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Original Article

Efficiency of Self‑Adhering Flowable Resin Composite and Different

Surface Treatments in Composite Repair Using a Universal Adhesive
S Şişmanoğlu

Department of Restorative Aims: The aim of this in vitro investigation was to evaluate the efficiency

Abstract
Dentistry, Faculty of
Dentistry, Altınbaş
of self‑adhering flowable resin composite (Vertise Flow, Kerr, Orange,
University, Istanbul, Turkey CA, USA) and different surface treatments in the repair microtensile bond
strength (µTBS) of aged nanofill resin composites using a universal adhesive.
Materials and Methods: Aged substrates (×5000 thermocycling) were prepared
using a nanofill (Filtek Ultimate; 3M ESPE) resin composite and randomly
assigned to different surface treatments: (1) no treatment (control), (2) acid etching
with 37% phosphoric acid, (3) Al2O3 sandblasting, and (4) sandblasting with
CoJet (3M ESPE). After surface treatment, specimens were further divided into
two groups: no universal adhesive application and universal adhesive application.
Vertise Flow was added to the substrates at 2‑mm layer increments to a height of 5
mm and light cured. Restored specimens were sectioned to obtain 1.0‑mm2 beams
for µTBS testing. Data were analyzed with two‑way analysis of variance and
Tukey’s honest significant difference tests (P < 0.05). Results: The lowest µTBS
values were recorded in the control and acid etching groups with no universal
adhesive application (P < 0.05). Universal adhesive application significantly
increased the repair µTBS values of all surface treatments (P < 0.05), except
CoJet treatment. There were no significant differences between Al2O3 sandblasting,
Received: CoJet application, and acid etching groups with the universal adhesive
26-Apr-2019; application (P > 0.05). Conclusion Vertise Flow can be used effectively in the
Revision: repair of old nanofill resin composites. The usage of universal adhesive with prior
26-May-2019; acid etching to obtain acceptable repair performance would be the practical choice
Accepted: under clinical conditions.
07-Jun-2019;
Published: Keywords: Bond strength, composite repair, resin composites, sandblasting,
03-Dec-2019 universal adhesives

Introductıon restoration repair, which is a more conservative approach

C omposite restorations have been preferred more
than amalgam in posterior region due to their
aesthetic properties and elimination of mercury‑related
concerns.[1] Although great developments have been
achieved in the development of adhesive procedures and
resin composites, failures such as microleakage, wear,
fracture, discoloration, and secondary caries may occur
due to various reasons.[2] In such cases, total replacement
of the restoration may result in disadvantages such as
loss of sound dental substrates and risk of pulpal trauma.
For these reasons, it is recommended to give priority to
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rather than restoration renewal.[3,4] The success of the
repair process depends on the bond strength between the
old, defective, and the new repair composite. The bond
between the two composite layers is achieved by the
nonpolymerized oxygen inhibition layer.[5,6] However,
aging and water absorption lead to the removal of the
oxygen inhibition layer and the reduction of unsaturated
Address for correspondence: Dr. S Şişmanoğlu,
Department of Restorative Dentistry, Faculty of Dentistry, Altınbaş
University, Bakırköy, TR‑34147 Istanbul, Turkey.
E‑mail: soner.s@hotmail.com
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as
appropriate credit is given and the new creations are licensed under the identical
terms.

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DOI: 10.4103/njcp.njcp_233_19

How to cite this article: Şişmanoğlu S. Efficiency of self-adhering flowable

PMID: ******* resin composite and different surface treatments in composite repair using
a universal adhesive. Niger J Clin Pract 2019;22:1675-9.

