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 Table of Contents  
ORIGINAL RESEARCH
Year : 2017  |  Volume : 9  |  Issue : 4  |  Page : 165-173

To evaluate and compare postcementation sensitivity under Class II composite inlays with three different luting cements: An In vivo study


Department of Conservative Dentistry and Endodontics, Government Dental College, Jaipur, Rajasthan, India

Date of Web Publication21-Aug-2017

Correspondence Address:
Pankaj Prasad
Government Dental College, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_14_17

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  Abstract 

Aim: The purpose of this study is to evaluate and compare postcementation sensitivity under Class II composite inlay with three different luting cements. Materials and Methods: A comparative prospective study was carried out in 45 patients age ranged from 18 to 28 years for 2 years, who fulfilled the criteria. Clinically and radiographically, presence of mild initial dental caries on proximal surface of maxillary and mandibular first molar. Tooth preparation for composite inlay was performed and composite inlay restorations were made by indirect technique. Three different luting cements were used for cementation of composite inlay. Cold water test, compressed air test, and biting pressure test were used to measure the tooth sensitivity in this study. Results: As per the findings of this study, there was no significant difference between all the three groups immediately after cementation. We noted a significant difference between Group I and Group III and Group I and Group II and Group II and Group III after 1 and 6 months. Conclusions: Based on the results of this study, we concluded that restorations cemented with self-adhesive resin cements showed least postoperative sensitivity followed by Resin-modified glass ionomer cement (GIC) and GIC has the highest sensitivity at all intervals of time evaluated using different tests.

Keywords: Composite, luting, microleakage, polymerization shrinkage, resin cement, self-adhesive


How to cite this article:
Prasad P, Gaur A, Kumar V, Chauhan M. To evaluate and compare postcementation sensitivity under Class II composite inlays with three different luting cements: An In vivo study. J Int Oral Health 2017;9:165-73

How to cite this URL:
Prasad P, Gaur A, Kumar V, Chauhan M. To evaluate and compare postcementation sensitivity under Class II composite inlays with three different luting cements: An In vivo study. J Int Oral Health [serial online] 2017 [cited 2019 Jun 15];9:165-73. Available from: http://www.jioh.org/text.asp?2017/9/4/165/209268


  Introduction Top


Amalgam restorative material has been widely used for the restoration of posterior teeth.[1] Esthetic alternatives to amalgam restorations include direct composite resins, composite inlays, and ceramic inlays.[2],[3] Indirect composite resin restorations, it has an advantage such as esthetics, conservative tooth structure removal, improved strength of remaining tooth structure, but problems were various fractures, wear and loss of the marginal seal leading to pulpal irritation, postoperative sensitivity, marginal staining, and secondary caries.[4] Furthermore, other problems related to direct composite resins were insufficient interproximal and occlusal morphology due to difficult clinical handling procedures. Inlays are single-tooth restorations that compensate a proximal-occlusal or gingival lesion with minimal or moderate extensions.[5] The most noticeable advantage of the indirect restorative technique relates to its better potential for generating the appropriate anatomic form, as well as proximal contact and contour and although meticulous attention to detail is important, indirect composite resin procedures may be less technique sensitive than direct ones.[6],[7] Additional clinical benefits include exact marginal integrity, wear resistance similar to enamel, wear compatibility with opposing natural dentition, optimal esthetics, ideal proximal contacts, and excellent anatomic morphology.[3] They can be adjusted, repolished easily and can be repaired with light-cured composite resin as compared to porcelain inlay.[8]

When an indirect restoration is placed into a tooth the relatively narrow interface between the cavosurface area and restoration are concerned with polymerization shrinkage not the entire preparation void that can leads to microleakage and postoperative sensitivity. Placement of a pre-polymerized restoration and use of a chemically cured luting resin substantially lowers the inherent polymerization stress forces at the resin-bonded cavosurface. Therefore, the clinical long-term success of an indirect restorative procedure is strongly influenced by luting cement and its sealing ability.[9]

Dentinal hypersensitivity and other pulpal adverse effects are often occurred, if prepared tooth is left uncovered, this is due to the removal of protective enamel layer while preparing the tooth. This hypersensitivity is taken care by cementation with definitive luting cements.

