Journal of Adhesion Science and Technology

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Does lining class-II cavities with flowable

composite improve the interfacial adaptation?

Turki A. Bakhsh, Alireza Sadr, Yasushi Shimada, Alaa Turkistani, Roaa

Abuljadayel & Junji Tagami

To cite this article: Turki A. Bakhsh, Alireza Sadr, Yasushi Shimada, Alaa Turkistani, Roaa
Abuljadayel & Junji Tagami (2020) Does lining class-II cavities with flowable composite improve
the interfacial adaptation?, Journal of Adhesion Science and Technology, 34:4, 400-416, DOI:
10.1080/01694243.2019.1676589

To link to this article: https://doi.org/10.1080/01694243.2019.1676589

Published online: 21 Oct 2019.

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JOURNAL OF ADHESION SCIENCE AND TECHNOLOGY
2020, VOL. 34, NO. 4, 400–416
https://doi.org/10.1080/01694243.2019.1676589

Does lining class-II cavities with flowable composite

improve the interfacial adaptation?
Turki A. Bakhsha , Alireza Sadrb , Yasushi Shimadac, Alaa Turkistania ,
Roaa Abuljadayela and Junji Tagamid
a
Restorative Dentistry Department, Faculty of Dentistry, King Abdulaziz University, Jeddah 213-81,
Saudi Arabia; bDepartment of Restorative Dentistry, University of Washington School of Dentistry,
Seattle, WA, USA; cDepartment of Operative Dentistry, Graduate School of Medicine, Dentistry and
Pharmaceutical Sciences, Okayama University, Okayama, Japan; dCariology and Operative Dentistry,
Department of Restorative Sciences, Graduate School of Medical and Dental Sciences, Tokyo Medical
and Dental University, Tokyo, Japan

ABSTRACT ARTICLE HISTORY

The objective of this study was to assess in-vitro interfacial cavity Received 27 June 2019
adaptation of different adhesive/composites systems in class-II Revised 24 August 2019
restoration using SS-OCT and to confirm the findings with a con- Accepted 17 September 2019
focal laser scanning microscope (CLSM). Standardized rectangular-
KEYWORDS
shaped class-II cavities were prepared on 24 extracted human OCT; class-II; self-etch
molar teeth, bonded with adhesive and lined with flowable com- adhesive; gap;
posite. Cavities were further restored by bulk filling using pack- microleakage; compos-
able composite. Specimens were divided into four groups (n ¼ 7) ite; adaptation
according to restorative materials used; PrimeFil with Estelite
Posterior composites (PF; Tokuyama Dental), Clearfil Tri-S Bond
Plus with Majesty LV flowable and Majesty Posterior composites
(TS; Kuraray Noritake Dental), Adper Easy bond with Filtek Z350
XT flowable and Filtek Z350 XT packable composites (AE; 3 M
ESPE) or Palfique Bond adhesive with Estelite Flow Quick flowable
and Estelite Posterior composites (BF; Tokuyama Dental). To evalu-
ate the cavity adaptation of these restorative materials, tomo-
graphic images of pulpal (P) and gingival (G) walls were obtained
by SS-OCT with a central wavelength of 1330 nm, followed by
cross-sectioning and CLSM observation to confirm OCT findings.
The results showed a significant increase in the backscattered
reflection was attributed to the interfacial gaps. AE groups dem-
onstrated the highest interfacial adaptation percentage (p < 0.05),
while TS and PF groups showed no significant difference
(p > 0.05). BF group presented the least adaptation percentage,
and the gaps were frequently observed at the adhesive/compos-
ite interface. In addition to the sensitivity of the SS-OCT to the
interfacial gaps, the success of flowable lining relies on the inter-
actions between the adhesive/tooth and adhesive/compos-
ite substrates.

