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Effect of Bleaching on Marginal Adaptation of

Class V Bonded Composite Restoration

Safa H A Elhakeem

a

, Hisham A Mohamed

b

, Abeer S Farag

c

a Master student in Operative Dentistry Faculty of Dentistry Minia University

bProfessor of Operative Dentistry Faculty of Dentistry Ain Shams University

cLecturer of Operative Dentistry Faculty of Dentistry Minia University

Abstract

Objectives:This investigation was carried to determine the effect of in-

office and home bleaching applied before or after restorative procedures

on the marginal adaptation of class v bonded composite restorations

utilizing different adhesive systems; self etch and total etch.

Methods: One hundred extracted sound human anterior teeth were

divided into two groups of fifty teeth each according to the type of

adhesive used; total etch ( Excite PF) or self etch (AdheSE). Each group

was further subdivided into five subgroups of 10 teeth each; B0 not

received any bleaching treatment only cavity preparation and restoration

(control), B1 received in-office bleaching ( 38% H2O2 opalescence

Boost) one week before cavity preparation and restoration, B2 received

in-office bleaching one month after cavity preparation and composite

resin restoration, B3 received home bleaching (35% carbamide peroxide,

opalescence PF) one week before cavity preparation and restoration, B4

received home bleaching one month after cavity preparation and

composite resin restoration. Class V cavity were prepared in the labial

surface of all teeth. Teeth were restored with nano hybrid composite

(Tetric Evo-Ceram) and thermocycled for 1000 cycles at 5-55C. Dye

penetration test were done using ammonical silver nitrate. Teeth were

sectioned and examined by scanning electron microscope. EDAX


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microanalysis was done and the average concentrations of silver ions at

the tooth restoration interface were recorded

Results: There were statistical significant differences in silver uptake

between total etch and self etch bonded composite restorations in the

control subgroups B0 (P 0.001) and in pre restorative home bleaching

B3 subgroups (P 0.01). Home bleaching with total etch bonded

composite restorations B3 & B4 showed a statistically significant

(P0.05) lower silver uptake than other subgroups. There were statistical

significant differences (P 0.05) between pre and post-restoration home

or in-office bleaching with both adhesives except for in-office bleaching

with total etch bonded composite restorations.

Conclusion:pre and post-restoration Home bleaching doesn't adversely

affect the adaptation of nano-hybrid composite bonded with total etch or

self etch adhesive. Marginal adaptation of nano-hybrid composite to

home bleached teeth is superior to that of in-office bleaching using total

etch adhesive. Pre and Post-restoration in-office bleaching adverselyaffect the adaptation of nano-hybrid composite bonded with total etch but

it didn't adverse the adaptation of composite restorations bonded with self

etch adhesive.

Introduction

Teeth-whitening or bleaching systems have caused much interest and

controversy in the area of restorative dentistry (Crim et al., in 1992).Bleaching techniques may be classified by whether they involve vital or

non-vital teeth or by whether the procedure is performed in-office or at-

home (polydorou et al., 2007).

Nowadays tooth bleaching is based upon hydrogen peroxides as the

active agent which may be applieddirectly, or produced in a chemical

reaction from sodium perborate or carbamide peroxide. Several studieshave shown changes in enamel structure, composition, and bond strength


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when exposed to 35% hydrogen peroxide for in-office vital bleaching

(McGuckin et al., 1992; Loppes etal., 2002; Dahi and Pallesen, 2003; Lee

et al., 2006).

Bonding of resin based composite to tooth structure can be accomplished

by means of etch-and-rinse adhesive systems. The etch-and-rinse

approach has been considered techniquesensitive. In an attempt to

reduce technique-sensitivity, a second approach was developed, in which

self-etching primers were applied without further rinsing, and followed

by application of a solvent-free hydrophobic adhesive layer. Recently, a

more userfriendly one step self-etching\self-priming technique was

introduced (Reis et al., 2007).Comparison of etch-and-rinse and self-etch

systems in terms of microleakage has been well documented. However,

little information is available in the literature regarding the influence of

bleaching agents on the microleakage of these adhesive systems (Deliperi

et al., 2006; Moule et al., 2007; Yazici et al., 2010).

