. J. and et al. (1985) The use of glass-
io n o m er cem ents in b o n d in g com posite resins to dentine. British Dental
Journal, 158:410^414.
M eechan, J. G. and W inter, R. A. (1996) A com parison of topical anaesthesia and
electronic nerve stim ulation for reducing the pain of in tra-o ral injections.
British Dental Journal, 181:333-335.
Mejare, I. and Mjor, I. A. (1990) Glass ionom er and resin-based fissure sealants: a
clinical study. Scandinavian Journal of Dental Research, 98:345-350.

149
M eryon, S. D., Tobias, R. S. and Jakeman, K. J. (1987) Sm ear rem oval agents; A
q u a n tita tiv e stu d y in vivo an d in vitro . Journal o f Prosthetic D en tistry,
1987:174-179.
M eurm an, J. H., Voegel, J. C., Rauham aa-M akinen, R. and et al. (1992) Effects of
cabon dioxide, Nd:YAG and carbon dioxide-Nd:YAG com bination lasers at
high energy densities on synthetic hydroxyapatite. Caries Research, 26:77-83.
M idda, M. a n d R enton-H arper, P. (1991) Lasers in D entistry. British Dental
Journal, 170:343-346.
M iears, J. R., Charlton, D. G. and Herm esch, C. B. (1995) Effect of d entin m oisture
and storage tim e on resin bonding. American Journal o f D entistry, 1995:80-92.
M iller, M. an d Truhe, T. (1993) Lasers in dentistry: A n overview . Journal o f The
American Dental Association, 124:32-35.
M ixson, J. M., Eick, J. D., Chappell, R. P., Tira, D. E. and M oore, D. L. (1991)
C om parison of two-surface and m ultiple-surface scoring m ethodologies for in
vitro m icroleakage studies. Dental Materials, 7:191-196.
Mjor, I. A. (1996) G lass-ionom er cem ent restorations and secondary caries: A
prelim inary report. Quintessence International, 27:171-174.
Mjor, I. A. and Toffenetti, F. (1992) Placem ent and replacem ent of resin-based
com posite restorations in Italy. Operative Dentistry, 17:82-85.
Mjor, I. A. and Um, C. M. (1993) Survey of am algam and com posite restorations
in Korea. International Dental Journal, 43:311-316.
M oderesi, A., Lindsay, S. J., Gould, A. and Smith, P. (1996) A p artial d o u b le­
blind, placebo-controlled study of electronic dental anaesthesia in children.
International Journal o f Paediatric Dentistry, 6:245-251.
M ohanda, U. and Reddy, V. V. S. (1993) In vitro evaluation of m icrom arginal
leakage of three filling system s - an autoradiographic analysis using radio
isotope S35 as a tracer. Journal of the Indian Society o f Pedodontics and Preventive
Dentistry, 111:4-8.
M olin, C. (1992) A m algam — Fact or fiction. Scandinavian Journal o f Dental
Research, 100:66-73.
M om oi, Y., Iw ase, Y., Kohno, A., A sanum a, A. and Y anagisaw a, K. (1990)
G rad u al increase in m arginal leakage of resin com posite restorations w ith
therm al stress. Journal of Dental Research, 69:1659-1663.

150
M oseley, H., Strang, R. and M acDonald, I. (1987) Evaluation of the risk associated
w ith the u se of b lu e lig h t p o ly m erisin g sources. Journal o f D entistry,
1987:12-15.
M ount, G. J., P apaeorgiou, A. and M akinson, O. F. (1992) M icroleakage in the
sandw ich technique. American Journal o f Dentistry, 5:195-198.
M ukai, M., Ikeda, M., Y anagihara, T., H ara, G., Kato, K., N akagaki, H. and
Robinson, C. (1993) Fluoride uptake in h u m an dentine from glass-ionom er
cem ent in vivo. Archives of Oral Biology, 38:1093-1098.
