Does Different Application Modes of Universal Adhesives with Universal Resin Composites Affect the Microleakage in Class V Cavities? An In Vitro Study 

Does Different Application Modes of Universal Adhesives with Universal Resin Composites Affect the Microleakage in Class V Cavities? 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An In Vitro Study Ceyda SARI, Sinem AKGUL, Oya BALA This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3660696/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective The aim of this in vitro study was to evaluate the levels of microleakage of different modes of the Scotchbond Universal (3M ESPE, St. Paul, MN, USA) and the two novel resin composites. Materials and Methods Sixty-six freshly extracted sound human central incisors of the similar size were randomly assigned to 2 groups (n:33 per group) according to the brand of resin composite. Each group was further divided into 3 subgroups based on the universal adhesive application protocol used: (a) total etch, (b) self-etch and (c) selective etch. Each tooth was immersed in a 0.5% basic fuchsin dye solution at 37C 0 for 24 hours. After dye penetration, teeth were sectioned and evaluated with conventional (scoring) and digital methods (Image J). The intra- and inter-examiner agreement was estimated according to the Kappa statistics and the results were analyzed with the one-way ANNOVA and the Kruskal Wallis statistical tests (p < 0.05). Results The microleakage of the gingival and incisal margins are statistically similar, regardless of the composite brand and the method of application of the universal adhesive. Conclusion The microleakage exhibited by current adhesives and resins is independent of the adhesive application mode and measurement method. Clinical relevance: Evaluation of microleakage in Class V cavities using novel universal composites (Omnichroma and 3M Filtek Universal) with Scotchbond Universal adhesive, providing essential insights for clinicians grappling with challenges in adhesive restorations, such as aesthetic outcomes, polymerization stresses, and optimal adhesive protocols. Composite ImageJ Microleakage Universal adhesive Figures Figure 1 Clinical Relevance The evaluation of microleakage in Class V cavities with novel universal composites (Omnichroma and 3M Filtek Universal) and Scotchbond Universal adhesive in different modes provides valuable information for clinicians, guiding them to optimize adhesive protocols and overcome challenges related to aesthetic outcomes and restoration longevity in modern dentistry. 1. Introduction Modern dentistry aims to create biomimetic and biocompatible restorations while preserving a sound tooth tissue and maintaining the dental seal, which has been made possible with the development of adhesive techniques. One of the critical contributions has been the introduction of composites and adhesives with different properties to the market to ensure marginal tooth integrity and achieve a sufficient aesthetic. The most remarkable development in adhesives for this century is the introduction of 'universal-multimode' adhesives that can be used in any bonding strategy, such as etch-and-rinse, self-etch, or selective enamel-etch [ 1 ]. The primary concern in the literature related to these clinically simplified adhesive systems, which reduce the number of steps, is decreased bond durability after aging and indirectly occurring nano leakage, similar to self-etch adhesives [ 2 ]. Microleakage occurring at the interface between the restoration and the tooth poses a significant risk factor for various postoperative complications such as sensitivity, secondary caries, pulpal necrosis, and inflammation [ 3 ]. In order to avoid these negative effects of adhesive restorations caused by microleakage, factors such as the physical-mechanical and viscoelastic properties of the composite resin, the type of the adhesive bond, the restoration technique and cavity configurations should be carefully evaluated during restoration [ 4 ]. The progress of cervical lesions is attributed to multifactorial etiologies, with a significant contribution from microorganisms that colonize the tooth surface and cause demineralization of the enamel and dentin, leading to the eventual destruction of tooth structure[ 5 ]. In addition, masticatory forces and lateral excursive movements place tensile and shear forces on the cervical area of the teeth, which contributes to the development of non-carious cervical lesions [ 6 ]. Class V cavity restorations have many challenging conditions that affect the longevity of the restoration related to controlling moisture, reaching caries, and working close to the gingival margin [ 7 ]. Also, the high configuration factor of class V restorations makes them more susceptible to polymerization stresses, which can cause shrinkage and deformation during the light-curing process, ultimately leading to microleakage of the restoration [ 8 ]. The primary requirement of esthetic resin composite restoration is to achieve excellent color matching and to maintain optical properties over time while obtaining morphologic and biologic results that mimic natural enamel and dentine [ 9 ]. Resin composites with blending effect have been developed to provide 16 VITA Classical shade color matches with just one shade. That is possible by the composite's advanced color-matching capabilities and patented translucent filler technology [ 10 ]. Determining the best adhesive protocol for universal adhesives, whether it should involve pre-etching or self-etch strategy, is still controversial despite numerous recently developed adhesives in Class V cavities [ 11 ]. Furthermore, limited literature is available regarding the microleakage behavior exhibited by several novel resin composites that vary in color and structural characteristics. Therefore, the aim of this in vitro study was to evaluate the microleakage levels of different application modes of Scotchbond Universal (3M ESPE, St. Paul, MN, USA) performed with two novel universal composites. 