CONTACT Turki A. Bakhsh taabakhsh@kau.edu.sa Department of Restorative Dentistry, Faculty of Dentistry,

King Abdulaziz University, P.O. Box 80209, Jeddah 215-89, Saudi Arabia
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
 JOURNAL OF ADHESION SCIENCE AND TECHNOLOGY 401

1. Introduction
Over the past five decades, the practice of dentistry has undergone remarkable changes,
induced by innovation of resin composite and its different bonding techniques [1].
Thereafter, adhesive dentistry has been continuously revolving and advancing toward
the reduction of the number of application steps and technique simplification [2–4].
Flowable resin-based dental composite is widely used in the current dental practice,
mostly as an esthetic dental restorative material. Despite the ease of use, good place-
ment properties and the necessity of minimal tooth intervention, polymerization
shrinkage with flowable composite is an inevitable drawback. This composite shrinkage
with low bonding performance may induce marginal discoloration, micro-leakage,
hypersensitivity, and eventually secondary caries, which may compromise the restora-
tion’s longevity and durability [5]. Thus, achievement of satisfactory composite adapta-
tion and interfacial seal is essential for the success of composite restorations.
In proximal composite restorations with two or three surfaces (known as class II res-
toration), the gingival floor is the most susceptible location for microleakage.
Therefore, several attempts were made by the manufacturers and operators to over-
come this problem by introducing new chemical formula and filling techniques [5–7].
Application of flowable composites has been advised for deep parts of proximal resto-
rations to improve cavity adaptation, marginal sealing and to act as a stress-absorbing
layer [6].
Recently, PrimFil (Tokuyama, Tokyo, Japan) was introduced as a new material
where a self-etch adhesive is combined with its specific flowable composite. The simpli-
fied restorative system differs from conventional restorative materials in that this sys-
tem does not require light activation of adhesive following the air-drying step. The
initiators required for polymerization of the adhesive layer are included in the compos-
ite and are released upon light activation of the composite. The adhesive is formulated
with a functional hydrophilic, three-dimensional self-reinforcing methacryloyloxyalkyl
acid phosphate (3 D-SR) monomer interacting with dental tissue at multiple sites [8,9].
The adhesion mechanism of this system is based on the ability of the PrimeFil primer
(bonding agent) to dissolve the smear layer and to form multiple interactions between
3 D-SR monomer and the released Ca ions from the hydroxyapatite (HA) at the tooth-
adhesive interface. Then, when PrimeFil flowable composite comes in contact with the
applied bonding agent, it will induce polymerization reaction within the bonding agent,
so-called ‘Contact-Cure mode’, which would promote chemical adhesion at the adhe-
sive-composite interface. Then, composite polymerization and interfacial adhesion will
be completed by the light irradiation.
Several evaluation techniques had been established in the dental literature for assess-
ment of internal and marginal adaptation of composite restoration. However, none of
these conventional techniques; including conventional X-ray, marginal staining and
other microleakage tests, could assess and quantify the internal composite adaptation
non-invasively and non-destructively [10,11]. In the early 1990s, optical coherence
tomography (OCT) had been introduced as a new non-invasive and non-destructive
imaging technique that can produce tomographic images of the internal scattering bio-
logical structures and non-metallic biomaterials at submicron level. Obtaining consecu-
tive cross-sectional images (B-scan) can produce three-dimensional images (C-scan)
402 T. A. BAKHSH ET AL.

[10,12]. Moreover, ‘optical biopsy’ can be attained by this system in real-time, allowing
picturing of tissue microstructure non-destructively. In dentistry, visualization of den-
tal hard and soft tissue using OCT had been reported in 1998. Later, several studies
confirmed the effectiveness of OCT in diagnosing caries, enamel remineralization, den-
tin changes, periodontal diseases as well as restoration defects [10,13–16]. The initial
system was time domain-based technology followed by frequency domain that had led
lately to development of swept-source optical coherence tomography (SS-OCT), which
is considered as one of the latest implementation of imaging technology [10]. Our
research group was able to validate the interfacial gaps in restored class-I cavities with
dental composite using SS-OCT. There was a significant correlation between elevated
values of signal intensity in B-scans appearing as bright cluster of pixels and interfacial
gap observed in confocal laser scanning microscopy (CLSM) images [5,10].
Therefore, the objective of the study was to compare the interfacial adaptation of
dentin- in class-II cavities bonded with different adhesive/composite combinations
using SS-OCT. The proposed null hypothesis was that there was no difference between
internal cavity adaptations in class-II cavities obtained from different adhesive/compos-
ite combinations.