M unechika, T., Suzuki, K., N ishiyam a, M., O hashi, M. and H orie, K. (1984) A
com parison of the tensile bond strengths of com posite resins to longitudinal
an d tran sv erse sections of enam el prism s in h u m an teeth. Journal o f Dental
Research, 63:1079-1082.
M u n k sg aard , E. C. and Irie, M. (1988) Effect of load cycling on bon d betw een
com posite fillings and den tin e established by G lum a an d v ario u s resins.
Scandinavian Journal of Dental Research, 96:579-583.
M urray, J. J. (1996) A ttendance p atterns and oral health. British Dental Journal,
181:339-342.
N akabayashi, N., N akam ura, M. and Yasuda, N. (1991) H ybrid layer as a dentin-
bonding m echanism . Journal of Esthetic Dentistry, 3:133-138.
N am m o u r, S., Renneboog-Suilbin, C. an d N yssen-Behets, C. (1992) Increased
resistance to artificial caries-like lesions in d en tin treated w ith CC>2 laser.
Caries Research, 26:107-175.
N arh i, M. V. O., Jyvasjarvi, E., H irvonen, T. and H u o p an iem i, T. (1982)
A ctivation of heat-sensitive nerve fibres in the dental p u lp of the cat. Pain,
14:317-326.
N elsen, R. J., W olcott, R. D. and Paffenbarger, G. C. (1952) Fluid exchange at the
m arg in s of d en tal restorations. Journal o f the American Dental Association,
44:288-295.
N iem z, M. H. (1995) C avity p rep aratio n w ith the Nd:YLF picosecond laser.
Journal of Dental Research, 74:1194-1199.
N ortheast, S. E. and Della Bonna, A. (1998) U ltrastructure of dentine treated w ith
prim ers for com pom ers and resin-m odified GICs. Journal of Dental Research,
77:635 (abstract 627).
O'Brien, M. (1994) D ental treatm ent and care. In Children's dental health in the
United Kingdom, HMSO, London, pp. 55-62.

151
O'Shea, R. M., Corah, N. L. and Ayer, W. A. (1984) Sources of d entist's stress.
Journal o f the American Dental Association, 109:48-51.
O m an, C. R. (1955) U ltrasonic cavity preparation II. Progress report. Journal o f the
American Dental Association, 50:414-417.
O ritz, R. F., Phillips, R. W., Swartz, M. S. and O sborne, J. W. (1979) Effect of
com posite resin bonding agent on microleakage and bond strength. Journal of
Prosthetic Dentistry, 41:51-57.
O w ens, B. M., H alter, T. K. and Brown, D. M. (1998) M icroleakage of tooth-
c o lo re d re s to ra tio n s w ith a b e v e le d g in g iv a l m a rg in . Quintessence
International, 29:356-361.
Pashley, D. H. and Carvalho, R. M. (1997) D entine perm eability an d d entine
adhesion. Journal of Dentistry, 25:355-372.
Pashley, D. H., Ciucchi, B., Sano, H. and H om er, J. A. (1993) Perm eability of
dentine to adhesive agents. Quintessence International, 249:618-631.
Pashley, D. H., Depew , D. D. and Galloway, S. E. (1989) M icroleakage channels:
SEM observation. Operative Dentistry, 14:68-72.
Pashley, D. H., Kepler, E., William, S. E. L. and Okabe, A. (1983) P rogressive
decrease in dentin perm eability following cavity preparation. Archives o f Oral
Biology, 28:853-858.
Pashley, D. H., Livingston, M. J. and Greenhill, J. D. (1978) Regional resistances to
fluid flow in hu m an dentine in vitro. Archives o f Oral Biology, 23:807-810.
P eutzfeldt, A. (1997) Resin com posites in dentistry: the m onom er system s.
European Journal of Oral Science, 105:97-116.
P eutzfeldt, A. and A sm ussen, E. (1991) Influence of carboxylic an h y d rid es on
selected m echanical p roperties of heat cured resin com posites. Journal o f
Dental Research, 70:1537-1541.