2. Material Method This study was conducted according to stipulations of the Helsinki Declaration (2000) and previously approved by the Research Ethics Committee of the Gazi University under protocol number E-21071282-050.99-60064. Sixty-six freshly extracted sound human central incisors of similar size were selected for this study. Each tooth was examined microscopically (Leica DMS 1000®, Leica Microsystems, Wetzlar, Germany) under 20x magnification to rule out the presence of any structural defects, caries, restorations, cracks, and defects. A periodontal scaler was used to remove any calculus deposits and remaining connective tissue. The teeth were disinfected with a 1% Chloramine-t solution for 24 hours and then stored in distilled water at 4°C prior to use for this study to preserve their optimum mechanical and physical properties. Standardized rectangular class V conventional cavities were prepared on each tooth's buccal surface. Cavities prepared with high-speed handpiece under water cooling using cylindrical diamond bur. Cervical margins were prepared above the cemento-enamel junction (CEJ), and all cavosurface angles were 90 0 without bevel design. After five cavity preparations, the diamond bur was changed. The overall dimensions of the cavities were standardized as follows: 3 mm width, 2 mm depth, and 2 mm height incisal direction, with the gingival margin extending at least 1 mm above the enamel-cementum junction on the root surface. Then, all cavities were checked by a single operator with a periodontal explorer to ensure that they conformed to the dimensions. The specimens were randomly assigned to two groups (n:33 per group) according to the resin composite: group 1. Omnichroma (Tokuyama Dental, Tokyo, Japan), group 2. 3M Filtek Universal (3 M, Saint Paul, MN). Each group was further divided into three subgroups (n:11 per group) based on the universal adhesive application protocol used: (a) total etch, (b) self-etch, and (c) selective etch. Material compositions used in the restorations and full descriptions are illustrated in Table 1. Table 1: Products used in this study. Product Manufacturer Lot Number Composition Filler Wt% / Vol% Omnichroma Tokuyama Dental Corp., Tokyo, Japan 205S2 UDMA, TEGDMA Spherical SiO2 -ZrO2 Particle size of 260 nm 79 wt% / 68 vol% Filtek Universal Restorative 3M ESPE, Saint Paul, MN, USA NA66211 AUDMA, AFM, diurethane-DMA, and 1,12-dodecane-DMA Composed of 20 nm silica, 4 to 11 nm zirconia, and 100 nm ytterbium trifluoride 76.5 wt% / 58.4 vol% Single Bond Universal 3M ESPE, Saint Paul, MN, USA 8934765 10-MDP, HEMA, Dimethacrylate resins, Methacrylate-modified polyalkenoic acid copolymer, Filler, Ethanol, Water, Initiators, Silane - Abbreviations: AFM, addition-fragmentation monomers, AUDMA, aromatic urethane dimethacrylate, HEMA 2-Hydroxyethyl Methacrylate, bisphenol A glycidyl methacrylate, TEGDMA, triethylene glycol dimethacrylate, UDMA, diurethane dimethacrylate. For total etch mode, 37% phosphoric acid (FineEtch, Spident Co., Ltd., Korea) was applied for 30 seconds (s) to enamel and 15s to dentine; for selective etch mode, acid was applied just enamel for 30s and rinsed for 15s and air dried for 5s. The Scotchbond Universal adhesive system was applied to the cavity according to manufacturers' instructions and light cured with Elipar (Elipar FreeLight S10, 3M ESPE, USA) to all specimens for 20s. All cavities were restored with Omnichroma and 3M Filtek Restorative according to their group and then light cured for 20s. Restorations were finished with fine needle-shaped diamond burs to obtain accurate marginal adaptation. A series of aluminum oxide-coated flexible discs (Sof-Lex Contouring and Polishing Disks, 3M ESPE) were used to polish the restorations (with medium grit for 10,000 rpm and with fine and super-fine grits for 30,000 rpm for 30s) by the same operator. All specimens were subjected to 500 cycles at 5-55 C0 with a dwell time of 15s for thermal aging (MTE-101, MOD Dental, Turkey). Then, two layers of nail varnish were applied on the remaining exposed area except for 1 mm away from the restoration margins, and the apical foramina was sealed with cyanoacrylate (BOSS 8.07, Boss Industrial, Turkey). The teeth were immersed in a %0.5 basic fuchsin dye solution at 37C 0 for 24 hours. And then removed from the solution and rinsed for 30 seconds with distilled water. The samples were sectioned mid-sagitally in the mesiodistal plane with a double-face diamond saw (Horico, Diamond Instruments, Germany). Each sectioned restoration's surface was examined under a stereomicroscope with 40x