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Research Article

Comparative Evaluation of Different Properties of Various Luting Agents Used for Cementing Stainless Steel Bands on Molars. An Ex-Vivo Study

Mansi Tyagi1, Vivek Rana2, Nikhil Srivastava3* and Himanshu Kapoor4

1Post Graduate Student, Department of Pediatric and Preventive Dentistry, Subharti Dental College, Swami Vivekanand Subharti University, Meerut, India2Professor, Department of Pediatric and Preventive Dentistry, Subharti Dental College, Swami Vivekanand Subharti University, Meerut, India3Professor and Head, Department of Pediatric and Preventive Dentistry, Subharti Dental College, Swami Vivekanand Subharti University, Meerut, India4Associate Professor, Department of Pediatric and Preventive Dentistry, Subharti Dental College, Swami Vivekanand Subharti University, Meerut, India

Citation: Nikhil Srivastava., et al. “Comparative Evaluation of Different Properties of Various Luting Agents Used for Cementing Stainless Steel Bands on Molars. An Ex-Vivo Study”. EC Dental Science 18.5 (2019): 934-942.

*Corresponding Author: Nikhil Srivastava, Professor and Head, Department of Pediatric and Preventive Dentistry, Subharti Dental College, Swami Vivekanand Subharti University, Meerut, India.

Received: March 04, 2019; Published: April 26, 2019

Abstract

Background: The aim and objective of this investigation was to compare the different properties of various luting agents with stain-less steel bands on extracted molars.

Method: Ninety extracted molars used in the study were banded with stainless steel (SS) bands, then randomly and equally di-vided in to 2 groups for the evaluation of retentive force and microleakage assessment. Each group was further subdivided in to 3 as per the luting agents used for cementation i.e. Glass Ionomer Cement (GIC), Resin modified Glass Ionomer Cement (RMGIC) and Self-Adhesive Resin Cement. Retentive force in Group 1 was checked using Instron Machine while Methylene blue dye was used to evaluate microleakage in Group 2. Data collected was statistically analysed using One-way ANOVA test, post hoc Bonferroni test and Fischer’s Exact test.

Result: The statistical analysis of ANOVA and post hoc Bonferroni test revealed highly significant differences among the groups for tensile strength values (p-value ≤ 0.001). Similarly, for microleakage highly significant differences (p- value ≤ 0.001) were found us-ing Fischer’s Exact test.

Conclusion: Self Adhesive Resin Cement was found to be the best luting agent in terms of providing maximum retentive properties at the same time exhibited minimum microleakage when used for the cementation of SS bands.

Keywords: Luting Agents; Stainless Steel Bands; Microleakage; Retentive Properties

Natural teeth are believed to be the best space maintainers of oral cavity and that is main reason that they are important to be saved even carious teeth by restorations or endodontic therapy unless the extraction is unavoidable. Despite the best efforts in prevention,

Introduction

GIC: Glass Ionomer Cement; RMGIC: Resin Modified Glass Ionomer Cement; SS Bands: Stainless Steel Bands

Abbreviations

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premature loss of primary teeth continues to be a common problem in pediatric dentistry due to many reasons like unawareness, result-ing in disruption of arch integrity which adversely affects the proper alignment of permanent successors. In that condition, space main-tainers are the choice of appliances used for maintaining space created due to premature loss of primary teeth. The fixed space maintain-ers are usually indicated to maintain the space created by unilateral/bilateral premature loss of primary teeth in either of the arches [1]. Bands are the passive components that help in fixing various attachments like loops, molar tubes and brackets etc. onto the teeth either through soldering or welding [2]. The band material must be soft enough to permit close adaptation to contour of the teeth and at the same time strong enough to withstand the stresses and deglutition as well. Retention and cementation as well are responsible for increas-ing the life of space maintainers and vice-versa [3]. Retention of SS bands has been the cause of concern from last several years, as the SS bands achieve their retention from the morphology of tooth and the use of luting agents [4]. Also, microleakage and increased incidence of cervical caries has drawn attention of clinician world over, as other cause of failure of stainless steel bands. Microleakage occurs due to seepage of oral fluids at the tooth restoration interface, thereby increasing the incidence of secondary caries. Many other problems may arise due to improper band adaptation and cementation like loosing of bands, microleakage, demineralization, irritation to adjacent tis-sues, poor oral hygiene and recurrent caries. In today’s scenario, dentistry uses a wide range of luting cements to retain crowns, bands or FPD etc. to tooth structure. So, there should be good understanding of the properties of luting cements to ensure the long-term clinical success of cemented restorations like stainless steel crown, stainless steel bands, space maintainers etc. Long-term clinical success of band adaptation is influenced by many factors, one important factor being the selection of an appropriate luting agent. No single luting agent is capable of meeting all the requirements, which is one reason why there is such a wide choice of luting agents currently available from conventional water-based to contemporary adhesive resin cements. Luting agents have widely been used for cementing metallic crowns or bands for a long time but the proper selection of a luting cement is a last most important step that require meticulous execution for long term success of fixed restorations [1].

