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Assessment of microleakage and interfacial adaptation following

simultaneous activation technique in primary molars

Article in Pediatric Dental Journal · November 2022

DOI: 10.1016/j.pdj.2022.10.001

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Available online at www.sciencedirect.com

Pediatric Dental Journal

journal homepage: www.elsevier.com/locate/pdj

Research Paper

Assessment of microleakage and interfacial

adaptation following simultaneous activation
technique in primary molars

Heer Kadhi, Jasmin Winnier*, Ishani Ratnaparkhi

Department of Pediatric and Preventive Dentistry, D Y Patil University - School of Dentistry, Nerul, Navi Mumbai,
Maharashtra, India

article info abstract

Article history: Background: Simultaneous Activation Technique is a newer method of co-curing resin
Received 17 May 2022 modified glass ionomer (RMGI) and self-etch adhesive.
Received in revised form Aim: Assessment of microleakage and interfacial adaptation following simultaneous acti-
19 October 2022 vation technique in primary molars.
Accepted 31 October 2022 Design: Standardized Class I cavities were prepared in 66 non-carious primary molars and
Available online xxx randomly allocated to Group I e Simultaneous activation of RMGI and self-etch adhesive
(SAT); Group II e SAT with enamel etching (SAT þ EE); Group III e Conventional Sandwich
Keywords: Technique (ST) and restored with bulk fill composite. Time taken was calculated using
Glass ionomer stopwatch. Microleakage was assessed using dye penetration method under stereomicro-
Primary teeth scope. Seven samples per group were sent for Scanning Electron Microscopy (SEM) anal-
Scanning electron microscopy ysis. One-Way Analysis of Variance and Post- Hoc Tukey's test were applied at P < 0.05.
Results: Mean microleakage of group I, II and III were 1.23, 1.41 and 1.59 respectively. Time
taken was least for SAT followed by SAT þ EE and ST group. Statistically significant dif-
ference was seen between SAT and ST group (p < 0.0001) and SAT þ EE and ST group
(p < 0.0001). SEM analysis showed better mean interfacial adaptation in SAT þ EE (1.00)
followed by ST (2.14) and SAT (3.57) group. Difference between SAT þ EE and SAT group
was significant (p ¼ 0.005).
Conclusion: Simultaneous activation technique with selective enamel etching resulted in
less microleakage and better interfacial adaptation.
© 2022 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

placed over a glass ionomer (GI) base [1e3]. It provides ad-

1. Introduction vantages of GI such as chemical adhesion to the tooth,
continuous fluoride release as well as reduces the bulk of
Sandwich restoration is a commonly used technique in pri- composite thereby decreasing the polymerization shrinkage
mary teeth in deep carious lesions where resin composite is

* Corresponding author.
E-mail addresses: [email protected] (H. Kadhi), [email protected] (J. Winnier), [email protected] (I. Ratnaparkhi).
https://doi.org/10.1016/j.pdj.2022.10.001
0917-2394/© 2022 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Kadhi H et al., Assessment of microleakage and interfacial adaptation following simultaneous activation
technique in primary molars, Pediatric Dental Journal, https://doi.org/10.1016/j.pdj.2022.10.001
2 pediatric dental journal xxx (xxxx) xxx