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Şişmanoğlu: Efficiency of self‑adhering flowable resin composite in composite repair
double carbon–carbon bonds, thus causing reduction in
microtensile bond strength (µTBS) between defective
and repair resin composites when repair is required.[7,8]
Various surface treatments including macromechanical,
micromechanical, and chemical are applied to the
restoration surface to be repaired, to improve µTBS
values.[9,10] Roughing of the defective composite by
methods such as bur abrasion, acid etching, laser
irradiation, and air abrasion increases mechanical
bonding, while application of agents to the defective
composite such as adhesive resin and silane
contributes to chemical bonding. Tribochemical
coating (silica‑coated silane sandblasting) is also used
to increase both mechanical and chemical bonding.[11‑13]
However, there is still no consensus on the most efficient
composite repair protocol.[14] Among all these surface
treatments, adhesive resin application to the bur‑abraded
old resin composite surfaces is the most commonly used
method in clinical conditions. It has been reported that
roughening the defective composite with diamond burs
enhances the surface energy by removal of the superficial
layer, thus increasing the mechanical retention of the
repair material.[15,16]
Recently, self‑adhering, flowable resin composites are
gaining popularity with simplified application technique.
With their simplified application, self‑adhering flowable
resin composites could be used in the repair of defective
direct composite restorations. Therefore, the aim of this
in vitro study was to evaluate efficiency of self‑adhering
flowable resin composite in the repair µTBS of
defective nanofill resin composite using different
surface treatments. The null hypotheses were as follows:
(1) there would be no differences between the surface
treatments and (2) surface treatment would not increase
the µTBS values.
Materials and Methods
Ninety‑six specimens were fabricated for this study.
Nanofill restoration material (Filtek Ultimate A3.5; 3M
ESPE, St. Paul, MN, USA) was loaded into a Teflon
mold (5‑mm cubiform) incrementally (2 mm maximum
thickness) and a polyethylene strip was used by covering
the top layer to obtain smooth surface. The resin
composite specimens were light‑cured for 20 s using
an LED curing light (Elipar DeepCure; 1750 mW/cm2;
3M ESPE), and the light intensity was controlled before
each curing operation. After removal from the mold,
the samples were further polymerized for 20 s on all
surfaces. All samples were kept in distilled water at 37°C
for 24 h. Next, the polymerized samples were immersed
in a water bath and aged by thermocycling (5000 cycles,
5°C and 55°C with a dwell time of 30 s). The upper
1676 Nigerian Journal of Clinical Practice ¦ Volume 22 ¦ Issue 12 ¦ December 2019
surfaces of the aged resin composites were wet‑ground
flat with 320‑grit silicon carbide paper[2] and randomly
divided into five groups in accordance with the surface
treatments:
Group 1: no treatment (as a control, n = 24).
Group 2: resin composite surfaces were etched for
20 s with 37% phosphoric acid (Scotchbond Etchant;
3M ESPE) and rinsed (n = 24).
Group 3: sandblasting was applied using a
sandblaster (Basic quattro IS; Renfert GmbH,
Hilzingen, Germany) from a 10‑mm distance at
2.5 bar pressure, and 50 µm Al2O3 particles (Cobra;
Renfert GmbH) were used (n = 24).
Group 4: silica‑coated sand particles (CoJet Sand;
30 µm; 3M ESPE, Seefeld, Germany) were used
to treat resin composite surfaces using the same
sandblaster as described in Group 3 (n = 24).
After the completion of surface treatment procedures,
the specimens were randomly divided into two
subgroups according to the adhesive application:
no universal adhesive application and universal
adhesive (Single Bond Universal; 3M ESPE)
application in accordance with the manufacturer’s
recommendations [Table 1]. A self‑adhering flowable
resin composite material (Vertise Flow; Kerr Dental,
Italy) was applied as 2‑mm‑thick increments as a
repair and light‑cured for 20 s using the same curing
device. Polymerized resin samples were stored at 37°C
for 24 h in distilled water. The repaired specimens
were sectioned across the adhesive interfaces using
a precision sawing machine (Isomet; Buechler, Lake
Bluff, IL, USA) to acquire 1‑mm2 sticks. The resin–resin
sticks in the peripherals of the specimens were not
included in µTBS testing. Then, the sticks were fixed to
a jig with cyanoacrylate for µTBS testing (Microtensile
Tester; Bisco Inc., Schaumburg, IL, USA). The tensile
load was performed until failure at a crosshead speed
of 0.5 mm/min and recorded in megapascal. Failure
modes were examined with a stereomicroscope at
30× magnification. The failure modes were categorized
as adhesive failure, cohesive failure, or mixed failure.
Statistical analysis
The data were analyzed using a two‑way analysis of
variance (ANOVA), to determine the effects of surface
treatments and universal adhesive application on the
repair µTBS values. Post hoc analyses were done using
Tukey’s honest significant difference, and α = 0.05 was
considered as statistically significant threshold.
Results
Microtensile repair bond strength values of the repaired
specimens are given in Table 2. The two‑way ANOVA
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Şişmanoğlu: Efficiency of self‑adhering flowable resin composite in composite repair