GIC show long-acting fluoride release and reduced demineralization both in vitro and in vivo, but they have weak bond strengths than composite resins [5]. So, the modifications were done in GIC to enhance its properties. Komori and Ishikawa [6], found that the bond strength of RMGIC, in response to shear and tensile forces, was almost double than that of conventional GICs used for bonding orthodontic brackets. In addition, Yamazaki., et al. [7], suggested that RMGIC for luting had greater shear strength than the conventional GICs during water immersion. Also, Self-Adhesive Resin Cements have been popular choice for luting application. They are acidic, do not require a separate adhesive and form a thin hybrid layer with dentin as they polymerize [8]. As very few studies have been conducted to compare the longevity of bands using different luting cements, the aim of this in vitro study will be to determine their retentive and microleakage properties of different luting agents used in cementing stainless steel bands on molars.

Methodology

A total of 90 human molars extracted due to periodontal problems or orthodontic treatment purposes were selected for the study and called as samples (n = 90). All the samples were cleaned and kept in normal saline. Preformed stainless steel bands of appropriate size were selected and adapted on all the samples, which were then divided into two equal groups i.e. Group 1 and Group 2 of 45 each.

Retentive force assessment

Before the cementation of preformed stainless steel bands on the extracted molars, all the 45 samples of Group 1 were mounted into the acrylic blocks made of 50 mm × 12 mm size. The roots of each tooth was embedded in acrylic resin block up to 1mm below the cement-enamel junction in such a manner that the roots were embedded and crowns were exposed. After the acrylic was set, stainless steel band of selected size was adapted onto the prepared samples. Small holes were made on mesial and distal surfaces of the selected SS bands using high speed hand piece and straight bur and the stainless steel wires (‘O12) were passed through the holes on both the surfaces, one on mesial aspect and the other on distal aspect. All the four ends of stainless steel wire were tied together making an arch (Figure 1). All the sample were then sent to the laboratory for the assessment of retention of all the cements by applying 5kgf load for 10 minutes with the help of Instron Tensile Testing machine.


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Microleakage assessment

Group 2 samples were assessed for microleakage of various luting agents (GIC, RMGIC and Self-Adhesive Resin Cement). Preformed SS bands were selected, adapted on to samples and then cemented by using different luting as divided in sub-groups i.e. group 2A, 2B and 2C. 1/4th of the root were embedded in the wax blocks to prevent dye penetration from apical third of the root. Exposed portion of the root and crown surface were then painted with the help of nail polish (Figure 2). Samples were kept in methylene blue dye for 48 hrs. Section were cut buccolingually into two halves separating mesial and distal surfaces. Both the sections were observed under stereomicroscope for dye penetration. The images were captured and each section was assessed to check the depth of penetration (Figure 3) according to the criteria as below (Table 1). The bands were luted using same luting agents for same subgroups, viz GIC for 1A and 2A, RMGIC for 1B and 2B and Self-Adhesive Resin Cement for 1C and 2C respectively.


Figure 1: Samples prepared for retentive assessment.

Figure 2: Samples prepared for microleakage assessment.


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Figure 3: Scoring criteria according to the depth of dye penetration.