A scanning electron microscopic study of the adhesion of a light-cured resin to bleached enamel has indicated that there is an alteration of

resin quality following exposure to hydrogen peroxide (Crim et al., in

1992). Some authors reported reduced bond to human dentin and

suggested a one week delay of the bonding procedure after bleaching

(Uysal et al., 2003). Other researchers suggested 3weeks gap between

bleaching and bonding procedures (Cavalli et al.,2001).Literature showed that the bleaching agent can contain products that are

able to promote degradation of the adhesive interface, which may affect

the adaptation and reduce the longevity of the restoration (Sartori et al.,

2009). That is why practitioners suggest the use of a bleaching agent

before restorative treatment involving the use of composite resin

restorations, porcelain crowns or veneers. In cases where such

restorations are in place prior to bleaching, the restoration may need to be


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replaced to match the shade of the whitened tooth structure. In either

situation, the restoration would be placed in tooth structure that had been

exposed to prolonged bleaching (Crim et al., in 1992) which may affect

the adaptation of restoration to cavity wall. A few studies have evaluated

the effect of bleaching on microleakage of restorations, and little is

known about the bleaching effect prior to restoration placement on

microleakage (Yazici et al., 2010)

This investigation was carried to determine the effect of in office and

home bleaching applied before or after restorative procedures on the

marginal adaptation of class v bonded composite restorations utilizing

different adhesive systems; self etch and total etch.

Methods

1- Selection of teeth:

A total of 100 extracted sound human anterior teeth were used in the

study. Teeth were cleaned, polished with NUPRO Prophylaxis Paste

(DentSply,

Caulk), examined carefully using magnifying lens to exclude

any cracked tooth and stored in distilled water till use.

2-Grouping of teeth

The selected teeth were divided into two groups of fifty teeth each

according to the type of adhesive used; total etch or self etch. Each group

was further subdivided into five subgroups of 10 teeth each. The first

subgroup (B0) not received any bleaching treatment only cavitypreparation and restoration (control). The second subgroup (B1) received

in-office bleaching one week before cavity preparation and restoration.

The third subgroup (B2) received in-office bleaching one month after

cavity preparation and composite resin restoration. The fourth subgroup

(B3) received home bleaching one week before cavity preparation and

restoration. Then the fifth subgroup (B4) received home bleaching onemonth after cavity preparation and composite resin restoration.


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3-Cavity preparation and restoration:

3.1- Cavity preparation

Standardized uniform kidney shaped class V cavities were prepared in the

gingival third of the labial surface of each tooth. The cavity dimensions

were; 3.0 mm mesio-distal, 2.0 mm inciso-gingival, and 1.5 mm cavity

depth. The dimensions of the cavities were kept identical by using a

composite replica made for one cavity then the same dimensions were

duplicated in other cavities. Cavities were cut using #009 fissure diamond

burs (Komet. Germany) in a high speed air water cooled hand piece.

3.2. Restoration

Fifty cavities were restored using a total etch adhesive and nanohybrid

composite resin while the other fifty were restored using a self etch

adhesive and same composite. All restorative procedures were done

according to the manufacture instructions. In the total etch group, 37%

phosphoric acid gel (Ivoclar Vivadent, Schaan, Liechtenstein) was

applied for 30 seconds on the enamel and 15 seconds on the dentin. The

etching gel was removed with water spray for 5 seconds then excess

water was plotted with cotton pellets. The adhesive ExiTE F (Ivoclar

Vivadent, Schaan, Liechtenstein) was applied into the cavity and light

cured for 10 seconds using light emitting diode LED with spectrum

ranged from 380 to 515 nm (blue phase C8, Ivoclar Vivadent, Schaan,

Liechtenstein). In the self etch group the AdheSE primer(Ivoclar

Vivadent, Schaan, Liechtenstein) was applied and brushed into the entire

surfaces of the cavity left for 30 seconds. Then AdheSE bond was applied

to entire surfaces of the cavity and light cured for 10 seconds. Tetric

EvoCeram composite shade A3 (Ivoclar Vivadent, Schaan, Liechtenstein)

was inserted into the cavity in two increments; first increment applied to


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the entire incisal wall down to pulpogingival line angle then cured for 40

seconds. The second increment was packed to the remainder of the cavity

then cured for 40 seconds under pressure of Myler strip. Finishing and

polishing were accomplished using sequential Soflex disc (3M ESPE,

USA) from coarse to fine.

4-Bleaching procedure:

4.1.In-office bleaching:

The teeth of subgroups B1&B2 were mounted in a cast using an

impression compound. The bleaching procedures were done according to

the manufacture instructions. The in-office bleaching agent 38%

hydrogen peroxide, Opalescence boost (Ultradent Products, South Jordan,

Utah) was applied to the labial surface of the teeth, left for 20 minutes

and agitated every 5 minutes then teeth were rinsed with water and air

dried. The bleaching process was repeated three times.