The cementation brings the preparation surface, especially its circumferential constituents, as close as possible to the tooth substance. The function of traditional luting cement is to provide retention by interlocking and chemical adhesion between the minor irregularities on both the prepared tooth surface and the restoration surface. The narrower the cement lute, the stronger the bond and better the marginal fit of the restoration.

The purpose of using luting material is make intimate contact between the tooth structure and the casting, and hence that it prevents postoperative sensitivity and secondary caries, make an effective seal between the tooth structure and the restoration.[10] Luting cement must be sufficiently viscous and be able to flow into a continuous film of 25μ thickness or less. The lower the viscosity of the material the better its wetting ability and greater its adaptability. The important physical property of a luting cement is its compressive and shear strength.[5],[11]

To cement inlays and crowns the use of different luting cements has increased. Hence to evaluate the postoperative sensitivity of three different luting cements, that is, glass ionomer, resin-modified glass ionomer and self-adhesive resin at various intervals of time that this study was undertaken.


  Materials and Methods Top


Inclusion criteria

  1. Healthy young individuals (age group of 18–28 years were selected)
  2. Clinically and radiographically presence of mild initial dental caries on the proximal surface of maxillary and mandibular first molar.


Exclusion criteria

  1. Periodontally compromised teeth
  2. Presence of high caries index (decay-missing-filled teeth [DMFT] score >9)[12]
  3. Noncarious lesions such as attrition, abrasion, erosion in same and adjacent teeth
  4. Parafunctional habit like bruxism.


The institutional ethical clearance was obtained (no. COS/GS/2014/6782). A comparative prospective study was carried out in 45 patients for 2 years, who fulfilled the criteria. The patients' age ranged from 18 to 28 years.

The entire treatment procedure, possible outcomes, and other treatment options (in the case of unfavorable results) were explained to the patients and their parents/guardians. Furthermore, they were told that follow-up appointments are obligatory to assess the outcome of the treatment. Informed consent signed by the patient's parent/guardian was obtained. The participation in this study was completely voluntary.

Groups

  • Group 1: Composite inlay luted with glass ionomer cement (GIC) (n = 15 patients)
  • Group 2: Composite inlay luted with resin-modified GIC (RMGIC) (n = 15 patients)
  • Group 3: Composite inlay luted with self-adhesive resin cement (n = 15 patients)
  • For all patients selected for the study, medical and dental history was recorded
  • DMF indices was carried out in all selected patients to rule out high caries index patients
  • DMFT value between 0 and 4 is considered low caries status, the value in the range of 5–9 is moderate caries status and value >9 is high caries status [12]
  • Intraoral examination was carried out to assess the oral hygiene status, nature of presenting illness, periodontal status, and restorability of involved tooth. Intraoral periapical radiograph (IOPAR) and radiovisiography were obtained
  • Electric pulp vitality test was performed to assess the vitality of the teeth
  • Oral prophylaxis was done before the treatment.


Following points were considered during class II inlay prepration [11]

  • 90° butt-joint cavosurface angle to ensure the marginal strength of the restoration.
  • All line and point angles, internal and external, were rounded to avoid stress concentration
  • Occlusally divergent facial and lingual walls (gingival-occlusal divergence of the preparation greater than the 2°–5° per wall recommended)
  • The occlusal step was prepared 1.5–2 mm in depth
  • Isthmus and any groove extension be at least 1.5 mm wide to decrease the possibility of fracture of the restoration
  • Facial and lingual walls extended to sound tooth structure, with no undercuts
  • The pulpal floor was prepared smooth and relatively flat
  • The facial, lingual, and gingival margins of the proximal boxes were extended to clear the adjacent tooth by at least 0.5 mm
  • For all walls, a 90° cavosurface margin is desired because composite inlays are fragile in thin cross-section.


Indirect technique

Here, an impression was made of the prepared tooth, with addition silicone impression material and die poured by die stone.