Score Criteria0 No penetration1 ≤ 25%2 > 25 % to ≤ 50%3 > 50 % to ≤ 75%4 > 75 % to ≤ 100%

Table 1: Scoring criteria to check depth of dye penetration.

Statistical analysis

Inferential statistical analysis has been carried out in the present study. Results on continuous measurements are presented on Mean ± SD and results on categorical measurements are presented in Numbers (%). Significance is assessed at 5% level of significance. Fischer’s Exact test and ANOVA with post hoc bonferroni for multiple comparison has been used to find the significance of study parameters on categorical scale and ordinal scale between more than two groups.

Results

Retentive force assessment

Table 2 showed that the mean retentive force was the highest for subgroup 1C (Self Adhesive Resin Cement) followed by subgroup 1B (RMGIC) and subgroup 1A (GIC). Highly significant difference (p-value < 0.001) was found in mean retentive force between subgroup 1C (Self Adhesive Resin Cement) and subgroup 1A (GIC).


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Table 3 revealed the intergroup comparison of all the subgroups namely 1A, 1B and 1C. Highly statistically significant difference was found between subgroups 1A and 1B, subgroups 1A and 1C and subgroups 1B and 1C (p-value < 0.001) with the mean difference of 52.80 N, 112.86 N and 60.06 N respectively using Post-hoc Bonferroni test.


Sub groups Retentive Force (N) ANOVA

p - valueMean SD

1A (GIC) 105.73 26.948

45.088 < 0.001 (VHS)1B (Resin-Modified GIC) 158.53 44.791

1C (Self-Adhesive Resin Cement) 218.60 21.223One- way ANOVA Test

VHS - Very Highly Significant (p-value ≤ 0.001)

Table 2: Retentive force comparison amongst different groups.

Subgroups Mean Difference p - valueGIC (1A) vs RMGIC (1B) - 52.80 N < 0.001 (VHS)

GIC (1A) vs Self-Adhesive Resin Cement (1C) - 112.86 N < 0.001 (VHS)RMGIC (1B) vs Self-Adhesive Resin Cement (1C) - 60.06 N < 0.001 (VHS)

Post-hoc Bonferroni test VHS - Very Highly Significant difference

Table 3: Intergroup comparison of all the subgroups.

Table 4 revealed least microleakage penetration in subgroup 2C (Self Adhesive Resin Cement) while it was maximum in subgroup 2A (GIC). All the samples of subgroup 2C (Self Adhesive Resin Cement) showed score 1 while maximum of the samples of subgroup 2A (GIC) showed score 2. A highly significant difference was found amongst subgroup 2A, 2B and 2C using Fischer’s Exact Test with the p-value < 0.001.

Sub-Groups

Depth of Penetration

TotalScore 1

(< 25%)

Score 2

(> 25% to < 50%)

Score 3

(> 50% to < 75%)

Score 4

(> 75% to < 100%)

2A (GIC) N 05 10 00 00 15% 33.30% 66.70% 00.00% 00.00% 100.00%

2B (RMGIC) N 13 02 00 00 15% 86.70% 13.30% 00.00% 00.00% 100.00%

2C (Self-Adhesive Resin Cement) N 15 00 00 00 15% 100.00% 00.00% 00.00% 00.00% 100.00%

Fisher’s Exact test = 18.112

Very Highly Significant (p-value < 0.001)

Table 4: Intergroup assessment for microleakage amongst all the three subgroups.

Discussion

As we know space maintainers have high success rates, but a clinical significant failures do occur due to cement loss. Hence, for better retention of SS bands, a good luting agent is required which must possess dual abilities of adhering with the tooth and SS bands as well as providing good marginal seal. These both the qualities are the key to retain the SS bands and eliminating coronal microleakage [9]. Poor marginal seal of SS bands may allow microleakage of bacteria and their toxic metabolic waste products into the tooth structure. Such mi-croleakage can lead to recurrent decay, plaque accumulation or carious tooth. So, to achieve optimal marginal adaptation, it is important


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to prevent the failure of stainless steel bands [10]. Likewise, the retentive force of luting agent is necessary for the success of the retention of SS band in the oral cavity. In this study, three luting agents were used: GIC, RMGIC, and Self-Adhesive Resin Cement.