and hence microleakage [4]. However due to certain draw- samples (7 per group) were selected for SEM analysis in the
backs of conventional GI such as prolonged setting time and present study.
moisture sensitivity, a weak bond strength is obtained be- The restorative materials used in the study were Primer
tween the resin composite and GI [5,]]. [6] To counter these (Vitremer™ e 3M Minneapolis, Minn., USA), Resin Modified
disadvantages, use of resin-modified glass ionomer (RMGI) as Glass Ionomer (Vitremer™ Tri-Cure Glass Ionomer System-
base has been investigated in sandwich restorations. Studies 3M Minneapolis, Minn., USA), Self-etch adhesive (Adper™
have shown that RMGI shows improved bonding with com- Easy Bond- 3M Minneapolis, Minn., USA) and Resin Composite
posites, lesser moisture sensitivity and a decreased working (Z250 Xt Composite- 3M Minneapolis, Minn., USA).
time. According to a study by Subrata et al., in conventional
sandwich restoration, etching of the GI base was recom- 2.1. Specimen preparation and restoration
mended to increase the bond strength between the resin
composite and the GI base [7]. However, there is no consensus, The following procedures were carried out by a single inves-
regarding the need for etching of RMGI to increase the bond tigator. Collected extracted teeth were cleaned off any soft
strength. tissue or debris with an ultrasonic scaler followed by pro-
Self-etch adhesives are the new generation bonding agents phylaxis with a rubber cup and pumice slurry [12,13]. Teeth
that do not require acid etching and rinsing procedures to be were washed with distilled water and stored in 0.1% thymol
performed separately, reducing the chair-side time. Several solution at room temperature for up to 1 month, in order to
studies have shown that self-etch adhesives when used in preserve the micro-hardness of enamel and dentin [14,15].
primary teeth show good sealing ability [8,9]. Pinheiro et al. Standardized Class I cavities of 2 mm width and 2.5 mm depth
(2003) introduced a newer technique called simultaneous were prepared by a single calibrated operator using a high
activation technique, where RMGI and self-etch adhesive speed air rotor hand piece and a straight fissure diamond bur
were polymerized together in a sandwich restoration was (SF-12) under continuous water flow. Each bur was replaced
proposed [10]. An increase in the bond strength was seen be- with a new one after preparation of 15 cavities [16]. Cavity
tween the resin composite and RMGI. dimensions were verified with the help of a periodontal probe.
Extensive search of literature however revealed inconclu- These teeth were then randomly divided into 3 groups -
sive evidence on effect of simultaneous activation of RMGI Group I eSimultaneous Activation Technique (SAT)
and self-etch adhesive on microleakage in a sandwich resto- Group II e Simultaneous Activation Technique þ Enamel
ration in primary teeth. Hence, the purpose of this study was Etching (SAT þ EE)
to assess the microleakage and interfacial adaptation Group III e Conventional Sandwich Technique (ST)
following the simultaneous activation technique as a modi- Prepared cavity in each tooth was washed with distilled
fied sandwich restoration procedure in primary teeth. water and dried completely using air-water spray. The primer
was applied with a micro-brush for 30 s to both dentin and
enamel and air dried for 5 s followed by light curing for 20 s.
2. Materials and methods In Group I (SAT), RMGI powder and liquid were dispensed
and mixed according to the manufacturer's instructions. The
This study was conducted in the Department of Pedodontics and material was applied on the pulpal floor of the cavity using a
Preventive Dentistry, D.Y Patil University, School of Dentistry, plastic placement instrument, so that the thickness of the
Navi-Mumbai. Institutional review board approval was obtained RMGI base was approximately 1 mm. This base was not cured.
before beginning the study (IREB/2021/PEDO/01). Non-carious Self-etch adhesive was immediately applied onto the base and
primary molars extracted for the purpose of eruption guidance was light cured (30 s). Resin composite was placed using bulk
or orthodontic reasons were selected for the study. Teeth with fill technique and was cured (40 s). In Group II (SAT þ EE), RMGI
developmental enamel defects or cracks or teeth showing base of 1 mm thickness was applied and was not cured. Self-
complete resorption of roots were excluded. The sample size etch adhesive was immediately applied onto the base and
was calculated based on the findings from a previous study by was light cured (30 s) similar to group I. Then an additional
Shafiei and Akbarian (2014) [11]. A total sample of 42 (14 in each step of selective etching of the enamel was carried out with
of the three groups) achieved a power of >90% to detect the phosphoric acid (15 s), washed with air water spray followed
differences among the means using one-way ANOVA test based by placement of resin composite using bulk fill technique and
on a significance level of 95% (alpha 0.05). Thus, a minimum cured (40 s). In Group III (ST), RMGI base of 1 mm thickness was
sample size required for this study was calculated to be 42 applied and was light cured (30 s). Self-etch adhesive was
consisting of 14 teeth in each group. Since the data obtained for applied onto the base and light cured (30 s), followed by
reference was from a study based on permanent teeth, consid- placement of resin composite using bulk fill technique and
ering some margin of error, sample size was planned to be 22 per cured (40 s).
group with a total of 66 teeth. The time required for the restorative procedure from start to
The required minimum sample size was obtained by finish for each tooth was recorded in seconds, using a stopwatch.
applying the following formula: 1 e b ¼ Fv,n-p,⅄(Fv,n-p,1-f);
where, F.,.,⅄ (.) is the cdf of a non-central F distribution. 2.2. Microleakage test
For Scanning Electron Microscopy, an empirical formula
n ¼ 6 was applied and minimum samples required were 18 (6 The restored teeth were stored for 1 week in distilled water at
per group). Considering some margin of error a total of 21 37  C, following which the teeth were subjected to thermocycling