P eutzfeldt, A. an d A sm ussen, E. (1992a) Influence of ald eh y d es on selected
m ech an ical p ro p e rtie s of resin com posites. Journal o f D ental Research,
71:1522-1524.
P eu tzfeld t, A. an d A sm ussen, E. (1992b) Influence of ketones on selected
m ech an ical p ro p e rtie s of resin com posites. Journal o f D ental Research,
71:1847-1850.
Peyton, F. A. and Arbor, A. (1955) Evaluation of dental handpieces for high
speed operations. Journal of the American Dental Association, 50:383-391.

152
Phair, C. B. and Fuller, J. L. (1985) M icroleakage of com posite resin restorations
w ith cem entum m argins. Journal o f Prosthetic Dentistry, 53:361-364.
P hillip s, R. W., G ilm ore, H. W., Sw artz, M. L. an d Schenker, S. I. (1961)
A d ap tatio n of in vivo restorations as assessed by Ca45. Journal o f the American
Dental Association, 62:9-20.
Pick, R. M. (1993) U sing lasers in clinical dental practice. Journal o f the American
Dental Association, 124:37-47.
Pickard, H. M. an d G ayford, J. J. (1965) Leakage at the m argins of am algam .
British Dental Journal, 119:69-77.
Piesco, N. P. (1994) H istology of dentine. In Oral Development and histology, (Ed,
J.K., A.) Thiem e M edical Publishers, Inc., pp. 242-260.
P in tad o , M. R. an d D ouglas, W. H. (1988) The com parison of m icroleakage
b e tw e e n tw o d iffe re n t d e n tin e d o n d in g re sin sy stem s. Quintessence
International, 19:905-907.
Pow is, D. R., Prosser, H. J., Shortall, A. C. and W ilson, A. D. (1988) Long term
m o n itoring of m icroleakage of com posites. Part I: Radiochem ical diffusion
technique. Journal o f Prosthetic Dentistry, 60:304-307.
P rati, C., M ongiorgi, R., Pareschi, A., G alloni, C. an d F errieri, P. (1993)
C orrelation betw een bond strength of bonding agents and d en tin conditions.
Journal of Dental Research, 72:386 (abstract 2266).
Prevost, A. P., Fuller, J. L. and Peterson, L. C. (1984) Com posite and interm ediate
resin tag form ation in acid-etched enamel: A scanning electron m icroscopy
evaluation. Journal of Prosthetic Dentistry, 52:204-207.
Q u arn stro m , F. and Libed, E. N. (1994) Electronic anesthesia versus topical
an esth esia for the control of injection pain. Q u in tessen ce In tern a tio n a l,
25:713-716.
Q vist, V. (1983) The effect of m astication on m arginal ad ap tatio n of com posite
restorations in vivo . Journal of Dental Research, 62:904-906.
Qvist, V. (1985) M arginal adaptation in vivo w ith different acid-etch restorative
procedures. Scandinavian Journal of Dental Research, 93:68-75.
Rankin, J. A. and Harris, M. B. (1984) Dental anxiety: the patient's point of view.
Journal of the American Dental Association, 109:43-47.
Reid, J. S., Saunders, W. P. and Chen, Y. Y. (1991) The effect of bonding agent and
fissure sealant on m icroleakage of com posite resin restorations. Quintessence
International, 4:295-298.

153
Retief, D. H., M andras, R. S., Russell, C. M. and Denys, F. R. (1992) P hosphoric
acid as a den tin etchant. American Journal o f Dentistry, 5:24-28.
Retief, D. H., W oods, E. and Jam ieson, H. C. (1982) The effect of cavosurface
treatm ent on m arginal leakage in ClassV com posite resin restorations. Journal
o f Prosthetic Dentistry, 47:496-501.