  • Pindex system is used for making working cast
  • Die spacer was applied on all the prepared surfaces
  • Composite is laid out in increments to avoid shrinkage
  • Proximal and occlusal anatomy carving was done
  • As per a manufacturer instructions light cured for 10 s then inlay removed from working die and then light cured for an additional 10 s
  • After finishing and polishing composite inlay were inserted in patients oral cavity
  • Any debris that could interfere with seating of inlay is debrided
  • Cement mix is coated on the prepared cavity walls and also on the impression surface of composite inlay
  • The inlay is seated with a moderate hand pressure and the patients were asked to bite till the cement sets and later excess flash was removed
  • High occlusion points were checked with articulating paper and then final finishing and polishing was done.


Follow up and evaluation criteria

The patients were recalled after 1 day, 1 week, 1 and 6 months the following protocol was followed at each follow-up visit. A short history was taken regarding any symptoms in the tooth after the treatment procedures. This was followed by the evaluation of clinical and radiographic criteria.

Clinical examination

  1. Intraoral examination: the periodontal examination of the tooth was done for pocket or mobility. The percussion of the tooth was done to evaluate any tenderness
  2. Vitality testing: Electric and thermal sensitivity tests were done.


Radiographic evaluation

At every recall visit, the following was evaluated by taking IOPAR:

The following tests were done:

  • Cold water test: Here, the tooth is irrigated with ice cold water for 5 s with a syringe of 5 ml and the test was stopped as soon as the patient started experiencing pain
  • Compressed air test: For 10 s a stream of compressed air (90 psi) was directed on to the facial and palatal/lingual surface of the tooth using an air water syringe
  • Biting pressure test: The patient is asked to bite firmly on the end of icecream stick in this test to check the sensitivity to biting.


Sensitivity evaluation

Schiff Scale (0–3) by Schiff et al. in (1994).[13],[14]

Categorical data of all three groups were compared using unpaired t-test. The value of P < 0.05 was considered statistically significant.

Due to continuous and quantitative type data parametric test were used for analysis. Mean and standard deviation were calculated and for multiple group comparison one-way analysis of variance test was used. The clinical and radiological pictures were added for the present study [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6].
Figure 1: (a) Preoperative intraoral periapical radiographs showing proximal carious lesion of 16. (b) Preoperative intraoral periapical radiographs showing proximal carious lesion of 46

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Figure 2: (a) Proximal carious lesion involving mesial surface of 16 (occlusal view). (b) Proximal carious leison involving distal surface of 46 (occlusal view)

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Figure 3: (a) Class II inlay preparation on 16. (b) Class II inlay preparation on 46

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Figure 4: Composite inlay prepared on die

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Figure 5: (a) Composite Inlay luted with Resin Modified glass ionomer Cement on 16. (b) Composite Inlay luted with Self Adhesive Resin Cement on 46

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Figure 6: Final restoration as same in intraoral periapical

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  Results Top


[Table 1] and [Graph 1] represent the mean values for postcementation sensitivity due to the air pressure of all groups at different intervals of time. Mean values found to be smaller for self-adhesive resin cements and greater for GICs at different intervals of time. There was a significant difference (P < 0.05) between Group I and Group III after 1 and 6 months.

Table 1: Comparison of Mean ± SD and Analysis of variance (ANOVA) of postcementation sensitivity due to air pressure among all groups

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[Table 2] depicts statistically intergroup comparison of postcementation sensitivity due to air pressure between all three groups using unpaired t-test. Comparison between in all the groups immediately is statistically not significant (P > 0.05). After 1 week, there is statistically significant (P > 0.05) difference between Group I and Group III. While after 1 and 6 months, there is statistically significant (P > 0.05) difference between Group I and Group II, Group II, and Group III and between Group I and Group III.
Table 2: Comparison of unpaired t test & P values of post cementation sensitivity due to air pressure among all g