2. Materials and methods

2.1. Restorative materials
The tested materials in this study are listed in Table 1. The lot number and chemical
composition of each material are listed according to the information provided by the
manufacturers. Four restorative bonding/composite systems were tested in this study;
(1) PrimeFil; a newly introduced primer/composite system that consist of a chemically
cured single-bottle self-etching agent and injectable flowable composites, with Estelite
Posterior packable composites (PF; Tokuyama Dental, Tokyo, Japan), (2) all-in-one
self-etch adhesive; Clearfil Tri-S Bond Plus with Majesty LV flowable and Majesty
Posterior packable composites (TS; Kuraray Noritake Dental, Tokyo, Japan). (3) Adper
Easy Bond; all-in-one self-etch adhesive, with Filtek Z350 XT flowable and Filtek Z350
XT packable composites (AE; 3 M ESPE, MN, USA), (4) all-in-one self-etch adhesive
system; Palfique Bond with Estelite Flow Quick flowable and Estelite Posterior as a
packable composites (BF; Tokuyama Dental, Tokyo, Japan).

2.2. OCT system

Swept source OCT is one of the latest non-invasive imaging modalities that encodes
the wavenumber over the time by quickly projecting the narrowband source through a
broad optical bandwidth. Reconstruction of the cross-sectional images is obtained from
a depth-reflectivity profile which is based on the detection of the fringe response
against frequency through a balanced detector. The used prototype SS-OCT system
(Dental SS-OCT Prototype II, Panasonic Healthcare, Ehime, Japan) is based on near-
infrared (NIR) imaging with a center wavelength of around 1330 nm with a waveband
of over 100 nm and sweep rate of 30 kHz [17]. This system can be used safely intra-
orally to provide two dimensional (2 D) and three dimensional (3 D) images, with an
 JOURNAL OF ADHESION SCIENCE AND TECHNOLOGY 403

Table 1. Composition of the tested materials in the study.

Material
Lot no.
(Manufacturer) Composition
PrimeFil Flow Primer:3D-SR monomer, Bis-GMA, TEGDMA, HEMA, silica
Flowable composite/primer system filler, acetone, water. Primer pH ¼ 2.1
Lot no: J101 Composite:Bis-MPEPP, Bis-GMA, TEGDMA, CQ (initiators),
(Tokuyama Dental, Japan) silica zirconia filler(fillers content 48 % vol)
(shrinkage 2.7% linear).
Clearfil tri-S bond plus 10-MDP, Bis-GMA, HEMA, hydrophilic aliphatic
Clearfil SE One – Japan) dimethacrylate, hydrophobic aliphatic methacrylate,
(One-step self-etch adhesive) sodium fluoride, colloidal silica, CQ, accelerators,
Lot no: 00007A initiators, ethanol, water. pH ~ 2.3
Clearfil Majesty LV TEGDMA, silanated barium glass powder, silanted colloidal
Flowable Composite silica, hydrophobic aromatic dimethacrylate, other
(Shade A2) (filler content 62% vol), (shrinkage 2.9% vol).
Lot no: 00214A
Clearfil majesty posterior Bis-GMA, TEGDMA, silanted silica filler, silanated glass
Packable composite ceramics, surface treated alumina filler, hydrophobic
(Shade A2) aromatic dimethacrylate, Other (filler content 82% vol),
Lot no: 00111A (shrinkage 1.5% vol).
(Kuraray Noritake, Japan)
Adper easy bond Bis-GMA, HEMA, PAA (Vitrabond Copolymer), phosphoric
(One-step self-etch adhesive) acid-methacryloxy-hexylesters,1,6 hexanediol
Lot no: 436292 dimethacrylate, silane-treted silica, CQ, ethanol, water,
stabilizers. pH ~ 2.5
Filtek Z350 XT (Filtek Supreme Ultra) Flowable BisGMA, TEGDMA, procrylat resins, ytterbium trifluoride
Flowable composite fillers, silica fillers, zirconia/silica cluster fillers (filler
(Shade A2) content 46% vol), (shrinkage 3.2% vol).
Lot no: N287306
Filtek Z350 XT (Filtek Supreme Ultra) Packable Bis-GMA, Bis-EMA, UDMA, TEGDMA, PEGDMA, zirconia/
Packable composite silica filler clusters (filler content 63.3% vol), (shrinkage
(Shade A2) 2% vol).
Lot no: N309500
(3M ESPE, USA)
Palfique Bond (Tokuyama Bond Force) MAC-10, HEMA, Bis-GMA, TEGDMA, water, isopropyl
(One-step self-etch adhesive) alcohol, glass filler, photoinitiators. pH 5 2.3.
Lot no: 139M
Estelite Flow Quick Bis-MPEPP, TEGDMA, UDMA, CQ, silica zirconia fillers (filler
Flowable composite content 53% vol), (shrinkage 2.4% linear).
(Shade A2)
Lot no: E439MM
Estelite Posterior Bis-GMA, Bisphenol A polyethoxy dimethacrylate, CQ,
Packable composite dibutyl hydroxy toluene, MEQUINOL, triethylene glycol
(Shade A2) dimethacrylate (filler content 70% vol), (shrinkage
Lot no: W030 1.5% vol).
(Tokuyama Dental, Japan)
10-MDP: 10-methacryloyloxy methacrylate; HEMA: 2-hydroxyethyl methacrylate; 3D-SR monomer: Three dimensional
surface-reinforcing monomer; Bis-GMA: Bisphenol-A-diglycidyl methacrylate; TEGDMA: Triethyleneglycol dimethacry-
late; CQ: camphorquinone; UDMA: urethane dimethacrylate; 4-MET: 4-methacryloxyethyl trimellitic acid; MAC-10:
methacryloyloxyalkyl acid phosphate; Bis-MPEPP: 2,2-bis[4-(2-methacryloyloxyethoxy)phenyl] propane; PPA: polyalke-
noic acid co-polymer; PEGDMA-polyethylene glycol dimethacrylate; Bis-EMA: bisfenol A polyethylene glycol diether
dimethacrylate.