magnification. Then, sections were photographed at 4x magnification with a digital camera (Canon Eos 600D, Canon, Taiwan) to evaluate the degree of dye penetration in gingival/cervical and incisal plane of restorations. Photographs were saved as TIFF images and transferred to Image Analysis software (ImageJ, National Institute of Health, Maryland, USA) at a resolution of 1280x1024. To calculate the percentage of microleakage, dye penetration measured as mm has been recorded and calculated as follows: Stained surface / Total surface of the restorative material (Fig1). The extension of dye penetration was also measured by following the ISO score system (ISO/TS 11405: 2003): Score 0 = No dye penetration Score 1 = Dye penetration into ½ of the floor Score 2 = Dye penetration of more than ½ of the gingival floor Score 3 = Dye penetration into the cervical and axial wall To compare the inter-examiner perceptibility of digital measurement and scoring, digital measurement values were converted into scores as follows: 0% penetration = Score 0 1-50 % penetration = Score 1 51-99% penetration = Score 2 100% penetration = Score 3 Power analysis determined the number of test specimens by G*Power Ver. 3.1.9.4 (Franz Faul, Universität Kiel, Kiel, Germany) software; the level of significance (alfa) was set at 0.05 with %95 power, an effect size (d) 1.47. The kappa statistics were used to analyze the intra-examiner agreement and the agreement between the score-based and digital measurements. The resulting data recorded by Image J was statistically analyzed with one-way ANOVA analysis followed by Tamhane test at p = 0.05. Mann–Whitney U and Chi-square tests were used to compare the differences in microleakage scores among different groups, comparisons between independent groups, respectively. 3. Results The intra- and inter-examiner agreement by visual scoring and image analysis was examined with Kappa. The intraclass correlation coefficient (ICC) test showed an excellent inter-examiner correlation (incisal 0.92, gingival 0.86). In the kappa analysis, where digital measurements and scores were compared, the agreement between the measurement methods was determined as substantial correlation κ = 0.70 based on the gingival scores, while the agreement between the incisal measurements was determined as κ = 0.64. 3.1. Penetration percentage The mean percentage microleakage values of the test groups are presented in Table 2 . All test materials exhibited dye penetration along the tooth-restoration interface. The highest amount of microleakage was observed on the gingival site enamel of the Omnichroma group, where universal adhesive was used in self-etch mode. The statistical analysis showed no significant difference between the incisal site and gingival site enamel margins (p > 0.05) for all tested materials and adhesive modes. Table 2 Microleakage Penetration Percentages (%) Omnichroma Filtek Universal Restorative Self-Etch İncisal 36.07 ± 22.7 27.75 ± 24.8 Gingival 41.52 ± 30.4 34.93 ± 31.8 Total Etch İncisal 28.84 ± 15.8 24.41 ± 24.0 Gingival 32.09 ± 28.1 26.05 ± 23.5 Selective Etch İncisal 26.73 ± 15.5 25.36 ± 19.0 Gingival 40.77 ± 35.0 30.183 ± 25.1 3.2. Scoring The frequency of the different scores is shown in Table 3 . In the study, the results of the Kruskal Wallis test showed that 62.4% of teeth showed microleakage (scores 1, 2 and 3) in the gingival site enamel margins. In comparison, 75.6% had microleakage (scores 1, 2 and 3) in the incisal site enamel margins, with 37.5% and 34.16% of teeth showing no microleakage (score 0) in the respective sites. The Kruskal Wallis test showed no statistical difference between the microleakage scores regardless of application mode or composite brand on both side enamel margins. Examination of the adhesive application modes using both scoring and penetration techniques revealed that the total etch method exhibited the least microleakage, even though the difference between the application modes was not statistically significant (p > 0.05). Table 3 Microleakage Penetration Scores Omnichroma Filtek Universal Restorative Score 0 Score 1 Score 2 Score 3 Score 0 Score 1 Score 2 Score 3 Self-Etch İncisal 3 17 2 0 8 10 4 0 Gingival 7 8 7 0 9 6 3 3 Total Etch İncisal 5 15 2 0 12 6 2 2 Gingival 8 8 6 0 11 7 2 1 Selective Etch İncisal 7 13 3 0 8 12 2 0 Gingival 9 8 3 3 7 13 2 0 4. Discussion Today's resin composite restorations are widely utilized in various applications ranging from anterior aesthetic restorations to wider posterior restorations, and are predominantly limited by microleakage, attributed to material shrinkage during polymerization reactions [ 12 ]. Consistent adhesion between the tooth-restoration interface is crucial for protecting restorations from the negative effects of polymerization reactions and the oral cavity's mechanical and thermal stresses [ 13 ]. Accordingly, one of the most critical considerations in the evolution of a novel resin restorative material is to extensively examine and minimize the potential for microleakage. Different methodologies are available in the literature to evaluate microleakage in vitro and in vivo [ 14 ]. I n vitro methods make it possible to detect the movement of molecules, bacteria, and radioactive materials between the restoration-tooth interface[ 15 ]. Traditionally and as a most widely