Effect of

prewarming Resin
Composite and
Resin-modified GIC
on the microleakage
of Class II Sandwich
Restorations

INTRODUCTION

Composite resins: Routinely used as

restorative materials due to excellent
aesthetics, strong mechanical and physical
properties and high resistance to dissolution.

However, despite improvements in resin

composite formulations, polymerization
shrinkage is still considered problematic
which results in unsuccessful direct
composite resin restorations.

Poor adhesion between the

dentin and restorative material

Gap formation

Microleakage

To overcome the problem of

microleakage many restorative
techniques have been
developed, out of which,
sandwich technique (McLean
and Wilson), is being
successfully used especially in
class II restorations.

As a step to further improve the marginal interface sealing,

the prewarming of resin composite before placing it in
the cavity was introduced by Bertolotto et al in (2003).

Benefits of preheating of resin systems:

Flow of hybrid composites greatly increased.
Improved adaptation of the composite to the prepared
tooth walls.
Increased monomer conversion.
Decreased paste viscosity
free radicals and increasing
polymer chains become more fluid
more complete
polymerization reaction and greater crosslinking
Improved mechanical properties and increased wear
resistance.
Preheating devices are commercially used at a temperature
range of 37C68C.

Prewarming the capsules of RMGIC

Shortens the setting reaction time of RMGIC
Significantly increases the bond strength and surface
hardness
Decreasing the microleakage on the cervical walls.

However, no study has evaluated the effect of

prewarming on microleakage in class II open sandwich
restorations.

Thus, this in vitro study was undertaken to assess the

microleakage in class II cavities restored using open
sandwich technique with and without prewarming of
resin composite and RMGIC.

MATERIALS & METHOD

Forty non-carious,
freshly extracted
human mandibular
molar teeth

Cleaned and stored in

1% chloramine-t

Teeth presenting with a

difference of 0.5mm or
more in mesiodistal
and buccolingual
dimensions were
excluded.

For standardization,
the mesiodistal and
buccolingual diameters
of crown were
measured with a digital
caliper

Standardized class II
tooth preparations
were done on mesial
and distal sides of all
teeth.

7
Occlusal Box Preparation:
Depth of tooth preparation = 3mm
Bucco-lingual width = 3mm
Mesio-distal width = 4mm

Proximal Box Preparation :

Bucco-lingual width =3mm
Width of gingival seat = 3mm

Cervical margin of
proximal box was placed
1mm below the CEJ.
A minimum of 2mm of
tooth tissue remained
occlusally between the
two preparations (Mesio-

The samples were randomly divided8 into 4

groups according to the technique used for
restoration:
Group I (n=20): Open sandwich technique (MO)
Pre warmed RMGIC and resin composite at room temperature.
Group II (n=20): Open sandwich technique (DO)
RMGIC at room temperature and pre warmed resin composite.
Group III (n=20): Open sandwich technique (MO)
Pre warmed RMGIC and pre warmed resin composite.
Group IV (n=20): Open sandwich technique (DO)
RMGIC and resin composite both at room temperature.

Teeth were mounted in metallic jigs followed by application of sectional

matrix band and wooden wedges. GC Cavity Conditioner was applied for
10 seconds and rinsed.

Group I
Fuji II LC capsules were heated in a water bath (at 40 C) for 90
seconds prior to mixing and injected according to
manufacturers instructions.
Application of etchant for 30 seconds
Bonding agent was applied and cured for 10 seconds.
Filtek Z350 XT nanocomposite applied according to
manufacturers instructions and light cured for 40 secs.
Finishing and Polishing was done (Sof-Lex).

Group II
Fuji II LC RMGIC injected (1 mm) directly onto the cavity surface.
Etching and bonding
Composite was pre-heated in the Waxmelter that elevates
composite temperature to 68C.
Filtek Z350 XT nanocomposite was applied according to
manufacturers instructions as stated above.

10

Group III
Fuji II LC capsules were heated in a water bath (at 40 C) for 90
seconds prior to mixing and injected according to manufacturers
instructions.
Etching and bonding
Composite was pre-heated in the Waxmelter that elevates
composite temperature to 68C.
Filtek Z350 XT nanocomposite was applied according to
manufacturers instructions as stated above.