axial and lateral optical resolution of 12 mm and 20 mm, respectively [17]. The probe
power output radiates less than 10mW near-infrared Class-1 laser, within the
American National Standards Institute safety standard. The design of the OCT hand-
held probe has been considered for dental application. The hand-held probe is
equipped with CMOS based camera for rapid imagining and capturing of the surface
details being scanned instantaneously (Figure 1).
404 T. A. BAKHSH ET AL.

Figure 1. Diagram showing the components of SS-OCT system, Prototype-II.

2.3. Restorative procedure

The adopted research design in this study, particularly the use of twenty-eight freshly
extracted, non-carious human molar teeth that were kept in cold condition at 4  C, in
0.5% chloramine/water solution meets the guiding principles for experimental steps
found in the Declaration of Helsinki of the World Medical Association, and has been
approved by the Institutional Review Board and Institutional Ethics Committee of
Tokyo Medical and Dental University.
The collected extracted teeth were cleaned from calculus and any attached tissue
debris with a periodontal scaler, followed by roots sectioning up to the furcation area
and below cementoenamel junction (CEJ) by 1.5 mm.
Standard rectangular-shaped class-II cavities with the gingival floor located at the
CEJ; 5 mm in height (occluso-gingivally), 4 mm in width (bucco-lingually) and 1.5 mm
in depth (Mesio-distally), were prepared on the proximal surface of the specimens
using a flat-end tapered cylinder diamond bur (ISO #021, Shofu, Kyoto, Japan) and fin-
ished with superfine flat-end diamond bur (ISO #013, Shofu). These specimens were
mounted on an air turbine headpiece (Ti-Max X, NSK, Kanuma, Japan), operated
under copious cooling water. In order to maintain the cutting efficiency, the bur used
for cavity preparation was replaced after completing five cavity preparations.
Afterward, these specimens were divided into four groups according to the restorative
system; PF, TS, AE, and BF with seven specimens in each group. After fixing the pre-
pared specimen in a typodont, followed by encompassing the preparation with a
Tofflemire and clear celluloid matrix, an interdental wooden wedge was positioned
 JOURNAL OF ADHESION SCIENCE AND TECHNOLOGY 405

proximally and apical to the cavity margin. Then, the entire walls of the preparation
(pulpal, axial and gingival) were bonded and lined with corresponded flowable com-
posite as a thin liner (300 mm–500 mm thickness) and light cured. Then, the corre-
sponded conventional composite was applied in bulk filling technique and light cured.
All used materials were placed and photo-cured from all aspects according to the
manufacturers’ instructions using a quartz tungsten halogen dental light cure (Optilux
501, Kerr, CA, USA; 550 mW/cm2 intensity) that was verified for consistent power
output before each application. All specimens were stored in a hydrated state for 48 h
at 37  C.