4.2. Home bleaching:

Teeth of Subgroup B3 & B4 were mounted in specially fabricated plastictray to facilitate stabilization of teeth during bleaching. Half of the

bleaching syringe content (35% carbamide peroxide, opalescence PF,

Ultradent Products, South Jordan, Utah) was injected in the plastic tray,

then teeth were mounted in the tray. The application period was 30

minutes per day for 14 days. After each bleaching session teeth were

rinsed and stored in distilled water.5 Thermocycling

All specimens were exposed to a thermocycling regimen of 1000 cycles

between 5 c and 55 c, with a 30 seconds dwell time in water bath.

(Thermocycling device, Dep of Biomaterial, Alex University).

6- Microleakage assessment and evaluation:

6.1. Dye penetration and sectioning


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Two coats of nail varnish (Avon, USA) were applied to the entire

specimen surface except the restoration and 1mm all around the cavity

margins. Apical Foramens were sealed with sticky wax (Dentsply

DeTrey, Bois Colombes, France). A modified silver staining technique

(Tay et al., 2002) was used with basic 50wt% ammoniacal silver nitrate

(pH=9.5). The teeth were immersed into a freshly-prepared ammoniacal

silver nitrate solution and kept in black covered box for 24 hours. The

specimens were thoroughly rinsed with distilled water for 5 minutes and

placed in a photo developing solution (Kodak, Rochester, USA) for 8

hours under fluorescent light to reduce the diamine silver ions into

metallic silver grains. The teeth were then placed in distilled water for 5

minutes. The stained teeth were sectioned labio-lingual through the center

of the restoration using diamond disc in low speed hand piece with water

spray. The cut surfaces were finished, polished using sequential Soflex

disc (3M ESPE, USA) from coarse to fine and conditioned with

polyacrylic acid 10 %( 3M ESPE, USA) for 10 seconds.6.2 Examination of marginal adaptation:

The specimens were mounted on SEM scanning electron microscope

stubs (InspectTM

F50, FEI Company, USA) with the cut surface exposed

for examination at working distance 10.0mm and 30kv then images were

captured.

6.3. Energy dispersive X-ray microanalysis (EDAX):EDAX is an X-ray spectro-chemical technique which allows

determination of the local chemical composition of a solid sample by

means of an in situ, non-destructive analysis on a microscope scale. The

silver ions at the tooth restoration interface of the specimens were

identified using EDAX analysis supplied with the Scanning electron

Microscope (Genesis spectrum EDAX INC, USA). Randomly selected 3

spots at the tooth restoration interface of each specimen were analyzed at


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between both of them. While the other subgroups that bonded with self

etch adhesive system (B1, B2 & B4) showed less silver ions uptake.

Table (1): Descriptive statistics and test of significance for the effect of bleaching

agents on silver uptake within each adhesive system.

Bleaching

agent

Total etch Self etch

Mean SD dt Mean SD dt

B0

B1

B2

B3

B4

4.17 0.21 ab 5.49 0.07 a

4.42 0.44 a 4.62 0.88 ab

4.41 0.62 a 3.65 0.95 b

2.85 0.40 c 5.38 0.55 a

3.45 0.38 bc 4.27 0.54 ab

S.D.= Standard deviation.

Dt = Duncan's Multiple Range Test for the effect of bleaching agent.

Means with the same letter within each column are notsignificantly different at p=0.05.

B0 = No bleaching control group

B1 = In-office bleaching before cavity preparation and restoration.

B2 = In-office bleaching after cavity preparation and restoration.

B3 = Home bleaching before cavity preparation and restoration.

B4 = Home bleaching after cavity preparation and restoration

Table (2): Descriptive statistics and test of significance for the

effect of adhesive systems on silver uptake within each bleaching agent.

Bleaching

agent

Total etch Self etch P

Mean SD Mean SDB0

B1

B2

B3

B4

4.17 0.21 5.49 0.07 0.001***

4.42 0.44 4.62 0.88 0.75 NS

4.41 0.62 3.65 0.95 0.31 NS

2.85 0.40 5.38 0.55 0.003**

3.45 0.38 4.27 0.54 0.96 NS

S.D = Standard deviation. P = Probability level.