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[Table 3] and [Graph 2] represent the mean values for post cementation sensitivity due to water pressure in all the groups at different intervals of time. Mean values found to be smaller for self-adhesive resin cements and greater for GICs at different intervals of time. There is a significant difference (P < 0.05) between Group I and Group III after 6 months.
Table 3: Comparison of Mean ± SD & Analysis of variance (ANOVA) of postcementation sensitivity due to water pressure among all groups

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[Table 4] depicts statistically intergroup comparison of post cementation sensitivity due to water pressure between all three groups using unpaired t-test. The comparison between all the groups immediately is statistically not significant (P > 0.05). After 1 week, there is statistically significant (P > 0.05) difference between Group I and Group III. While after 1 and 6 months, there is statistically significant (P > 0.05) difference between Group I and Group II, Group II and Group III and between Group I and Group III.
Table 4: Comparison of unpaired t test & P values of post cementation sensitivity due to water pressure among all groups

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[Table 5] and [Graph 3] represent the mean values for postcementation sensitivity due to biting pressure in all the groups at different intervals of time. Mean values found to be smaller for self-adhesive resin cements and greater for GICs at different intervals of time.
Table 5: Comparison of Mean ± SD & Analysis of variance (ANOVA) of post cementation sensitivity due to bitting pressure among all groups

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[Table 6] depicts statistically intergroup comparison of postcementation sensitivity due to bitting pressure between all three groups using unpaired t-test. The comparison between all three groups is statistically not significant (P > 0.05) difference at immediate, 1 week, 1 and 6 months interval of time.
Table 6: Comparison of unpaired t test & P values of post cementation sensitivity due to water pressure among all groups

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  Discussion Top


Inlay is defined as a fixed intracoronal restoration, a dental restoration made outside of a tooth to correspond to the form of prepared cavity, which is then luted into the tooth (Rosenstiel).[15] Metal inlays instead of good strength have problems of casting defects, marginal discrepancies and unesthetic display of metal. However, composite resin has the advantage to be less expensive and more user-friendly and repairable than ceramic (John R. Sturdevant, Clifford M. Sturdevant) and metal. In addition to inadequate wear resistance on the occlusal table, composite resin restorations conventionally more technique-sensitive and have been hampered by secondary caries.

The most obvious advantage of the indirect technique relates to a better potential for generating the appropriate anatomic form, as well as proximal contact and contour and indirect composite resin procedures may be less technique sensitive than direct ones.[6],[7]

Interestingly, a major in vitro study by Wendt revealed that heat-treating composite resins after light-curing produced appreciable increases certain mechanical properties. Specifically, Wendt found that a 5-min postlight heat treatment at 123°C (253°F) increased the hardness and wear resistance by as much as 60%–70%.[16]

Postoperative tooth sensitivity after the use of composite materials is usually transient and related to leakage next to the margins of the filling or, occasionally, to mechanical stress placed on the tooth as the filling material cures.[17] Shrinkage of the composite on curing can induce stress on the restoration/tooth bond, resulting in strain or bending of the tooth and in rare instances fracture. Failure of the tooth/composite bond also can be a source of early postoperative sensitivity.

The purpose of this study is to evaluate and compare post cementation sensitivity evaluation under Class II composite inlays with three different luting cements. In this study, indirect composite inlay is fabricated due to best esthetics, strength, and better contact and contours. Indirect inlay can be light cure treated or heat treated. We have used light cured Grand ISO inlay restorative material for Class II composite inlay restoration.

When an indirect restoration is placed into a tooth the relatively narrow interface between the cavosurface area and restoration are concerned with polymerization shrinkage not the entire preparation void that can lead to microleakage and postoperative sensitivity. Placement of a pre-polymerized restoration, and use of a chemically cured luting resin substantially lowers the inherent polymerization stress forces at the resin-bonded cavosurface.

The luting material is used to make intimate contact as well as to make an effective seal between the between the tooth structure and the restoration and also to prevent postoperative sensitivity. One of the major factors is microleakage that influences the long life of the luting cement.[18] Uncontrolled microleakage generally produces patient pain as well as to later allow bacterial infection resulting in recurrent caries and pulp inflammation. Therefore, the clinical long-term success of an indirect restorative procedure is strongly influenced by luting cement and its sealing ability.