2.4. Tomographic imaging and data analysis

A schematic drawing for the sample preparation and visualization under the OCT and
CLSM is shown in Figure 2. After 48 h, ten consecutive B-scan images (buccolingual)
at successive equal distance throughout the restored pulpal (P) wall were obtained by a
hand-held SS-OCT probe for each specimen to evaluate internal composite adaptation.
Then, the specimens were trimmed and reduced occluso-gingivally (3.5 mm in height)
using 600-grit silicon carbide papers followed by six sequential scans at 250 mm interval
distance throughout the restored gingival (G) floor in buccolingual direction.
OCT image reconstruction and data analyses were conducted using an image ana-
lysis software (ImageJ v. 1.45q, National Institutes of Health, MD, USA) as described
formerly [10]. Based on our previous findings, when there is a significant increase in
the signal reflectivity (A-scan), B-scan shows bright cluster of pixels along the tooth-
resin interface, which was perceived as loss of adaptation and gap existence [12].
Initially, the reconstructed image was converted into 8-bit grayscale picture, which
then was subjected to a median filter (2 px radius) to reduce the noise. Next, the image
was cropped to the area of interest including the cavity walls in both pulpal (P) and
gingival (G) walls. The cropped image of each wall (P, G) was subjected to the binariza-
tion process according to the Isodata algorithm in the auto-threshold function of the
software to determine the target pixels with significantly higher brightness compared
to other pixels in the background. Thus, the bright clusters along the bonded walls will
be transformed into dark pixels on a white background upon initializing the binariza-
tion process. The adaptation parameter was defined as Adaptation % ¼ [(total wall
length – sum of gap length)/total wall length]  1005.

2.5. CLSM observation

In order to accomplish interfacial imaging, the specimen was reduced up to the cross-
section that was previously imaged by OCT using different sizes of silicon carbide
papers (280  2000) grit in an ascending direction. Then, the specimens were addition-
ally polished with diamond paste down to a particle size of 0.25 mm in a circular
motion under running water. After polishing, micrographs were acquired for the
bonded/debonded tooth-resin interfaces using CLSM (1LM21H/W, Lasertec,
Yokohama, Japan) at (1250) magnification.
406 T. A. BAKHSH ET AL.

Figure 2. Schematic diagram showing specimens preparation, restoration and imaging with OCT
and CLSM. D: distal; B: buccal. M: mesial; L: lingual; G: gingival; O: occlusal; CR: composite resin;
D: dentin.

2.6. Statistical analysis

Statistical analysis of the obtained results was performed using a statistical software
package (SPSS; Chicago, IL, USA) with the significance level defined as alpha ¼ 0.05.
 JOURNAL OF ADHESION SCIENCE AND TECHNOLOGY 407

Figure 3. Bar charts showing the cavity adaptation percentage at P wall (a), and at G floor (b) of
various tested groups. Groups connected with horizontal bars are not significantly different
(p < 0.05). P: pulpal; G: gingival.

As the distribution of the data in the tested groups was not normal, non-parametric
Kruskal–Wallis test was performed to determine whether there was any difference
between restorative systems. Mann-Whitney U multiple comparisons with Bonferroni
correction were later used to compare percentage of bright cluster length between the
different tested groups.

3. Results
All tested groups showed a significant increase in the signal intensity along with the
scanned tooth-resin interfaces, which was detected as target pixel (dark) in the binary
image of the cropped interface and confirmed later as interfacial gap under CLSM
(Figures 3–6). Kruskal–Wallis test with Mann–Whitney U multiple comparisons with
Bonferroni correction showed significant differences among the tested
groups (p < 0.05).
408 T. A. BAKHSH ET AL.

Figure 4. Typical B-scans and CLSM images obtained for restored PF group. Arrows (1, 2) on B-
scans (a, b) point to the same area imaged under CLSM (a00 , b00 ). (a) At P wall, no backscattered
reflection was detected at the dentin-resin interface (between arrows). (a0 ) Arrows point to the
same location after applying the binarization step to the cropped interfacial area that did not con-
tour any target pixel. (a00 ) CLSM micrograph showed no interfacial gaps between the bonded sub-
strates. (b–b00 ) The interfacial area at the G floor (between arrows) with increased backscattered
reflection in (b) was marked as target pixels (between arrows) during the binary process in (b0 ),
which was observed as interfacial gaps in CLSM micrograph (b00 ). P: pulpal; G: gingival. CR: com-
posite resin; D: dentin.