Group IV
Fuji II LC RMGIC was inject (1 mm) directly onto the cavity
surface.
Etching and bonding
Filtek Z350 XT nanocomposite was applied according to
manufacturers instructions.

11

were
subjected
to
Samples
Samples
were
sectioned
thermocycling: 500 cycles at
in mesio-distal
5c,
37c and 55c,direction
dwell time
from
centerand
of the
of
30 seconds
transfer
time
of 15 seconds
restorations
andin a
customized thermocycling
observed under a
device.
stereomicroscope(12x)

Apices were sealed with

modelling
waxthe
anddegree
two coats
Scores for
ofof
nail polish.

dye penetration
microscopic
Samples were soaked in freshly
observations
were
prepared
0.5% basic
fuchsin
solution
24 hours
scoredfor
using
the and
iso
washed thoroughly for few
microleakage scoring
minutes.
system (iso/ts
11405:2003).

12

RESULTS

Score 0

Score 1

Score 2

Score 3

Group 1

14

Group 2

13

Group 3

12

Group 4

11

Score 0

Score 1

Score 2

Score 3

Group 1

15

Group 2

12

Group 3

14

Group 4

16

RESULTS

13

Obtained values were recorded and subjected to

Statistical analysis by Chi Square test, Kruskal
Wallis ANOVA test and Mann- Whitnney U Test.
The obtained values and results were depicted using
tables and bar diagrams at 5% level of significance.
The results revealed that there was no significant
difference observed for microleakage amongst all
the groups.
Microleakage was significantly lower at the occlusal
margins in comparison to cervical margins of Class II
open sandwich restorations.

14

No significant difference was observed for

microleakage in the frequency distribution of
scores amongst all the groups on the occlusal
surface of class II open sandwich restorations.
There was no significant difference observed for
microleakage amongst all the groups on
cervical margins of class II open sandwich
restorations.
However, there was a significant difference
observed for microleakage in frequency
distribution of scores on cervical margins of
group 2 and 4.
None of the techniques were able to completely
eliminate microleakage as far as cervical and
occlusal margins are concerned.

DISCUSSION

15

One of the major limitations of restoring

posterior teeth with composite resins is the
lack of proper adaptation of the material,
particularly at the gingival margin leading to
microleakage and further causing postoperative sensitivity, pulpal inflammation and
secondary caries in the restored tooth.
This has led to development of several
techniques such as sandwich technique,
centripetal build up technique, incremental
placement method, horizontal layering
technique, oblique layering technique etc. out
of which Sandwich technique is the most
popular which is being used extensively.

16

Use of rmgic as base material in open sandwich restoration

reduces the bulk of resin composite used, thereby
decreasing polymerization shrinkage of resin composite
and improving the marginal adaptation.

Fluoride releasing property of gic is considered to have

some inhibitory effect on caries formation and progression
around the restoration.

Aadvantages of rmgic includes longer working time and

operator control over setting reaction by light activation,
reduced brittleness, increase of tensile and flexural
strengths, resistance to desiccation and acid attack, lower
moisture sensitivity and solubility.

Hence, rmgic fuji ii lc capsules (gc america inc.) For open

sandwich technique was used in this study.

17

Although, it has been scientifically proven that adaptation

of composite improves with prewarming, there is very
limited data on effect of prewarming on RMGIC.
More recently a new category of resin composite based on
nanotechnology was developed (Nanofilled composites).
The increase in filler level results in a lower amount of
resin in nanocomposites and also significantly reduces
polymerization shrinkage.
Various authors have tested nanocomposites for
microleakage in Class II restorations and results were
found to be promising {Raju RK et al. (2003)20, Fabianelli
et al. (2010)}.

18

The concept of prewarming composites was conceived by

Bortolotto et al (2003).
It leads to improved flow with improved degree of monomer
conversion, polymerization rate and hardness especially in
deep class II restorations.
Hence, in this study the composite (Filtek Z350 XT, 3M ESPE)
was prewarmed to 688C before placement.
The samples were thermocycled to mimic cyclic temperature
changes in oral conditions.
The use of organic dyes is one of the most popular to assess
microleakage. The samples were immersed in 0.5% basic
fuchsin for 24 hrs. A most commonly used and advocated
magnification device, Stereomicroscope was used to score
samples.

19

Results suggested that microleakage scores were lower for the

occlusal margins as compared to cervical margins in all the
groups.