In 1970s and 1980s, GIC was introduced for the need of luting SS bands. GIC is most widely accepted material for the cementation of SS bands and SSCs because it can adhere to both enamel surface and metal as well. They have significant advantages, such as constant release of fluoride and the uptake, microbial inhibition, chemical adhesion to teeth and metal [11,12], low thermal coefficient of expansion and low solubility [13]. Despite these advantages, the use of GICs has not eliminated the problem of cement failure. According to results of previous clinical research, long term failure rates of space maintainers have been reported as ranging from 29% to 57% at periods from 9 to 14 months following application. The most frequent reason for failure of fixed SMs is a loss of cement around the SM band [14,15].

Studies have shown 85% of the cervical and occlusal margins of the band show cement defects [16]. The introduction of light polymerized systems enhanced initial GIC resistance [17]. According to McCabe there are three most widely used cements i.e. Modified Composites, RMGIC and Compomers [18].

RMGICs, introduced in mid 1990s, are cured by an acid-base reaction and may optionally be light activated; they are composed of com-posite and glass ionomer components. This new and modified resin cements in orthodontic treatments or space maintenance offers im-proved physical properties and clinical benefits. To increase fluoride release and obtain adequate bond strength compared to composites, the combination of GIC and composite resin were also developed to create “hybrid cement” which allowed snap set, decreased moisture contamination and increased strength. These materials are intended to overcome the disadvantages of conventional GIC while preserving their clinical advantages. RMGICs can be self-cured by acid-base reaction of GIC and have a diffusion-based adhesion between cement and tooth surface. In addition, this material can be cured quickly by light activation from the visible light-curing device. The light activates free radical polymerization of hydroxyethyl methacrylate (HEMA) and other two monomers to form a poly-HEMA matrix that hardens the ma-terial. It is believed that poly-HEMA and polyacrylic metal salt ultimately forms a homogenous matrix that surrounds the glass particles. Some advantages of RMGIC over GIC are like its excellent compressive and tensile strength, very less sensitive to moisture during initial setting time, water sorption and hygroscopic expansion, excellent bonding with composites, quality of fluoride release causes the forma-tion of fluoro-hydroxyapatite which makes it more resistant to demineralization, long working time and early strength, have low modulus of elasticity compared to water based GICs. But it has some disadvantages too, like its hydrophilic nature, dehydration and rough surface texture and opaqueness [21,22]. Then the next innovation in luting cements was modified composites i.e. Self Adhesive/Etch Resin Ce-ments. They have a best part as they do not require any pre-treatment of the tooth surface. Once the cement is mixed, its application is accomplished in a single clinical step. Self-adhesive resin cements are still relatively new and detailed information on their composition and adhesive properties is limited. They are cured by light polymerization and they contain glass particles that are chelated in an attempt to release fluoride. Although they release less fluoride than RMGICs and GICs, but still they maintain cariostatic properties [23].

In the present study, 90 extracted molars were collected and were randomly divided into two groups of 45 teeth each. These teeth were evaluated for retentive force and microleakage. For each major group, 3 further subgroups A, B and C respectively were made and SS bands in each subgroup were cemented with 3 different luting cements: GIC, RMGIC, Self-Adhesive Resin Cement. The samples for retentive force assessment were tested with Instron Universal testing machine and the samples for microleakage were kept under dye and viewed under stereomicroscope.

The mean retentive force for GIC, RMGIC, Self-Adhesive Resin Cement was 105.73 N, 158.53 N and 218.60 N. The SS bands cemented with resin cement provided higher retentive capability than the others. There were statistically highly significant differences seen between Resin Cement, GIC, and RMGIC (p < 0.001). In the present study, the mean retentive force of GIC was lower than those of resin cement fol-lowed by RMGIC. It could be because of lack of bonding agent application to cement stainless steel bands with RMGIC - as recommended by the manufacturer because of its enhanced material properties to achieve reliable material quality when automatically mixed in the mixing tip. If we had applied a bonding agent on the tooth, it could mean better retentive force and microleakage results. Some investigators sug-gested that when a bonding agent was applied to tooth tissues, both the bond strength and microleakage results of RMGIC were improved. The reason behind low retentive strength of GIC might be due to its low fracture toughness and its less modulus of elasticity due to which it is more susceptible to elastic deformation [14].