Adhesion of the cement to tooth surface will reduce or eliminate microleakage between the tooth and the restoration and thus prevent the consequent tooth sensitivity and secondary caries. Luting cement should be sufficiently fluid and be able to flow into a continuous film of 25μ thickness or less. The lower the viscosity of the material the better its wetting ability and greater its adaptability. The important physical property of a luting cement is its compressive and shear strength.

In this study, design three different luting cements, namely, GIC (Group 1), RMGIC (Group 2) and self-adhesive resin cement (Group 3) are used as luting agents under composite inlay so as to decrease long-term microleakage and postoperative sensitivity.

The luting cements tested in this study were all chemically cured except self-adhesive resin cement that is dual cure. Their polymerization is initiated by light and chemically and are therefore the materials of choice to lute indirect tooth-colored restorations.

Measurement and registration of dentine hypersensitivity

Usually, dentine hypersensitivity is measured by (a) tactile (pressure) stimulus or (b) thermal/evaporative (cold air blast) stimulus. The response of the patient to the air blast stimulus is usually scored by the clinical examiner, based on the patient's response, using an analog scale, such as the commonly used Schiff scale.[13],[14]

One of the reasons for immediate postcementation sensitivity could be due to the initial acidity of the luting cement for all the three groups, which can lead to the pulpal irritation. A study done by Smith and Ruse [19] found increase of pH for glass ionomer, zinc phosphate and polycarboxylate during the first 15 min. A study by Stanley [20] found the rapid penetration of low molecular weight phosphoric acid molecule into dentinal tubules as its cause for more sensitivity to low pH.

Mccomb found a significantly greater retentive strength for inlays cemented with glass ionomer than with zinc phosphate cement. William W. Bracket [21] found a reason for the decrease in postoperative sensitivity may be because the glass ionomers were superior to Zinc Phosphate in their retentive capacity.

Glass-ionomer materials have proven to be safe with little potential for soft-tissue irritation or other adverse responses. GICs cause potential postcementation sensitivity due to low initial setting pH and the setting reaction sensitivity to moisture contamination/desiccation.[22] These factors make glass ionomers are technique-sensitive material to place properly and one that requires good control of moisture. The bond to tooth structure is significantly reduced when the tooth is excessively dried, which also contributes to postcementation thermal sensitivity.

Johnson et al.[23] studied documented pulpal sensitivity after crown cementation, but none have determined its cause. By controlling technique variables in a large-scale clinical trial, the authors evaluated the contribution of zinc phosphate and glass ionomer luting cements in causing pulpal sensitivity or necrosis.[24]

Mitchem and Gronas [25] stated that probably due to their solubility in the oral environment may be the reason for the increased sensitivity of the teeth cemented with the GIC and the zinc phosphate luting cement. Phillips et al. conducted an in vivo study on the disintegration of luting cements comparing silcophosphate, glass ionomer and polycarboxylate and zinc phosphate for 12 months and found lower disintegration with RMGIC.

RMGIC [26] is obtained by addition of water soluble resin monomer into the liquid of traditional GIC. Thus, the goal of this process is to decrease the sensitivity against water. RMGICs are less sensitive to early moisture contamination and desiccation during setting and less soluble than the GIC. High bond strength to moist dentin as compared to GIC. These cements bond to tooth structure, have low microleakage when mixed properly and when applied to moist dentin produce little postcementation thermal sensitivity.

Resin cements essentially contain polymers to which fillers have been added to reduce the coefficient of thermal expansion and water sorption thereby increasing the strength of polymers. Fluoride agents were also added for anticariogenic property. Despite RMGIC has some demerits such as polymerization shrink-age, more water sorption due to the presence of HEMA(2-hydroxyethyl methacrylate).