By analyzing the obtained results, AE group demonstrated the highest adaptation per-
centage (95.8%±6.1), which was significantly different (p < 0.05) from other groups at
both scanned walls (P/G), followed by TS (53.6 ± 15.7) and PF (52.9 ± 13.6). There was no
statistically significant difference between TS and PF at P wall or G wall (p > 0.05). BF
group presented the least adaptation percentage (5.1 ± 5.5) and the gaps were frequently
observed at the adhesive/composite interface. Upon examining P wall, PF (34.1 ± 14.9)
and TS (63.9 ± 22.7) showed better adaptation compared to BF (1.7 ± 3.4). However, only
PF group (71.7 ± 12.4) showed superior adaptation in G wall compared to TS (43.3 ± 8.6)
and BF (8.5 ± 7.5) (Figure 7(a–c)). Regardless of the materials, the overall results showed
no significant difference between G and P walls among the tested groups (Figure 7(d)).
Summary of adaptation percentages are demonstrated in Tables 2–4.

4. Discussion
OCT has been extensively studied due to its non-invasive capability to obtain highly
defined, sophisticated tomographic images of biological samples. It can provide in-vivo
optical biopsy with resolutions approaching that of histopathology, but in real time and
 JOURNAL OF ADHESION SCIENCE AND TECHNOLOGY 409

Figure 5. Representative B-scans and CLSM images acquired for restored TS group. Arrows (1, 2)
on B-scans (a, b) point at the same area in binary image (a, b) imaged under CLSM (a00 , b00 ).
(a–a00 ) The interfacial area at the P wall (between arrows) did not detect any high signal intensity
in (a) nor marked any target pixels (between arrows) during the binary process in (a0 ), which did
not show any debonding at same location in CLSM micrograph (a00 ). (b) At G floor, a high back-
scattered reflection was detected at the dentin-resin interface (between arrows). (b0 ) Arrows point
to the same location after applying the binarization function to the cropped interfacial area that
marked a target pixel. (b00 ) CLSM micrograph showed interfacial gaps between the bonded sub-
strates at the composite-adhesive interface. P: pulpal; G: gingival. CR: composite resin; D: dentin.

with minimal sample preparation [18]. SS-OCT is the most recent implementation of
Fourier domain OCT to reveal depth information from the sample object, which can be
reconstructed as two dimensional and three-dimensional images. This system exploits a
wavelength-tuned laser and produce the spectrally resolved interference by rapidly sweep-
ing the laser wavelength [5,10,15].
In previous studies, SS-OCT was able to detect interfacial gaps between composite
and cavity walls in class-I restorations with high c-factor [5,10]. Similarly, the loss of
adaptation in this study was clearly demonstrated on B-scans as a band of bright clus-
ter of pixels along the P and G walls, while the sections that did not show any signifi-
cant increase in the signal intensities along the imaged interfaces had revealed no loss
of cavity adaptation. Basically, when the laser source was directed over the samples; the
emitted light beam was induced to travel at dissimilar speed and interact contrarily
depending on the air, resin and dental tissue refractive indices (RI) [5,10,12,19]. The
similarity in the refractive index of composite and dentin (RI ¼ 1.5  1.6) had enabled
the emitted light to travel at the same speed and drop gradually until it fades out
(Figure 8(a)). However, if interfacial gap is present under the restoration, the variation
in RI of composite and dentin and that of air (RI ¼ 1) and water (RI ¼ 1.3); which are
410 T. A. BAKHSH ET AL.

Figure 6. B-scans and CLSM images obtained for the restored AE group specimens. Arrows on OCT
images (a, b) point to the same area observed in binary image (a, b) and CLSM (a00 , b00 ). (a–a00 )
At P wall, the existence of white clusters in B-scans (a), was correlated with binarized image of the
selected interface (a0 ), and the actual gap was observed in the confirmatory CLSM image (a00 ).
(b–b00 ) The low backscattered reflection in (b) could not be mark any target pixels in (b0 ) and no
interfacial gaps were detected at G floor. P: pulpal; G: gingival; CR: composite resin; D: dentin.