Table 1: Composition, pH, and application strategy of the universal adhesive used
Material Type Composition
Filtek Ultimate, Body Nanofill Bis‑EMA, Bis‑GMA, UDMA, TEGDMA, PEGDMA, silica, zirconia filler, zirconia/silica cluster
A3.5 (3M ESPE, St. Paul, composite filler
MN, USA)
pH Composition Application
Vertise Flow (Kerr, 1.9 GPDM, HEMA, prepolymerized Dispense a thin layer (<0.5 mm) on a forcefully dried surface;
Orange, CA, USA) filler, nano‑sized ytterbium use a provided applicator with a brushing motion for 15-20 s;
#5045000 fluoride, 1‑µm barium glass filler, light cure for 20 s; syringe additional material in increments of
nano‑sized colloidal silica less than 2 mm and light cure each increment for 20 s
Single Bond 2.7 2‑HEMA, 10‑MDP, 1. Apply the adhesive or adhesive mixture to the prepared tooth
Universal (3M ESPE) dimethacrylate resins, and rub in for 20 s
#494756 Vitrebond™ copolymer, silane, 2. Gently air‑dry the adhesive for 5 s for the solvent to
filler, ethanol, water, initiators evaporate
3. Light cure for 10 s
Bis‑EMA, ethoxylated bisphenol‑A dimethacrylate; Bis‑GMA, bisphenol A glycidyl methacrylate; UDMA, urethane dimethacrylate; TEGDMA,
triethylene glycol dimethacrylate; PEGDMA: poly (ethylene glycol) dimethacrylate; GPDM, glycerol phosphate dimethacrylate; 2‑HEMA,
2‑hydroxyethyl methacrylate; 10‑MDP, 10‑methacryloyloxydecyl dihydrogen phosphate

Table 2: Mean and standard deviation microtensile bond

strength (MPa) values
Surface treatment Adhesive application
No adhesive Single Bond Universal
No treatment (control) 6.54±1.88a,A 9.69±1.36a,B
Al2O3 sandblasting 10.28±1.87 b,A
14.34±2.32b,B
CoJet application 12.10±2.02 c,A
13.33±2.51b,A
Acid etching 7.26±1.66a,A
12.16±2.17b,B
Two‑way ANOVA
Surface treatment P<0.001
Adhesive application P<0.001
Interaction P<0.001
ANOVA: analysis of variance. Same lower case letters imply no
significant difference between the surface treatments, while same
upper case letters imply no significant difference between the adhesive Figure 1: Failure mode distribution
applications according to pairwise comparisons (P>0.05)
Two‑way ANOVA results indicated that universal
exhibited significant differences between the study adhesive application and surface treatment–type
groups (P < 0.05). The lowest µTBS values were significantly influenced the repair µTBS values
recorded in the no surface treatment (6.54 ± 1.88) and (P < 0.001). Also, an interaction was detected among
acid etching (7.26 ± 1.66) groups with no universal these two factors (P < 0.001). The findings of the
adhesive application (P < 0.05). No significant failure mode observations are presented in Figure 1. The
difference was detected between no surface treatment universal adhesive application reduced adhesive failure
and acid etching groups with no universal adhesive rates and increased the mixed and cohesive failure rates.
application (P > 0.05). On the other hand, the
highest µTBS values were recorded in the CoJet Discussion
application (12.10 ± 2.02; P < 0.05), followed by Al2O3 This study aims to evaluate the efficiency of
sandblasting (10.28 ± 1.87). self‑adhering flowable resin composite in the repair
µTBS of defective nanofill resin composite using
Universal adhesive application significantly increased the
universal adhesive application and different surface
repair µTBS values of all surface treatments (P < 0.05),
treatments. In this in vitro study, universal adhesive
except CoJet. In addition, there were no significant
application and surface treatments increased the repair
differences between Al2O3 sandblasting, CoJet
µTBS values significantly. Therefore, both hypotheses
application, and acid etching groups with universal
were rejected.
adhesive application (P > 0.05). Lowest repair µTBS
values were exhibited by no surface treatment (control) The absence of an oxygen inhibition layer is a
group (P < 0.05). problem in the repair of defective, old resin composite