accepted method, evaluation of microleakage with a conventional scoring system is used to rate the degree of dye penetration [ 16 ]. However, examination with dye penetration alone is a conventional method of which does not yield quantitative results, and intermediate intervals can be attributed to the same score [ 17 ]. As can be seen from the kappa analysis used in our study, microleakage scores evaluated with dye penetration by more than one person have different results than 10–20% of the rest [ 18 ]. In line with this approach, in the current study, image analysis was used with Image J software in addition to the dye penetration scoring method, and the two methods were compared for reliability. Digital imaging has been suggested as a suitable method for identifying minor endodontic filling abnormalities, early stages of caries lesions, periodontal bone defects, and marginal microleakage [ 19 ]. Comparison of the results showed that the two different microleakage measurement methods used were 'substantially' correlated. Contrary to expectations, although 'no agreement' was detected between the microleakage values evaluated by digital and scoring in our study, 'perfect agreement' was not detected either. While in vivo studies are considered the best method for evaluating dental materials, in vitro simulations help to predict the longevity of mechanical and structural behaviors of the composites despite some limitations [ 20 ]. In the present study, thermocycling with a range of 5–55°C and a dwell time of 15 seconds, totaling 500 cycles, was used to evaluate microleakage. This approach was chosen as it closely mimicked clinical conditions, although there is no standard methodology for thermal cycling in such studies, as observed in most research [ 21 – 23 ]. Restoration of Class V lesions is challenging, and the optimal restoration technique is still controversial among clinicians due to the presence of oblique dentin tubule morphology at the marginal edges, the difficulty of isolation, adhesion, finishing, and polymerization pattern of resin composites [ 24 , 25 ]. The preparation of Class V cavities with incisal margins produces stronger coherence bonds and poses unique challenges in the cervical surface bond due to the structure of the cement substrate [ 26 ]. Also, the high configuration factor (C-factor: 5) in Class V cavities influences the polymerization stress that occurs within the restoration during the photopolymerization of the resin and may result in microleakage. Due to the morphological differences observed in the incisal and gingival margins, these two margins were compared separately in the current study. Although more microleakage is expected to be observed due to the more significant number and diameter of dentinal tubules in the cervical region, no statistically significant difference was detected due to the contribution of current materials to successful restorations. In order to manage the polymerization kinetics in clinical conditions, the chemical components of restorative materials, primarily filler distribution and shape, have been improved [ 27 ]. Filtek Universal and Omnichroma resin composites contain nanofillers to increase the filler ratio and improve the aesthetic properties of the material [ 28 ]. While these fillers are in the form of homogeneous nano-fillers in the structure of Omnichroma composites, patented TRUE nanofiller technology is used in the structure of Filtek Universal composites, according to the manufacturer's claim. These newly developed TRUE-type fillers comprise sub-100 nm particles and clusters, providing increased filler ratio and mechanical properties. The increased filler ratio also reduced the polymerization shrinkage of the material and may explain the reduced microleakage values of the composites in the current study [ 29 ]. New resin composite materials, Filtek Universal and Omnichroma, were released to the market to overcome aesthetic issues on the anterior regions with color adjustment potential ability and new chemical composition [ 30 ]. Microleakage comparison of the two new composites yielded that both groups exhibited a low level of microleakage. However, the group where Omnichroma resin composites were applied to the cavity using the self-etch method showed a slightly higher incidence of microleakage, even though not statistically significant. Filtek Universal composites contain newly released Aromatic urethane dimethacrylate (AUDMA) and addition-fragmentation monomers (AFM), which reduce polymerization shrinkage during photopolymerization and may minimize the gaps between tooth-restoration interfaces [ 31 ]. Filtek Universal and Omnichroma, which have the blending effect feature, provide color adjustment by reflecting light from neighboring hard tissues with increased translucency by the manufacturers [ 32 ]. Omnichroma manufacturers claim that sufficient polymerization can be achieved even in deeper cavities due to increased translucency. These materials may also have provided reduced microleakage by increasing the degree of conversion with increased translucency [ 33 ]. Although it is known that the etch and rinse systems achieved higher bond strength than the self-etch systems, the formulation of the adhesives and application methods are constantly changing [ 34 ]. It is necessary