Please cite this article as: Kadhi H et al., Assessment of microleakage and interfacial adaptation following simultaneous activation
technique in primary molars, Pediatric Dental Journal, https://doi.org/10.1016/j.pdj.2022.10.001
 pediatric dental journal xxx (xxxx) xxx 3

for 500 cycles between 5  C and 55  C with a dwell time of 30-s in

each bath. The root apices of the restored teeth were sealed with 4. Results
epoxy glue to prevent dye penetration. All tooth surfaces were
covered with two coats of clear nail polish leaving a window of The mean microleakage of group I e SAT was 1.23, group II e
1 mm around the cavity-restoration margins. Teeth were then SAT þ EE was 1.41 and group III e ST was 1.59. According to one-
immersed in 1% methylene blue solution for 24-h at 37  C.12 way ANOVA test, there was no statistically significant differ-
After removal from the dye, these teeth were sectioned longi- ence between the groups (Table 1). The mean time taken was
tudinally through the centre of the restorations with a low- also found to be the least for SAT group (168.18 s) followed by
speed, water-cooled double-sided diamond disc [17,18]. SAT þ EE group (174.18 s) and ST group (185 s). This difference in
The dye penetration of the occlusal margin of each section time taken was found to be significant between SAT and ST and
was evaluated independently by two trained calibrated asses- SAT þ EE and ST groups (p < 0.0001). The mean SEM scores of
sors, who were blinded to the restorative technique used, under SAT, SAT þ EE and ST group were found to be 3.57, 1.00 and 2.14
a stereo-microscope at a magnification of 10X. In case of respectively. SEM analysis showed better interfacial adaptation
disagreement between two observers, a third independent in the SAT þ EE group as compared to the SAT group which was
observer was consulted to make the final decision. To determine statistically significant (p < 0.05) (Table 2, Fig. 1).
the intra-examination reliability, 15 randomly selected molars
were re-evaluated for microleakage. Scoring was repeated by
the same examiners 1 month after the initial scoring to assess 5. Discussion
the reproducibility of the examiners. Microleakage of the
occlusal margins of Class I restorations were assessed with Simultaneous activation technique is a modified restorative
degree of dye penetration using a 4-graded scale [19]. (0 - No dye approach which has shown to increase the bond strength in
penetration; 1 - Dye penetration into the enamel part of the primary teeth.6 However, not much research has been con-
cavity wall; 2 - Dye penetration into the dentin part of the cavity ducted in this aspect. Hence, the aim of this study was to
wall but not including the pulpal floor of the cavity; 3 - Dye evaluate the microleakage and interfacial adaptation using
penetration including the pulpal floor of the cavity). this technique and compare it with the conventional sand-
wich technique.
2.2. 1Scanning electron microscopy analysis Conventional GI has been considered as an essential
Seven samples from each group were randomly selected and restorative material for primary teeth. However, according
subjected to the scanning electron microscopy (SEM analysis) to a clinical study, when conventional GI and resin modified
for evaluation of surface interface between dentin and RMGI GI was compared in the restoration of primary molars, it
base. The samples were assessed by 2 trained calibrated ex- was seen that conventional GI showed five times higher
aminers who were blinded to the sample groups. In case of failure rate as compared to resin modified GI in Class II
disagreement between two observers, a third independent cavities [21]. According to microleakage studies carried out
observer was consulted to make the final decision. To deter- in Class II restorations in primary teeth where conventional
mine the intra-examination reliability, 5 randomly selected GI was compared to RMGI for sandwich restorations, it was
samples were re-evaluated for analysis. Scoring was repeated seen that RMGI showed less microleakage. Hence, in our
by the same examiners 1 month after the initial scoring to study, RMGI was considered as a base for the restorative
assess the reproducibility of the examiners. The samples were procedures.
assessed at 500X magnification in order to obtain the best Self-etch adhesives are the generation of bonding agents
images and evaluated according to a five point rating scale which are considered to have less post-operative sensitivity.
with increasing degree of marginal deficiencies [20]. (Score 1 - They are less technique sensitive due to the decreased num-
Good adaptation, no marginal opening, no deficiencies; Score ber of procedural steps [22]. However, according to previous
2 - Slight marginal irregularities, no gap; Score 3 - Severe study where the clinical performance of composite restora-
marginal irregularities, no gap visible; Score 4 - Gap, hairline tions placed with different adhesive systems was assessed in
crack with bottom visible; Score 5 - Severe gap, bottom hardly primary teeth, etch-and rinse adhesive systems showed bet-
or not visible). ter marginal adaptation than self-etch adhesives [23]. Hence,
it was concluded that pre-etching of the primary enamel
might help improve the clinical performance of the self-etch
3. Statistical analysis

All data was entered into a Microsoft Office Excel (Office version Table 1 e One-Way ANOVA for Microleakage score of the
365) in a spreadsheet and checked for errors and discrepancies. three different groups.
Data analysis was done using IBM SPSS STATISTICS 20.0 (IBM
Sum of df Mean P value
Corporation, Armonk, NY., USA) and data was generated. Squares Square
Analysis of variance (ANOVA) was used to find the significance
Between Groups 1.455 2 0.727 0.272 (NS)
of study parameters between the groups (Inter group analysis). Within Groups 34.500 63 0.548
Tukey's post hoc analysis was carried out. Results on contin- Total 35.955 65
uous measurements were presented on Mean ± SD. Level of
*p-value significanlt at level 0.05, df: Degree of Freedom, NS: Not
significance was fixed at p ¼ 0.05 and any value less than or significant.
equal to 0.05 was considered to be statistically significant.