It was also observed that there was no statistical difference in

mean occlusal scores amongst all the groups (1, 2, 3 and 4) but
a statistically significant difference was observed in frequency
distribution of scores between groups for cervical microleakage.

In our study, since all the margins of occlusal box were in

enamel so that can be one of the reasons for comparatively
lesser scores on occlusal surface as compared to cervical part
of class II preparations.
The reason could be higher inorganic content in enamel on
account of which acid etching creates microporosities and
allows better penetration of adhesive system, thus forming a
strong micromechanical bond with composite resin.

20

Regarding the role of lining material, some

studies have shown that there were no significant
difference in microleakage with or without the use
of RMGIC when the margins were placed in the
enamel (Neme et al. 2002) and (Tredwin et al.
2005).
Moreover, the choice of material i.e nanofilled
composite, which has a high filler loading and
lower resin matrix and hence lower polymerization
shrinkage must have also added to the lower
microleakage scores on occlusal surfaces.
This is in aggrement with the studies done by
Fabianelli A et al. (2010), Bichacho N et al. (1994),
Belli S et al. (2007), Efes BG et al. (2006).

21

REPLACEMENT /ANKYLOTIC

No statistically significant difference among the

RESORPTION
groups
in occlusal microleakage also suggest that
prewarming does not play a significant role in
reducing
involves
the progressive
replacement
microleakage
in our study,
inspite of of
increased
adaptationby
of alveolar
composites
because
tooth structure
bone
andof
prewarming.
ultimately tooth loss.
Inspite of the lower occlusal microleakage scores, all
ofReplacement
resorption
follows the death
the groups exhibited
microleakage.

of viable PDL cells due to compression or

drying
cells.of less resin matrix
This
couldof
bethe
the ligament
due to presence
available to wet cavity walls as nanocomposites have
high filler loading and less resin matrix and
polymerization
Sometimes an
intactinherent
cementum/
shrinkage
in resins which
cementoid
layer may
act as a biological
cannot
be completely
eliminated.

barrier, so that ankylosis is not

accompanied
byobtained
replacement
resorption.
Similar
results were
by Dietrich
T et al

(1999), Loguercio AD et al (2002), Dietrich T et al

(2000), Friedl KH et al (1997), Miller MB et al (1996)
and
JF et
al (1997)
(GSRoulet
Heithersay,
Australian
Dental Journal Supplement 2007;52)

22

The results of mean microleakage on the cervical

surface when compared showed a statistically
insignificant difference between the groups but there
was a statistically significant difference between the
groups according to frequency distribution score for
microleakage.
Group 1 and group 3 showed better performance than
group 2 and group 4.
Since in both the groups (1 and 3), RMGIC was
prewarmed before placement so, it can be presumed
that prewarming of RMGIC could have led to better
results.
The possible reason could be that prewarming of RMGIC
resulted in better flow leading to better marginal
adaptation with less voids.
Secondly, prewarming could have initiated better
movement of monomer radicals of resin component as
well leading to better polymerization with improved
properties.

23
23

Ankylosis in the developing dentition can

severely disrupt arch formation.
Another probable reason could be that as RMGIC sets by
base and
polymerization
reaction
and
each
acid
In some
cases
of ankylosis
and
limited
mechanism depends on reactant diffusion prior to gelation.

replacement resorption, a surgical

repositioning
behave
attempted
The
application of procedure
heat to RMGICcan
could
resulted into
restore
arch integrity.
better
penetration
of reacting moieties in the dentinal
tubules leading to a more consistent bonding.

This procedure can be supplemented with

the application of Emdogain to the affected
Since, this is a study with limited no. of samples, we
root area
an attempt
suggest
someinmore
research toto
berepopulate
done involvingthe
more no.
denuded
surface
with cementoblasts.
of
samples and
more parameters
before advocating
prewarming of RMGIC or composite or both in a class II
restoration as a standard procedure to
open
Evensandwich
if re-ankylosis
and replacement
improve marginal adaptation and hence longevity of the
resorption continue, the damage to arch
restoration.

development can often be avoided or

24

CONCLUSION
Within the limitations, this study
concluded that prewarming RMGIC
leads to improved flow and marginal
adaptation in class II open sandwich
restorations extending onto root
surface and prewarming composites
also has some additional advantages
but not very significant in class II open
sandwich restorations.

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