Rigsby, D. F., Retief, D. H., Bidez, M. W. and Russell, C. M. (1992) Effect of axial
load an d tem perature cycling on m icroleakage of resin restorations. American
Journal of Dentistry, 5:155-159.
Rigsby, D. F., Retief, D. H., Russell, C. M. and Denys, F. R. (1990) M arginal
leakage an d m arginal gap dim ensions of three dentinal b o n d in g system s.
American Journal of Dentistry, 3:289-294.
Roulet, J. F. (1988) The problem s associated w ith substituting com posite resins
for am algam : a status rep o rt on posterior com posites. Journal o f D entistry,
16:101-113.
Roydhouse, R. H. (1968) Penetration aound the m argins of restorations. 2. N ature
and significance. Journal of the Canadian Dental Association, 34:21-28.
Rueggeberg, F. A. and M argeson, D. H. (1990) The effect of oxygen inhibition on
an u n filled /filled com posite system. Journal of Dental Research, 69:1652-1658.
Ruse, N. D. an d Sm ith, D. C. (1991) A dhesion to bovine d e n tin e —surface
characteristics. Journal of Dental Research, 70:1002-1008.
R uyter, I. E. (1985) M onom er system s and polym erization. In In tern a tio n a l
symposiu?n on Posterior Composite Resin Dental Restorative M aterials., (Eds,
V anherle, G. and Smith, D. C.) Peter Szulc, Utrecht, pp. 109-135.
Sano, H., Shono, T., Takatsu, T. and Hosoda, H. (1994) M icroporous dentin zone
beneath resin-im pregnated layer. Operative Dentistry, 19:59-64.
S au n d ers, W. P. an d M u irh ead , J. M. (1992) M icroleakage of com posite
restorations w ith Syntac Bond and Denthesive. American Journal o f Dentistry,
5:255-257.
Saunders, W. P. and Saunders, E. M. (1996) M icroleakage of bonding agents w ith
w et and dry bonding techniques. American Journal of Dentistry, 9:34-36.
S au n d ers, W. P., Strang, R. and A hm ad, I. (1990) Effect of com posite resin
p lacem ent an d use of an unfilled resin on the m icroleakage of tw o d en tin
bonding agents. American Journal of Dentistry, 3:153-156.

154
Saunders, W. P., Strang, R. and A hm ad, I. (1991) Effect of M irage Bond prim er on
m icroleakage of resin com posite restorations. American Journal o f D entistry,
4:211-213.
Shen, C. an d Sarrett, D. (1992) Effect of cavity design on the m icroleakage of
com posite resins. Journal of Dental Research, 71:209 (abstr 826).
Shoben, E. J. and Borland, L. (1954) An em pirical study of the etiology of dental
fears. Journal of Clinical Psychology, 10:171-174.
Shortall, A. C., Powis, D. R., Prosser, H. J. and Wilson, A. D. (1985) Q uantitative
in vitro assessm en t of m arg in al leakage an d cavity w all a d a p ta tio n of
com posite resin restorative m aterials. Journal o f Dental Research, 64:663 (abstr
661).
Sidhu, S. K. (1994) M arginal contraction gap form ation of lig h t-cu red glass
ionom ers. American Journal of Dentistry, 7:115-118.
S idhu, S. K., Soh, G. an d H enderson, L. J. (1991) Effect of d e n tin age on
effectiveness of dentin bonding agents. Operative Dentistry, 16:218-222.
Soames, J. V. and Southam , J. C. (1993) D ental Caries. In Oral Pathology, Vol. 2
O xford U niversity Press, Oxford, pp. 19-33.
S oderholm , K. J. M. (1985) Filler system s and resin interface. In International
sym posium on Posterior Composite Resin Dental Restorative M aterials, (Eds,
Vanherle, G. and Smith, D. C.) Peter Szulc, Utrecht, pp. 139-159.