Mathis and Ferracane [27] stated that early contamination is prevented by the low solubility of Resin-modified glass ionomer luting cement. Adhesive resin cements have the ability to bond to both tooth structure and restoration. The integration produces reinforcement of both structures, and reduces microleakage at the restoration-tooth interface, postoperative sensitivity, marginal staining, and recurrent caries.[28]

Recently, a self-adhesive universal resin cement without surface pretreatment has been introduced (RelyX Unicem; 3M ESPE) that is based on a new monomer, filler, and initiation technology. A recent controlled trial in which ceramic inlays/onlays were luted using RelyX U100 showed acceptable performance after 4 years of clinical service. RelyX Unicem has unique, moisture-tolerant chemistry with a low risk of postoperative sensitivity. Independent studies indicate a rate of postoperative sensitivity <0.5%. With a broad range of indications, a simplified procedure, and moisture tolerant chemistry the self-adhesive cements can be considered the first true universal indication cements.[29]

Self-adhesive cements leave the dentin smear layer and produce an intermediate bond to dentin compared with total-etch cements. The cement acidity needed to etch the tooth lasts only in brief, and near neutrality is achieved over a short period. Fabianelli et al. in 2005[30] evaluated wall-to-wall adaptation of a self-adhesive resin cement used for luting gold and ceramic inlays in vitro and compared it with Fuji Cem and Variolink [31] and attributed its optimal seal to its hydrophilic properties. This finding indicates improvement in the properties of self-adhesive cements over time.

Burrow et al.[32],[33] investigate the ability of a GIC lining to reduce postoperative sensitivity in occlusal cavities restored with resin composite. They also compared the effects of total- and self-etch adhesive on postoperative sensitivity and found no difference.

As we noted in this study that there was no significant difference immediately postcementation between the three groups using compressed air test, cold water test and biting pressure test. A significant difference was there between Group I and Group III when cold water test and compressed air test were compared 1 week postcementation; there was no significant difference between Group II and Group III. Group I had the maximum sensitivity. After 1 and 6 months, there was significant difference between Group I and Group III and Group I and Group II and Group II and Group III.

The reasons for maximum sensitivity in Group I could be higher solubility, initial acidity, microleakage and hydraulic pressure during cementation. Group III had the least sensitivity due to the ability to bond to both tooth structure and restoration. The integration produces reinforcement of both structures and reduces microleakage at the restoration-tooth interface, postoperative sensitivity, marginal staining, and recurrent caries.

As there is no accurate method available to determine postoperative sensitivity, there is a possibility of experimental error in judgment of responses clinically. The follow-up period in this study was 1 and 6 months and it is felt that longer duration study may be taken up to have critical evaluation. In this study, the better performance of Group III over Group II and Group I may be attributed to the probable reasons.


  Conclusion Top


Under the conditions of the present in vivo evaluation, the following conclusions can be drawn.

As we noted in our study that there was no significant difference immediately postcementation between the three groups using compressed air test, cold water test, and biting pressure test. A significant difference was there between Group I and Group III when cold water test and compressed air test were compared 1 week postcementation; there was no significant difference between Group II and Group III. Group I had the maximum sensitivity. After 1 and 6 months, there was significant difference between Group I and Group III and Group I and Group II and Group II and Group III.

Group I had the maximum sensitivity GICs cause potential postcementation sensitivity due to low initial setting pH and the setting reaction sensitivity to moisture contamination/desiccation. These factors make glass ionomers are technique-sensitive material to place properly and one that requires good control of moisture. The bond to tooth structure is significantly reduced when the tooth is excessively dried, which also contributes to postcementation thermal sensitivity.

Group III had the least sensitivity because adhesive resin cements have the ability to bond to both tooth structure and restoration. The integration produces reinforcement of both structures and reduces microleakage at the restoration-tooth interface, postoperative sensitivity, marginal staining and recurrent caries.

Based on the results of this study, we finally concluded that the patients with restorations cemented with self-adhesive resin cements demonstrated lowest postcementation sensitivity followed by RMGIC and GIC, and GIC evaluated by different tests showed the highest sensitivity at all intervals of time. It is felt that long-term studies and large sample size are required to have more confirmative and extensive opinion about the topic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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