to identify the optimal etching mode in order to reduce microleakage in current composite resins. Etching the dental hard tissue aims to increase the surface roughness by dissolving the hydroxyapatite minerals in the structure to eliminate the smear plugs in the dentinal tubules and to achieve adequate adhesion. Moreover, phosphoric acid etching dissolves enamel rods, creating a porose surface where the adhesive can diffuse [ 35 ]. Aside from its benefits, dentin etching could potentially result in reduced interfibrillar space, inducing a collapse in collagen fibril structure and consequently restricting the extent of monomer penetration and low quality hybrid layer [ 36 ]. Self-etch adhesives dissolve the smear layer and the underlying dentin structure with the acidic monomers in their structure, eliminating the need for a separate acid application [ 7 ]. Although they are user-friendly with these features, their adhesion success is controversial because they cause superficial demineralization of the dentin, and the dentinal tubules are partially occluded by the smear [ 37 ]. Furthermore, having low acidity may cause low bond strength at the tooth restoration interface, which may be responsible for the higher rates of marginal discoloration of cervical lesions [ 38 ]. In addition to the advantages of roughening the surfaces by etching on the inorganic structures in the enamel, the disadvantages of the organic structure were evaluated, and the concept of separate etching of enamel (selective etching) was developed to be applied with multipurpose (universal) or self-etch adhesives [ 39 ]. Although there are few results in the literature regarding the clinical outcomes of selective etching techniques, studies pointed out that the selective etching of enamel creates a more durable marginal integrity [ 38 , 40 ]. In the present study, the difference between the adhesive methods applied in different modesis not statistically significant. Similar to our results, Perdiago et al. evaluated the application of Scotchbond Universal adhesive with multi-modes in vivo and did not detect a significant difference between the application methods during the 18-month follow-up period [ 38 ]. That can be explained by the fact that Scotchbond Universal adhesive, unlike conventional self-etch adhesives, causes deeper demineralization with reduced acidity (pH > 2.5) with acidic monomers [ 41 ]. In addition to these innovations, the adhesives used in this study contain hydroxyethyl methacrylate (HEMA) and Methacryloyloxydecyl dihydrogen phosphate (MDP) monomers. 10-MDP monomers interact with calcium without deep demineralization on the dentin and enamel surface, and by providing the formation of MDP-Ca salts, it aims to increase the bond strength [ 42 ]. At the same time, the HEMA molecule in the adhesive interacts chemically with hydroxyapatite and increases the adhesion to dental tissues by increasing the wettability of dentin with its hydrophilic character [ 43 ]. Furthermore, the consistent performance of the Scotchbond Universal adhesive across different groups suggests its versatility and reliability. These findings highlight the potential of this adhesive in various applications within the field of dentistry. 5. Conclusions According to the results, it can be concluded that: 1. There is no statistically significant difference between the microleakage values of Omnichroma and Filtek Universal resin composites. 2. The microleakage of the gingival and incisal margins is statistically similar, regardless of the composite brand and the universal adhesive's application method. 3. Resin composites with color adjustment potential are suitable for use in class V cavities while being easy to handle, providing aesthetics and reduced microleakage. 4. Evaluation of microleakage in vitro can be done by conventional or quantitative methods. Declarations Funding statement: No funding was obtained for this study. Conflict of interest disclosure: The authors deny any conflicts of interest related to this study. Ethics approval statements: This study was conducted according to stipulations of the Helsinki Declaration (2000) and previously approved by the Research Ethics Committee of the Gazi University under protocol number E-21071282-050.99-60064. Patient consents statements: No references from previously published articles were used in the current study. Permision to reproduce materials from other sources: No published material (including figures/diagrams, or short extracts, or content taken from websites) from previously published articles were used in the current study. Acknowledgments: None declared Author Contribution: Ceyda SARI: Formal analysis, investigation, resources, writing, visualization, project administration, funding; Sinem AKGUL: Writing, conceptualization, methodology, investigation, resources, supervision; Oya BALA : Conceptualization, methodology, validation, resources, funding Informed Consent statements: Not applicable References Golbari N, Kasraei S, Afrasiabi A, Mostajir E, Mojahedi SM (2019) Effect of diode laser (810 nm) irradiation on marginal microleakage of multi-mode adhesive resins in class V composite restorations. 