Soetopo, Beech, D. R. and H ardw ick, J. L. (1978) M echanism of ad h esio n of
polym ers to acid-etched enamel: effect of acid concentration and w ashing on
bond strength. Journal of Rehabilitation, 5:69-80.
Sorem ark, R. and Bergman, B. (1961) Studies on the perm eability of acrylic facing
m aterial in gold crow ns. A lab o rato ry in v estig atio n u sin g N a 22. A c ta
Odontologica Scandinavia, 19:267-305.
Spanberg, L. S., Acierno, T. G. and Yonbum Cha, B. (1989) Influence of entrapped
air on the accuracy of leakage studies using dye penetration m ethods. Journal
of Endodontics, 1511:548-551.
Stanley, H. R. an d Sw erdlow , H. (1959) Reaction of the h u m an p u lp to cavity
p re p a ra tio n : re su lts p ro d u c e d by eig h t d ifferen t o p e ra tiv e g rin d in g
techniques. Journal of the American Dental Association, 58:49-59.
Stephens, R. R. (1986) The den tal handpiece - a history of its developm ent.
Australian Dental Journal, 31:165-180.

155
Stern, R. H. (1972) Laser inhibition of dental caries suggested by first tests in vivo.
Journal o f the American Dental Association, 85:1087-1090.
Stern, R. H., Renger, H. L. and Howell, F. V. (1969) Laser effects on vital dental
pulps. British Dental Journal, 148:26-28.
Stern, R. H. an d Soggnaes, R. F. (1964) Laser beam effect on dental h ard tissues.
Journal o f Dental Research, 43:873 (abstr 307).
Stern, R. H., Vahl, J. and Sognnaes, R. F. (1972) Lased enam el: U ltrastru ctu ral
observations of p u lsed carbon dioxide laser effects. Journal o f Dental Research,
51:455-460.
Stew art, G. P., Baida, B. A. and N orm an, R. D. (1986) The effects of m echanical
lo ad in g on m arg in al integ rity of com posite restorations. D ental M aterials,
2:151-152.
Stuever, C. H., Goldberg, A. F. and Gross, R. L. (1971) The effect of p u lp al tissues
on m icroleakage around dental restorations. Oral Surgery, 314:568-570.
Sw artz, M. L. and Phillips, R. W. (1961) In vitro studies on the m arginal leakage of
restorative m aterials. Journal of the American Dental Association, 62:14-25.
Swift, E. J. and Cloe, B. C. (1993) Shear bond strengths of new enam el etchants.
American Journal of Dentistry, 6:162-164.
Sw ift, E. J. an d H ansen, S. E. (1989) Effect of new b o n d in g sy stem s on
microleakage. American Journal of Dentistry, 2:77-80.
Swift, E. J. and Triolo, P. T. (1992) Bond strengths of Scotchbond M ulti-Purpose to
m oist enam el and dentine. American Journal o f Dentistry, 5:318-320.
Swift, E. J., Triolo, P. T., Barkmeier, W. W., Bird, J. L. and Bounds, S. J. (1996)
Effect of low -viscosity resins on the perform ance of d en tal adhesives.
American Journal of Dentistry, 9:100-104.
Taira, M., U rabe, H., Hirose, T., W akasa, K. and Yamaki, M. (1988) A nalysis of
photoinitiators in visible light cured dental com posite resins. Journal o f Dental
Research, 67:24-28.
Tanji, E. Y., M atsum oto, K. and Eduardo, C. P. (1997) Study of d en tin surface
conditioning w ith Er:YAG laser. Journal of Dental Research, 76:987 (abstr 213).
Tay, F. R., G w innett, A. J. and Wei, S. H. Y. (1996) The overw et phenom enon: A n
o p tical, m ic ro m o rp h o lo g ic al stu d y of surface m o istu re in th e acid-
conditioned, resin-dentin interface. American Journal o f Dentistry, 9:43-48.