NS = Insignificant (p>0.05)

** = Significant at 0.01 ***= Significant at 0.001

Table 2 showed that in the control groups (B0) there was a highly

statistical significant difference (p0.001) between total etch and self etch

adhesive systems in silver uptake. Also, a statistical significant difference

(p0.01) was observed between total etch and self etch adhesive when

home bleaching were done before cavity preparation and restoration (B3).

No statistical significant difference was observed between total etch and

self etch adhesive systems whether in office bleaching were done before


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Nanohybride

composite

Silver

deposites

dentin

Silver

deposites

dentin

Nanohybride

composite

Nanohybride

composite

Silver

deposites

dentin

Silver

deposites

Nanohybride

composite

dentin

Fig (5): SEM image of interface for in-office

bleaching before cavity preparation and

composite restoration specimen B1bondedwith total etch adhesive.

Fig (8): SEM image of interface for in-

office bleaching after cavity preparation

and composite restoration specimen B2

bonded with self etch adhesive.


office bleaching after cavity preparation

and composite restoration specimen B2

bonded with total etch adhesive.


office bleaching before cavity

preparation and composite restorationspecimen B1bonded with self etch

dentin

Nanohybrid

composite

resin

Silver depositsdentin

Nanohybrid

Composite

resin

Silver deposits

Fig (9): SEM image of interface for

home bleaching after cavity preparationand composite restoration specimen B4

bonded with self etch adhesive.

Fig (10): SEM image of interface for

home bleaching after cavity preparationand composite restoration specimen B4

bonded with totaletch adhesive.


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Discussion

Dentists must be concerned about the effect of bleaching on the marginal

adaptation of bonded composite restorations. .

In the present study Class V cavity preparations were selected as it was

reported by Raskin et al in 2001 that 62.5% of the microleakage studies

used Class V preparations, which allow evaluation of both enamel and

dentin margins concurrently. The location and size of class V cavities

were based on the ISO/TS 11405 technical specification for adhesion

tests in dental structure and published literature (Raskin et al., 2001 andHeintze S., 2007).

The application of bleaching procedures may occur prior to or after

restorative procedures that require bonding to enamel or dentin. In

subgroup B1 and B3 bleaching were done 7 days before cavity

preparation and composite resin restoration as suggested by Sundfeld et

al., in 2005 who proposed a gap period of at least 7 days between the use

of 35% hydrogen peroxide bleaching material and restorative procedures

that require acid etching and adhesive bonding materials. They mentioned

that the 7 days are a gap period in order to allow complete elimination of

residual peroxide which may interfere with resin polymerization.

Subgroups B2 and B4 received in-office or home bleaching after cavity

preparation and composite resin restoration by one month as

recommended by (Sung et al., 1999 and Nour Eldin et al., 2006).

To artificially age the specimens all specimens were received a

thermocycling regimen of 1,000 cycles between 5c and 55c, with a 30

seconds dwell time in water bath as suggested by Cencl et al., 2008.They

reported that composite resin restorations were affected by thermal

cycling only after 1.000 cycles/60 s dwell time at enamel margins or after

500 cycles/ 60 s dwell time at dentin margins. The thermocycling


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procedure was used as enamel, dentin, and composite restorations have

different behavior when subjected to temperature variations due to their

different thermal expansion coefficient (International Organization for

Standardization-ISO/TS 11405). Consequently, adhesive failure becomes

obvious through dye infiltration at the tooth-restoration interface which

occurs after thermocycling. .

SEM is a well established technique to examine the interface between

dentin and restorative materials and represent important means of

assessing the defective adaptation of restorative materials (Carvalho et

al., 2004). Although the use of silver nitrate dye was effective in

detecting the nanoleakage (Sano et al., 1995), in this study ammoniacal

silver nitrate dye was used because of its efficiency in doing the job and

to eliminate the drawback of the regular silver nitrate which

demineralized the dentin due to its low PH (Pashley et al., 2002). The

silver ions at the tooth restoration interface of the specimens were

identified using EDX analysis supplied with the Scanning electronMicroscope

The results of this study showed that in the control group B0 both

total etch and self etch adhesive systems demonstrate the presence of

silver deposition at tooth restoration interface which was significantly

more distinct in case of self etch adhesive. This was in agreement with

Tay and Pashley., in 2003 Who reported that the self-priming and self-etching adhesives are more hydrophilic and hence more permeable to