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Photomed Laser Surg 27(5):783-789. https://doi.org/10.1089/pho.2008.2313 Aminoroaya A, Neisiany RE, Khorasani SN, Panahi P, Das O, Madry H, et al (2021) A review of dental composites: Challenges, chemistry aspects, filler influences, and future insights. Compos B Eng 216:108852. https://doi.org/10.1016/j.compositesb.2021.108852 Al-Saudi K, Badran ON, Mohamed S, Nabil Amin AM (2022) Artificial accelerated aging effects on the color and gloss stability of modern universal resin composites: An in-vitro study. Egypt Dent J 68(3):2875-2886. https://doi.org/10.21608/EDJ.2022.131772.2063 Al Sunbul H, Silikas N, Watts DC (2016) Polymerization shrinkage kinetics and shrinkage-stress in dental resin-composites. Dent Mater 32(8):998-1006. https://doi.org/10.1016/j.dental.2016.05.006 de Abreu JLB, Sampaio CS, Benalcazar Jalkh EB, Hirata R (2021) Analysis of the color matching of universal resin composites in anterior restorations. J Esthet Restor Dent 33(2):269-276. https://doi.org/10.1111/jerd.12659 Cayo-Rojas CF, Hernández-Caba KK, Aliaga-Mariñas AS, Ladera-Castañeda MI (2021) Cervantes-Ganoza L.A., Microleakage in class II restorations of two bulk fill resin composites and a conventional nanohybrid resin composite: An in vitro study at 10,000 thermocycles. BMC Oral Health 21(1):1-8. https://doi.org/10.1186/s12903-021-01942-0 Furusawa K, Kobayashi S, Yamashita A, Tichy A, Hosaka K, Shimada Y, et al (2023) Effect of filler load on structural coloration and color adjustment potential of resin composites. Dent Mater J 42(3):343-350. https://doi.org/10.4012/dmj.2022-199 Salgado VE, Rego GF, Schneider LF, de Moraes RR, Cavalcante LM (2018) Does translucency influence cure efficiency and color stability of resin-based composites? Dent Mater 34(7):957-966. https://doi.org/10.1016/j.dental.2018.03.019 Rechmann P, Bartolome N, Kinsel R, Vaderhobli R, Rechmann BMT (2017) Bond strength of etch-and-rinse and self-etch adhesive systems to enamel and dentin irradiated with a novel CO2 9.3 μm short-pulsed laser for dental restorative procedures. Lasers Med Sci 32(9):1981-93. https://doi.org/10.1007/s10103-017-2302-y Silverstone L, Saxton C, Dogon IL, Fejerskov O (1975) Variation in the pattern of acid etching of human dental enamel examined by scanning electron microscopy. Caries Res 9(5):373-387. https://doi.org/10.1159/000260179 Pashley DH, Tay FR, Breschi L, Tjäderhane L, Carvalho RM, Carrilho M, et al (2011) State of the art etch-and-rinse adhesives. Dent Mater 27(1):1-16. https://doi.org/10.1016/j.dental.2010.10.016 Van Meerbeek B, Yoshihara K, Yoshida Y, Mine A, De Munck J, Van Landuyt K (2011) State of the art of self-etch adhesives, Dent Mater, 27(1):17-28. https://doi.org/10.1016/j.dental.2010.10.023 Perdigão J, Kose C, Mena-Serrano A, De Paula E, Tay L, Reis A, et al (2014) A new universal simplified adhesive: 18-month clinical evaluation. Oper Dent 39(2):113-127. https://doi.org/10.2341/13-045-C Francis T, Sakkir N, Soe H, Yeow T, Hwe H, Tze A (2020) Postoperative sensitivity of selective-etch and total-etch techniques in composite resin restorations: An in vivo study. J Clin Diagn Rest 14:ZC01-4. https://doi.org/10.7860/JCDR/2020/42997.13619 Peumans M, De Munck J, Van Landuyt KL, Poitevin A, Lambrechts P, Van Meerbeek B (2010) Eight-year clinical evaluation of a 2-step self-etch adhesive with and without selective enamel etching. Dent Mater 26(12):1176-84. https://doi.org/10.1016/j.dental.2010.08.190 Stape THS, Wik P, Mutluay MM, Al-Ani AAS (2018) Tezvergil-Mutluay A, Selective dentin etching: A potential method to improve bonding effectiveness of universal adhesives. J Mech Behav Biomed Mater 86:14-22. https://doi.org/10.1016/j.jmbbm.2018.06.015 Yoshida Y, Nagakane K, Fukuda R, Nakayama Y, Okazaki M, Shintani H, et al (2004) Comparative study on adhesive performance of functional monomers. J Dent Res 83(6):454-458. https://doi.org/10.1177/154405910408300604 Van Landuyt K, Snauwaert J, Peumans M, De Munck J, Lambrechts P, Van Meerbeek B (2008) The role of HEMA in one-step self-etch adhesives. Dent Mater 24(10):1412-1419. https://doi.org/10.1016/j.dental.2008.02.018 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3660696","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":254613333,"identity":"6cf58e51-ad7b-4657-9408-7e200ce111cc","order_by":0,"name":"Ceyda SARI","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIiWNgGAWjYJACCQiVwMDAw2CTAGEXEK8lLYGBDcQ2IF7LYYgWBjxa+Nt7DG/8YKhN3M6efPjF27bzefzy3YkfHhgwyPOLHcBuw5kzxpY9DMcTd/Y8S7Oc23a7WLKNd7ME0GGGM2cnYNViIJFjJsHDcCxxw40cM2PettuJG47xbgBpSTC4jUOL/BszyT8ILedAWjb/wKtFgsdMmoehBqTF+DFv2wGQlm14bZE4k1ZsLcNwwHjDmWdpjHPOJSfObMvdZpFgIIHTL/zthzfefMNQJ7vhePLhD2/K7BL7mc9uvvmjwkaeXxq7FgYGDgMGxn+HQSw2CWTrcSgHAfYHQKIOxGL+gEfZKBgFo2AUjGAAAJ3uZBkCHA6HAAAAAElFTkSuQmCC","orcid":"","institution":"İstanbul Medipol University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ceyda","middleName":"","lastName":"SARI","suffix":""},{"id":254613334,"identity":"9fef8de0-d2c9-46df-8b36-c51dc7db3e7d","order_by":1,"name":"Sinem AKGUL","email":"","orcid":"","institution":"Gazi University, Emek-Ankara","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sinem","middleName":"","lastName":"AKGUL","suffix":""},{"id":254613336,"identity":"b49c53d4-a178-46fe-8f38-1a4b9614ea79","order_by":2,"name":"Oya BALA","email":"","orcid":"","institution":"Gazi University, Emek-Ankara","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Oya","middleName":"","lastName":"BALA","suffix":""}],"badges":[],"createdAt":"2023-11-24 19:29:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3660696/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3660696/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":47469014,"identity":"93aa258e-106e-4533-aef0-fe018cbda54e","added_by":"auto","created_at":"2023-12-02 01:47:32","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":166815,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurements of the microleakage with ImageJ program.