156
Tay, F. R., Pang, K. M., G w innett, A. J. and Wei, S. H. Y. (1995) A m ethod for
m icroleakage ev alu atio n along the d e n tin /re s to ra tiv e interface. American
Journal of Dentistry, 8:105-108.
Taylor, M. J. and Lynch, E. (1992) M icroleakage. Journal o f Dentistry, 20:3-10.
Taylor, R., Shklar, G. and Roeber, B. S. (1965) The effects of laser rad iatio n on
teeth, d en tal p u lp, and oral m ucosa of experim ental anim als. Oral Surgery,
Oral Medicine and Oral Pathology, 19:786-795.
T odd, J. E. and Lader, D. (1991a) Barriers to dental care. In A d u lt dental health
1988. United Kingdom, HMSO, London, pp. 217-234.
T odd, J. E. an d Lader, D. (1991b) D ental a tte n d a n c e patterns. In A d u lt dental
health 1988. United Kingdom, HMSO, London, pp. 203-216.
T odd, J. E. and Lader, D. (1991c) Lifetime treatm ent experience. In A d u lt dental
health 1988. United Kingdom, HMSO, London, pp. 187-193.
T ortenson, B. and Brannstrom , M. (1988) Contraction gap u n d er com posite resin
restorations: effect of hygroscopic expansion and therm al stress. O perative
Dentistry, 13:24-31.
T row bridge, H. O. (1981) Pathogenesis of pulpitis resulting from dental caries.
Journal o f Endodontics, 7:52-60.
Tsuchiya, T., Zidan, O. and Gom ez-M arin, O. (1986) M arginal gaps in ClassV
cavities: C om parative stu d y of dentinal b o n d in g agents an d application
techniques. Journal of Dental Research, 65:765 (abstr 353).
Tziafas, D. (1998) Patho-biology of the dental pulp. In Reparative Dentinogenesis:
A monograph on the dentinogenic potential o f pulp, U niversity Studio Press,
Thessaloniki, pp. 11-55.
Uno, S. an d A sm ussen, E. (1991) M arginal ad ap tatio n of a restorative resin
p o ly m erised at a red u ced rate. Scandinavian Journal o f D ental Research,
99:440-444.
U no, S., Finger, W. J. and Fritz, U. B. (1997) Effect of cavity d esig n on
m icroleakage of resin-m odified glass ionom er restorations. American Journal of
Dentistry, 10:32-35.
U nterbrink, G. L. and M uessner, R. (1995) Influence of light intensity on tw o
restorative systems. Journal of Dentistry, 23:183-189.
V an M eerbeek, B., P eum ans, M., V erschueren, M., G ladys, S., Braem , M.,
Lam brechts, P. and Vanherle, G. (1994) Clincal status of ten dentin adhesive
system s. Journal of Dental Research, 73:1690-1702.

157
V an M eerbeek, B., Willems, G., Celis, J. P., Roos, J. R., Braem, M., Lambrechts, P.
a n d et al. (1993) A ssessm ent by n an o -in d en tatio n of the h a rd n e ss and
elastic ity of the re sin -d e n tin b o n d in g aea. Journal o f D ental Research,
72:1434-1442.
V argas, M. A. and Swift, E. J. (1994) M icroleakage of resin com posites w ith w et
versus d ry bonding. American Journal o f Dentistry, 7:187-189.
V asudev, U. B., M oham m ed, H. and Shen, C. (1981) Real tim e q u an titatio n of
m icroleakage aro u n d dental restorations. Journal o f Dental Research, 60:521
(abstr 847).
Vichi, A., Ferrari, M. and D avidson, C. L. (1997) In vivo m icroleakage of resin
m o d ified glass ionom er cem ents. Journal o f Dental Research, 76:1146 (abstr
1412).
Visuri, S. R., W alsh, J. T. and W igdor, H. A. (1996) Erbium laser ablation of dental
h ard tissue: Effect of w ater cooling. Lasers in Surgery and Medicine, 18:294-300.