water derived from the underlying dentin, which is undesirable because

this permeability can lead to premature degradation of resin dentin bonds

over the time. Also, Silva Telles et al., in 2001 reported that the low PH

of self etch adhesives impair the polymerization of the resin monomers

and therefore does not allow the formation of a strong and stable hybrid

layer. The other explanation might be due to their different mechanisms


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of bonding to tooth structure. ExciTE F is a total etch system which

completely removes the smear layer. AdheSE is a self etch adhesive

system modifies the smear layer instead of removing it completely. It was

demonstrated by Tay et al., 1999 that self etch adhesives might have

residual water within the adhesive dentin interface, which might affect

the polymerization of the resin composite. On the contrary Frankenberger

et al., in 2000, Oliveira et al., in 2002 and Gueders et al., in 2006 claimed

that self etch adhesives simultaneously etch and infiltrate the dentin and

overcome the problem of excess water or dehydration encountered in

using etch and rinse adhesives. They also assume that the lower primer

acidity in self etch adhesive promote less dentinal tubules opening which

allow easier sealing of the dentin surface. They proposed that the self

etching adhesives obtained higher dentin sealing capability than etch and

rinse adhesives.

Results also showed that with both bleaching system, total etch

bonded restorations showed less silver uptake than self etch bondedrestorations but not up to the statistical significance level except in pre-

restorative home bleaching, a statistical significance different was

observed. This could be attributed to the presence of alcohol in the Excite

F total etch adhesive system. It has been stated that alcohol-based

adhesive systems might minimize the inhibitory effect of oxygen because

of the interaction of alcohol and oxygen Titley et al., 1993; Attin et al.,2004 ).

In the present study samples that bonded with total etch adhesive

system and treated by home bleaching showed statistical significant less

silver uptake than sample treated with in-office bleaching. One of the

factor that may contribute for this result is that carbamide peroxide

decompose after clinical application into urea, ammonia, carbon dioxide

and hydrogen peroxide which is the active ingredient and it constitute


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nearly one third of active ingredient released from equal concentration of

hydrogen peroxide bleaching agent (Canay and Cehreli., in 2003).

It was found in our study that in-office bleaching whether done before or

after cavity preparation and restoration adversely affect the adaptation of

the total etch bonded restorations. This was in consistent with

Barkhordaret al., in 1997 who reported that hydrogen peroxide alters the

tubular permeability and interprismatic area, facilitating the persistence of

peroxide which inhibits polymerization and leading to high rate of

microleakage. Another consideration is the presence of dentinal tubule

that may enhance the rate of penetration of the bleaching agents and

residual oxygen diffusion which considered a strong oxidizing agents that

may cause denaturing of proteins in the organic components producing

changes that could reduce the performance of resin bond restorations and

impaired marginal adaptability. Moreover Cadenaro et al., 2006 found

that etching and rinsing procedures were not able to eliminate residual

oxygen from the bleached surface.In our study the pre-restorative and post-restorative home

bleaching did not adverse the adaptation of the Nano-hybrid composite

restorations bonded by total etch or self etch adhesives used in the study.

This was in agreement with Crime 1992b, Klukowska et al.,2008; White

et al.,2008; yazici et al., 2010). Also it was noticed that the in-office and

home bleaching did not adverse the self etch bonded restorations. Wemay attribute this finding to the type of adhesive used, as it was stated

that the effect of the bleaching agents on microleakage of composite resin

restorations differs according to the type of adhesive material used yazici

et al., 2010.

Results also showed that pre-restorative home bleaching showed less

silver uptake than the post-restorative home bleaching in all restoration

bonded with total each adhesive. Crim G., in 1992b and Owens et al., in


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1998 did not find increased microleakage rates for the pre-restorative

bleaching samples and reported that pre-restorative bleaching by

carbamide peroxide did not affect the marginal seal of subsequently

placed restoration.

Conclusion:

Under the condition of this research it was concluded that

1- Total etch adhesive demonstrates superior marginal adaptation

compared to self etch adhesive.

2- Pre-restoration and Post-restoration Home bleaching doesn't adversely

affect the adaptation of nano-hybrid composite bonded with total etch

or self etch adhesive.

3- Marginal adaptation of nano-hybrid composite to home bleached

enamel is superior to that of in-office bleaching using total etch

adhesive.

4- Pre-restoration and Post-restoration in-office bleaching adversely

affect the adaptation of nano-hybrid composite bonded with total etch.

5- Pre-restoration and Post-restoration in-office bleaching doesn't

adversely affect adaptation of composite bonded with self etch

adhesive.

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