assumed to fill the gap space; is responsible for the appearance of bright clusters or
interfacial Fresnel effect (Figure 8(b)) [10,20]. The Fresnel phenomena concept could
be also applied to explain reflection from outer composite restoration, or so called
specular reflection (Figure 8). However, concerns may arise about the reflectiveness of
the adhesive layer. Although most of the adhesive are optimized compositionally with
functional monomers, photoinitiators, and nanofillers, they are still relatively transpar-
ent [21,22]. Thus, in the absence of the interfacial gaps, it would be possible to distin-
guish the adhesive layer in B-scans as a dark band interface if its thickness is within or
above the range of the OCT axial resolution system. However, this adhesive layer could
be masked or covered by Fresnel phenomena in the presence of interfacial gap [23].
It is worth mentioning that the imaging depth and NIR signal attenuation
could be affected by the pigments, size, and shape of the fillers and refractive
index of dental composite [24]. Moreover, difference in the dental composite
shades is mainly accounted for the amount of iron oxides pigments that have dif-
ferent absorption affinity to NIR wavelength [24–26]. Therefore, shallow cavity
with particular bright shade (A2) was investigated to reduce signal attenuation to
minimum [24].
In class-II composite restorations, gingival margin is the most common site for
bonding failure and hence requires optimum attention [27,28]. Numerous studies
attributed this failure to the higher number and wider diameter of the dentinal tubules
at that area when compared to the occlusal and pulpal walls [29,30].
 JOURNAL OF ADHESION SCIENCE AND TECHNOLOGY 411

Figure 7. Images for BF group specimens were obtained by OCT and CLSM. (a–a00 ) As the light
was traversing the bonded substrates in P wall, no high signal intensities were detected in (a). (a0 )
The binary image could not mark any target pixels, which showed no loss of adaptation at the
tooth-resin interface in CLSM micrograph (a00 (b–b00 ) in G floor, the high signal intensities (between
arrows) in B-scan (b) corresponded to the target pixels (between arrows) at the same location in
(b0 ) that confirmed as an interfacial gap, which most frequently was observed at adhesive-compos-
ite interface as shown in CLSM micrograph (b00 ).

Table 2. Adaptation percentage of P wall among the tested groups.

Group PF TS AE BF
Adaptation% 34.1 63.9 93.6 1.7
SD 14.9 22.7 8.8 3.4

Table 3. Adaptation percentage of G wall among the tested groups.

Group PF TS AE BF
Adaptation% 71.7 43.3 98.04 8.5
SD 12.4 8.6 3.4 7.5

Table 4. Overall adaptation percentage for the tested groups.

Group PF TS AE BF
Adaptation% 52.9 53.6 95.8 5.1
SD 13.6 15.7 6.1 5.5

Previous studies recommended the use of flowable lining with bulk filling technique
to improve the cavity adaption in class-II restoration, especially when the thickness of
the flowable lining composites is less than 1 mm [6,31,32]. However, others proposed
that residue of solvent/uncured resin monomer in some all-in-one adhesives could
interfere with adaption of the overlying flowable composite by hampering the copoly-
merization between adhesive/composite resins, especially in the absence of application/
412 T. A. BAKHSH ET AL.

Figure 8. Representative images showing the relation between Fresnel phenomena and the inter-
facial gaps in a bonded cavity restoration. (a) In the absence of the interfacial gap, the projected
light tends to cross the composite toward the dentin (relatively similar RI ¼ 1.5  1.6) at the same
speed and gradually decreases until it fades out. As a result, no interfacial Fresnel phenomena
could be detected underneath the composite. (b) However, if we assumed the gap space was filled
with air (RI ¼ 1) or water (RI ¼ 1.3), then and upon gap existence at the composite-dentin inter-
face, the detection of the bright clusters or interfacial Fresnel effect would be possible. Similar con-
cept could be applied to the outer surface of the composite to explain surface Fresnel phenomena
at air-composite interface.

displacement force required for breaking the barrier of low-reactive monomer [5,33,34].
Interestingly, this speculation was vividly noticed in BF group in the form of increased
backscattered reflection along the bonded interface before and after curing (Figure 9),
which was confirmed as loss of adaptation at the adhesive-composite interface in CLSM
images (Figure 6). Another possible contributing factor to the sub-optimal or less than
satisfactory results of this group is the nature of the utilized solvent; isopropyl alcohol
(vapor pressure 4.1 kPa at 20  C), that requires more time for complete evaporation;
during air-drying step, in comparison to solvents utilized in AE, TS (ethanol vapor pres-
sure 5.8 kPa at 20  C) and PF (acetone vapor pressure 24.5 kPa at 20  C) groups [5].
The concept of removing the light-curing step after air-drying of the adhesive fol-
lowed by flowable composite application advocated in PrimeFil adhesive/composite
system has attained the advantage of all-in-one adhesive system and flowable lining fill-
ing technique [5,9,35] in less chair-side time. According to the manufacturer, this sys-
tem requires 10 s for adhesive application and another 10 s for air-drying followed by
composite application and curing for 20 s, which had shortened the working time by
10 s. This system would be an effective approach for deep interproximal cavities espe-
cially in long restorative procedures and anxious patients.
 JOURNAL OF ADHESION SCIENCE AND TECHNOLOGY 413