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3660696/v1/281cf3f1742a21d90c789dd1.jpeg"},{"id":48455892,"identity":"1237e619-ae52-47db-a14e-0d6943dd7e78","added_by":"auto","created_at":"2023-12-19 12:14:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":426707,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3660696/v1/ef78ae7e-777a-4bc7-ba55-af5b44fe842d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does Different Application Modes of Universal Adhesives with Universal Resin Composites Affect the Microleakage in Class V Cavities? An In Vitro Study ","fulltext":[{"header":"Clinical Relevance","content":"\u003cp\u003eThe evaluation of microleakage in Class V cavities with novel universal composites (Omnichroma and 3M Filtek Universal) and Scotchbond Universal adhesive in different modes provides valuable information for clinicians, guiding them to optimize adhesive protocols and overcome challenges related to aesthetic outcomes and restoration longevity in modern dentistry.\u003c/p\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eModern dentistry aims to create biomimetic and biocompatible restorations while preserving a sound tooth tissue and maintaining the dental seal, which has been made possible with the development of adhesive techniques. One of the critical contributions has been the introduction of composites and adhesives with different properties to the market to ensure marginal tooth integrity and achieve a sufficient aesthetic.\u003c/p\u003e \u003cp\u003eThe most remarkable development in adhesives for this century is the introduction of 'universal-multimode' adhesives that can be used in any bonding strategy, such as etch-and-rinse, self-etch, or selective enamel-etch [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The primary concern in the literature related to these clinically simplified adhesive systems, which reduce the number of steps, is decreased bond durability after aging and indirectly occurring nano leakage, similar to self-etch adhesives [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Microleakage occurring at the interface between the restoration and the tooth poses a significant risk factor for various postoperative complications such as sensitivity, secondary caries, pulpal necrosis, and inflammation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In order to avoid these negative effects of adhesive restorations caused by microleakage, factors such as the physical-mechanical and viscoelastic properties of the composite resin, the type of the adhesive bond, the restoration technique and cavity configurations should be carefully evaluated during restoration [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe progress of cervical lesions is attributed to multifactorial etiologies, with a significant contribution from microorganisms that colonize the tooth surface and cause demineralization of the enamel and dentin, leading to the eventual destruction of tooth structure[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition, masticatory forces and lateral excursive movements place tensile and shear forces on the cervical area of the teeth, which contributes to the development of non-carious cervical lesions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Class V cavity restorations have many challenging conditions that affect the longevity of the restoration related to controlling moisture, reaching caries, and working close to the gingival margin [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Also, the high configuration factor of class V restorations makes them more susceptible to polymerization stresses, which can cause shrinkage and deformation during the light-curing process, ultimately leading to microleakage of the restoration [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe primary requirement of esthetic resin composite restoration is to achieve excellent color matching and to maintain optical properties over time while obtaining morphologic and biologic results that mimic natural enamel and dentine [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Resin composites with blending effect have been developed to provide 16 VITA Classical shade color matches with just one shade. That is possible by the composite's advanced color-matching capabilities and patented translucent filler technology [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDetermining the best adhesive protocol for universal adhesives, whether it should involve pre-etching or self-etch strategy, is still controversial despite numerous recently developed adhesives in Class V cavities [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, limited literature is available regarding the microleakage behavior exhibited by several novel resin composites that vary in color and structural characteristics. Therefore, the aim of this \u003cem\u003ein vitro\u003c/em\u003e study was to evaluate the microleakage levels of different application modes of Scotchbond Universal (3M ESPE, St. Paul, MN, USA) performed with two novel universal composites.