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Şişmanoğlu: Efficiency of self‑adhering flowable resin composite in composite repair
restorations. To solve this problem, it is tried to
increase the mechanical retention by roughening the
old composite surface.[17] Many methods such as laser
irradiation, Al2O3 blasting,[18‑20] CoJet application,[19]
acid etching with hydrofluoric acid,[21,22] or phosphoric
acid[18,21,22] have been investigated by the researchers.
However, no consensus has yet been reached on the
best surface treatment protocol. Clinicians often abrade
the old composite surface with a bur before repairing
resin composite restorations. Therefore, the surfaces of
aged composites were roughened using 320‑grit abrasive
paper, in this study.[2] The lowest repair µTBS values
were observed in the groups with no surface treatment.
Peterson et al.[19] observed the lowest repair µTBS
values in the no treatment group. They also found that
the etch‑and‑rinse adhesive application increases the
repair of Vertise Flow. These findings are in parallel
with the results of this study.
Silanes are often preferred in repair processes because
they act as a binding agent between the filler particles and
the organic matrix. It is also known that silanes increase
the wettability of the surface by modifying the surface
energy.[12] In this study, a silane‑containing universal
adhesive was used for adhesive applications. Studies
have reported that there was no significant difference
between the use of additional silane application and
silane‑containing universal adhesives.[23] In this study,
it was observed that the application of silane‑containing
universal adhesive significantly increased repair values
compared with the control group.
Fornazari et al.[23] examined the influence of surface
treatments and universal adhesive on the repair
microshear bond strength (µSBS) values. Similarly, in
this study, Al2O3 sandblasting and universal adhesive
application have been found to increase repair µSBS
values. On the other hand, they found that there was
no significant difference between the universal adhesive
application and Al2O3 sandblasting. Their findings
coincided with this study. According to the two‑way
ANOVA, there was no significant difference between
repair µTBS values of Al2O3 sandblasting (10.28 ± 1.87)
and universal adhesive application (9.69 ± 1.36). In
another study, Atalay et al.[18] reported that Al2O3
sandblasting increased the repair µTBS more than
etching with phosphoric acid prior to universal
adhesive application. In this study, no significant
difference was found between surface treatments (Al2O3
sandblasting, CoJet application, and acid etching)
prior to universal adhesive application. Vertise Flow
contains glycerol phosphate dimethacrylate (GPDM)
monomers. GPDM features a high hydrophilicity that
results in a strong etching effect and a superior dentin
1678 Nigerian Journal of Clinical Practice ¦ Volume 22 ¦ Issue 12 ¦ December 2019
wettability compared with other monomers.[24] Thus, the
self‑adhering, flowable composites possibly were able to
wet the roughened resin composite surface better than
conventional resin composites. Therefore, differences in
composition between repair materials may be the reason
of differences between two studies. On the other hand,
it was reported that 10‑methacryloyloxydecyl dihydrogen
phosphate (10‑MDP) monomers can chemically interact
with zirconia.[25] Considering the presence of the
zirconium filler in the Filtek Ultimate resin composite
material, another reason for the universal adhesive
application to improve the repair µTBS values may be
that it contains 10‑MDP monomer. When universal
adhesives are applied, the inability of the surface
treatments to make a significant difference on the repair
µTBS values may also be attributed to 10‑MDP monomer
in the composition of the universal adhesive used.
The application of phosphoric acid increases the surface
area by creating alterations on the resin composite
surface and reveals the composite surface under
the superficial layer.[26] However, Loomans et al.[22]
investigated the effect of various acid etching methods
on repair bond strength and reported that phosphoric
acid alone did not result in a significant increase in
repair bond strength. Similarly, the findings of our study
showed that phosphoric acid application alone did not
increase the repair µTBS values compared with the
control group. The universal adhesive, which is applied
after phosphoric acid etching, exhibited higher repair
µTBS values than the universal adhesive application
alone. In a different study, it has been reported that acid
etching prior to universal adhesive application does not
increase repair µTBS.[18] This difference may be related
to the use of self‑adhering flowable resin composite as
repair material in this study.
Conclusion
According to the result obtained, it can be concluded that
self‑adhering, flowable resin composite material can be
used effectively in the repair of old nanofill resin composite
restorations. Besides, it can also be estimated that additional
surface treatments are required to increase repair µTBS.
CoJet application and Al2O3 sandblasting surface treatments
with no universal adhesive application enhanced the repair
µTBS values. A significant improvement in repair µTBS
was observed with the application of universal adhesive
to bur‑abraded old composite surface. However, there
was no significant difference between Al2O3 sandblasting,
CoJet application, and acid etching after universal adhesive
application. Therefore, the findings of this in vitro study
suggest the usage of universal adhesive with prior acid
etching to obtain acceptable repair performance under
clinical conditions.
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Şişmanoğlu: Efficiency of self‑adhering flowable resin composite in composite repair
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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