Please cite this article as: Kadhi H et al., Assessment of microleakage and interfacial adaptation following simultaneous activation
technique in primary molars, Pediatric Dental Journal, https://doi.org/10.1016/j.pdj.2022.10.001
4 pediatric dental journal xxx (xxxx) xxx

Table 2 e Post-hoc Tukey's test for Time Taken (seconds) and Scanning Electron Microscopy score.
Time Taken Scanning Electron
Microscopy
Mean Difference (I-J) Std. Error P value Mean Difference (I-J) Std. Error P value
SAT þ EE SAT ST - 6.000 1.533 0.001a 2.571 0.697 0.005a
10.818 1.533 <0.0001a 1.143 0.697 0.355
SAT SAT þ EE ST 6.000 1.533 0.001a 2.571 0.697 0.005a
16.818 1.533 <0.0001a 1.429 0.697 0.165
ST SAT þ EE SAT 16.818 1.533 0.001a 1.143 0.697 0.355
10.818 1.533 <0.0001a 1.429 0.697 0.165
a
p-value significant at level 0.05, SAT: Simultaneous Activation Technique, SAT þ EE: Simultaneous Activation Technique with enamel
etching, ST: Conventional Sandwich Technique.

Fig. 1 e Scanning electron microscope image (500X magnification) showing interface between dentin and RMGI (a) Good
adaptation, no marginal opening, no deficiencies (SAT þ EE) (b) Slight marginal irregularities, no gap (ST) (c) Gap, hairline
crack with bottom visible (ST) (d) Severe gap, bottom hardly or not visible (SAT).

adhesive systems in primary teeth. Hence, in this study se- of composites in contrast to the maximum 2-mm in-
lective etching of the enamel was done and results were crements recommended for conventional resin compos-
evaluated along with self-etch adhesives. ites [24]. This technique helps in saving the restorative
Bulk fill composite technique is an advanced technique time and may thus be essential in young uncooperative
where manufacturers recommend 4- or 5-mm increments patients.

Please cite this article as: Kadhi H et al., Assessment of microleakage and interfacial adaptation following simultaneous activation
technique in primary molars, Pediatric Dental Journal, https://doi.org/10.1016/j.pdj.2022.10.001
 pediatric dental journal xxx (xxxx) xxx 5

Our study was conducted in order to assess the micro-

leakage and interfacial adaptation in primary teeth by using Ethical approval
this technique. Time taken for each restorative procedure
was calculated and interfaces between the tooth and RMGI This clinical study was performed on extracted teeth. Insti-
and RMGI and composite were assessed using the SEM tutional review board approval was obtained (IREB/2021/
analysis. PEDO/01).
The results of the present study suggest that microleakage
was least for SAT group followed by SAT þ EE and ST group.
However, the results were not statistically significant. Similar Declaration of competing interest
results were obtained in another study, in which SAT group
showed lesser microleakage as compared to the conventional The authors declare no conflict of interest.
technique.6.
Time taken for each restorative procedure was evaluated
in this study. SAT group (168.18 s) showed the least amount of Acknowledgement
time taken followed by SAT þ EE group (174.18 s) and the ST
group (185 s). The difference was found to be statistically The authors are grateful to the Faculty of Indian Institute of
significant between the SAT and ST group as well as SAT þ EE Technology Madras (Centre for Industrial Consultancy and
and ST group. This can be justified considering the reduced Sponsored Research, Chennai) for their help and support for
number of steps in SAT and SAT þ EE group. SEM analysis.
Seven samples from each group were evaluated for SEM
analysis, and the results showed that SAT þ EE group showed
the best bonding interface between the RMGI and composite. references
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Please cite this article as: Kadhi H et al., Assessment of microleakage and interfacial adaptation following simultaneous activation
technique in primary molars, Pediatric Dental Journal, https://doi.org/10.1016/j.pdj.2022.10.001
6 pediatric dental journal xxx (xxxx) xxx

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Please cite this article as: Kadhi H et al., Assessment of microleakage and interfacial adaptation following simultaneous activation
technique in primary molars, Pediatric Dental Journal, https://doi.org/10.1016/j.pdj.2022.10.001
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