V iv a d e n t (1996) C o m p o g la ss p ro d u c t d o c u m e n ta tio n . R esearch a n d
D evelopm ent Scientific Service, Vivadent, Schaan, pp. 1-30.
W elbury, R. R. an d M urray, J. J. (1990) A clinical trial of the glass ionom er
cem ent-com posite resin 'sandw ich' technique in Class 2 cavities in perm anent
prem olar and m olar teeth. Quintessence International, 21:507-512.
W elk (1976) R ationale for designing cavity p rep aratio n s in light of cu rren t
know ledge and technology. In The Dental Clinics o f North America: Operative
D entistry, Vol. 20 (Ed, Collard, E. W.) W. B. Saunders Com pany, Philadelphia,
London, Toronto, pp. 231-239.
W endt, S. L., M clnnes, P. M. and D ickinson, G. L. (1992) The effect of
them ocycling in microleakage analysis. Dental Materials, 8:181-184.
W enner, K. K., Fairhurst, C. W., M orris, C. F., H aw kins, I. K. and Ringle, R. D.
(1988) M icroleakage of root restorations. Journal o f the Am erican Dental
Association, 117:825-828.
W igdor, H., Abt, E., Ashrafi, M. S. and W alsh, J. T. (1993) The effect of lasers on
dental h ard tissues. Journal of the American Dental Association, 124:65-70.
W ilder-Sm ith, P., N guyen, A., Lin, S. and Berns, M. W. (1997) Effects of cavity
p rep aratio n using a nanosecond-pulsed Nd-YAG laser on tooth -restoration
interface. Lasers in Medical Science, 12:11-19.

158
W illem s, G., Lam brechts, P., Braem, M., Celis, J. P. and V anherle, G. (1992) A
classification of d en tal com posites according to their m orphological an d
m echanical characteristics. Dental Materials, 8:310-319.
W illems, G., Lambrechts, P., Braem, M. and Vanherle, G. (1993) Com posite resins
in the 21st century. Quintessence International, 24:641-658.
W ilson, A. D. a n d M cLean, J. W. (1988) The setting reaction an d its clinical
consequences. In Glass-ionomer cements, Q uintessence P ublishing Co. Inc.,
Chicago, Illinois, pp. 43-54.
W ilson, N. H. F., Burke, F. J. and Mjor, I. A. (1997) Reasons for placem ent and
replacem ent of restorations of direct restorative m aterials by a selected group
of practitioners in the U nited Kingdom. Quintessence International, 28:245-248.
W right, G. Z., M cConnell, R. J. and Keller, U. (1993) M icroleakage of ClassV
com posite restorations prepared conventionally w ith those p rep ared w ith an
Er-YAG laser: pilot study. Paediatric Dentistry, 156:425-426.
Xu, H. H., Kelly, J. R., Jahanm ir, S., Thom pson, V. P. and Rekow, E. D. (1997)
Enam el subsurface dam age due to tooth preparation w ith diam onds. Journal
o f Dental Research, 76:1698-1706.
Yam am oto, H. an d Ooya, K. (1974) Potential of yttrium -alum inium -garnet laser
in caries prevention. Journal of Oral Pathology, 3:7-15.
Yam om oto, S. and Sato, K. (1980) Prevention of dental caries by Nd:YAG laser
irradiation. Journal o f Dental Research, 59:2171-2177.
Youngson, C. C., Glyn Jones, J. C., Smith, I. and Fox, K. (1998) In vivo tem perature
changes d u rin g a stan d ard ised therm al challenge. Journal o f Dental Research,
77:955 (abstr 2585).
Zach, L. an d C ohen, G. (1965) P ulp resp o n se to externally ap p lie d heat.
Endodontics, 19:515-530.
Zijp, J. R. and Ten Bosch, J. J. (1991) A ngular dependence of H eN e-laser light
scattering by bovine and hum an dentine. Archives o f Oral Biology, 36:283-289.

159