Figure 9. Representative A-scans and B-scans for BF group acquired in occluso-gingival direction
and perpendicular to the P wall. (a) Before flowable composite curing, the first signal peak (solid
arrow) in A-scan represents the air-composite light interference, while the second peak (hollow
arrow) represents the interfacial Fresnel phenomena. (b) Flowable composite during the light-
curing step. Although the second peak (hollow arrow) did not disappear, the distance between the
two peaks in A-scan got closer due to the flowable composite polymerization. (c) After complete
composite curing, the second peak (hollow arrow) in A-scan was still present, which was corres-
pondent to the interfacial bright clusters in B-scan. The distance between the two peaks in A-scan
become narrower, which indicates that the light was traveling much faster through the polymer-
ized flowable composite. (d) Images for packable composite before light curing, (e) during curing,
and (f) after curing. The difference between the signal peaks of flowable composite’s A-scan and
that of packable composite could be attributed to the different composite thickness and the total
volume, which contributed to the degree of signal attenuation. E: enamel; CR: composite resin;
D: dentin.
414 T. A. BAKHSH ET AL.

The 3 D-SR monomer in PF adhesive and 10-MDP functional monomer in TS adhe-

sive have the ability to simultaneously etch and penetrate the substrate, forming a stable
ionic bond with the calcium in enamel and dentin [8,36]. However, the co-initiators in
the adhesive of PrimeFil system are optimized to initiate chemaical copolymerization
with the supplied composite upon light curing. This would be advantageous over the
light-activated adhesive in deep cavities and explains the significant difference between
both groups (TS, PF) at G wall. Moreover, the modulus of elasticity and filler loading in
the flowable composite and the subsequently applied packable composite in PF group
are relatively lower than that of flowable and packable composites in TS group. This dif-
ference could generate higher contraction stresses within the composite upon curing,
which could extend and affect the interfacial area and influence the overall bonding per-
formance and cavity adaption [9,10,37,38].
In AE group, the one-step self-etch adhesive utilizes phosphoric acid monomer that
could demineralize and infiltrate dentin effectively [36]. Furthermore, Belli et al. have
reported that increased filler contents in self-etch adhesives would increase the adhe-
sive film viscosity, improve mechanical properties and promote strengthening of the
adhesive resin interfaces with tooth and composite and strengthen the adhesive inter-
face between tooth and composite [39,40]. The increased viscosity of the all-in-one
adhesive in AE group that contains about 12% nanofillers by weight would significantly
increase its stickiness and enable it to act as a stress absorbing layer. The combination
of this adhesive with a moderate modulus of elasticity flowable composite in this group
had promoted the obtained results by reducing the generated contraction stresses,
enhancing the cavity adaptation perecentage.
Apart from the adhesive/composite combination, there was no significant difference
between the cavity adaptation at P and G walls. However, upon excluding the location
and comparing the adhesive/composite combination, the highest percentage of cavity
adaptation was seen in AE, while TS and PF groups were not significantly different,
which in turn were superior to the BF group. This could suggest that in low C-factor
cavity configurations, internal adaptation is material dependent.
Within the limitations of the study, which includes a narrow study design within a short
period and a limited number of tested materials, the proposed null hypothesis was rejected.

5. Conclusion
Success of flowable lining for class-II restoration relies on interactions of composite-
adhesive-dentin interfaces that could greatly influence the internal cavity adaptation of
composite restorations. Although further improvement in all-in-one adhesive/flowable
composites is desirable, the newly introduced PrimeFil system had shown relatively
promising results in lining large class-II cavities.
The prototype dental OCT system with a hand-held imaging probe can provide
micrometer resolution cross-sectional images of bonded substrates during routine
restorative procedures.

Disclosure statement
No potential conflict of interest was reported by the authors.
 JOURNAL OF ADHESION SCIENCE AND TECHNOLOGY 415

ORCID
Turki A. Bakhsh http://orcid.org/0000-0002-5953-4109
Alireza Sadr http://orcid.org/0000-0001-7658-0572
Alaa Turkistani http://orcid.org/0000-0002-2941-1271
Roaa Abuljadayel http://orcid.org/0000-0002-0668-6547

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