The superior retentive force of resin cement could be attributed to the fact that the resin cement used in our study was a dual cure self-adhesive cement containing methacrylate monomer having phosphoric acid group along with the rheology modifier. The reaction is


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started by light and/or by a chemical reaction of the initiator system (dual cure). The setting reaction is a radical polymerization during which the single monomer molecules are chemically cross-linked to form a three-dimensional polymer network. Simultaneously, neu-tralization reaction takes place, which enhances the long-term stability [24,25]. Formation of tags at dentin-cement interface resulting from the RMGIC polymer penetration into the dentinal tubules has been attributed to this increased compressive strength. In our study, the mean retentive force of RMGIC was found non-comparable to GIC. This finding is similar to a clinical trial done by Almuammar., et al. who showed increased retentive force of RMGIC when compared with GIC [26]. The retentive force of RMGICs specimens could have been reported that water sorption and hygroscopic expansion of RMGIC are useful in improving bonding ability and marginal seal [27,28].

In the present study, the mean microleakage values of the used 3 luting agents: GIC, RMGIC, Self-Adhesive Resin Cement were assessed and their values obtained under score 2 were 66.70%, 13.30% and 0% respectively whereas results found under score 1 were 33.30%, 86.70% and 100% respectively.

Therefore, out of the three luting cements, Self-Adhesive Resin Cement showed the least microleakage followed by RMGIC and GIC. Similar results were found in a clinical study done by Dalmiz., et al. [29] who stated that the higher the retentive force a crown or SS band possess, the lower will be the possibility of microleakage.

The least microleakage seen in Self Adhesive Resin Cement could be attributed to the fact that adhesion to enamel occurs through the micromechanical interlocking of resin to the hydroxyapatite crystals and the rods of etched enamel. Dentin adhesion is obtained by infilteration of resin into etched dentin, producing a micromechanical interlock with partially demineralized dentin, which underlies the hybrid layer or resin interdiffusion zone [30]. Less microleakage can also be attributed to the ability of Self-Adhesive Resin Cement in generating an effective seal at the interfaces between restorative alloy, cementing agent and dental tissue without requiring pre-treatment of the prepared tooth surfaces. The resin cement contains specific multifunctional phosphoric acid methacrylates which is able to interact with the tooth surface in multiple ways, such as by forming complex compounds with calcium ions or by different kinds of physical interac-tion like hydrogen bonding or dipole- dipole interactions [24].

For GIC, a possible explanation may lie in the fact that solubility of GIC is higher as compare to RMGIC, may be because of the nature of its dentin bond which is exclusively mechanical. GIC belongs to the group of acid-base cements that contains acid as a component which is responsible for high acidity of mixture during cementation. Acid component of the cement may demineralize smear layer and intact dentin. Cement mixture consistency is creamy and it is not capable of diffusing through the demineralized dentin. Exposed collagen fibres surrounded by empty spaces of demineralized dentin undergo hydrolysis in due course of time under the influence of oral fluids and wa-ter, which impair the accomplished bond and lead to the development of microcracks and microleakage [31]. Score 3 and score 4 were not seen in the study, might be because due to proper mixing and curing done according to the manufacturer’s recommendations.

Conclusion

Based on the results of the present study, the following conclusions were drawn:

1. All the cements used in the study were effective as luting agents.

2. Out of the three luting cements, Self-Adhesive Resin Cement was found to be the most effective in retaining the stainless steel bands as it provided the maximum resistance against dislodgement.

3. GIC was found to be least efficacious in retaining the stainless steel bands when used as luting cement.

4. In terms of microleakage, Self-Adhesive Resin Cement was found to be the most effective as it had minimum microleakage.

5. GIC proved to be the least effective in preventing microleakage.

Acknowledgement

I sincerely thanks Dr. Noopur Kaushik (Associate Professor) and Dr. Ritu Singh (Assistant Professor), Subharti Dental College, Swami Vivekanand Subharti University, Meerut, India, for their guidance and efforts to carry this study forward.



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