\u003c/p\u003e"},{"header":"2. Material Method","content":"\u003cp\u003eThis study was conducted according to stipulations of the Helsinki Declaration (2000) and previously approved by the Research Ethics Committee of the Gazi University under protocol number E-21071282-050.99-60064.\u003c/p\u003e\n\u003cp\u003eSixty-six freshly extracted sound human central incisors of similar size were selected for this study. Each tooth was examined microscopically (Leica DMS 1000\u0026reg;, Leica Microsystems, Wetzlar, Germany) under 20x magnification to rule out the presence of any structural defects, caries, restorations, cracks, and defects. A periodontal scaler was used to remove any calculus deposits and remaining connective tissue. The teeth were disinfected with a 1% Chloramine-t solution for 24 hours and then stored in distilled water at 4\u0026deg;C prior to use for this study to preserve their optimum mechanical and physical properties.\u003c/p\u003e\n\u003cp\u003eStandardized rectangular class V conventional cavities were prepared on each tooth\u0026apos;s buccal surface. Cavities prepared with high-speed handpiece under water cooling using cylindrical diamond bur. Cervical margins were prepared above the cemento-enamel junction (CEJ), and all cavosurface angles were 90\u003csup\u003e0\u003c/sup\u003e without bevel design. After five cavity preparations, the diamond bur was changed. \u0026nbsp;The overall dimensions of the cavities were standardized as follows: 3 mm width, 2 mm depth, and 2 mm height incisal direction, with the gingival margin extending at least 1 mm above the enamel-cementum junction on the root surface. Then, all cavities were checked by a single operator with a periodontal explorer to ensure that they conformed to the dimensions. The specimens were randomly assigned to two groups (n:33 per group) according to the resin composite: group 1. Omnichroma (Tokuyama Dental, Tokyo, Japan), group 2. 3M Filtek Universal (3 M, Saint Paul, MN). Each group was further divided into three subgroups (n:11 per group) based on the universal adhesive application protocol used: (a) total etch, (b) self-etch, and (c) selective etch.\u003c/p\u003e\n\u003cp\u003eMaterial compositions used in the restorations and full descriptions are illustrated in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Products used in this study.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"547\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.681318681318682%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProduct\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.681318681318682%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eManufacturer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.271062271062272%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLot Number\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.61538461538461%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComposition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.750915750915752%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFiller\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eWt% / Vol%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.681318681318682%\" valign=\"top\"\u003e\n \u003cp\u003eOmnichroma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.681318681318682%\" valign=\"top\"\u003e\n \u003cp\u003eTokuyama Dental Corp., Tokyo, Japan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.271062271062272%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;205S2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.61538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eUDMA, TEGDMA\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSpherical SiO2 -ZrO2 Particle size of 260 nm\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.750915750915752%\" valign=\"top\"\u003e\n \u003cp\u003e79 wt% / 68 vol%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.681318681318682%\" valign=\"top\"\u003e\n \u003cp\u003eFiltek Universal Restorative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.681318681318682%\" valign=\"top\"\u003e\n \u003cp\u003e3M ESPE, Saint\u003c/p\u003e\n \u003cp\u003ePaul, MN, USA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.271062271062272%\" valign=\"top\"\u003e\n \u003cp\u003eNA66211\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.61538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eAUDMA, AFM, diurethane-DMA, and 1,12-dodecane-DMA\u003c/p\u003e\n \u003cp\u003eComposed of 20 nm silica, 4 to 11 nm zirconia, and 100 nm ytterbium trifluoride\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.750915750915752%\" valign=\"top\"\u003e\n \u003cp\u003e76.5 wt% /\u003c/p\u003e\n \u003cp\u003e58.4 vol%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.681318681318682%\" valign=\"top\"\u003e\n \u003cp\u003eSingle Bond\u003c/p\u003e\n \u003cp\u003eUniversal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.681318681318682%\" valign=\"top\"\u003e\n \u003cp\u003e3M ESPE, Saint\u003c/p\u003e\n \u003cp\u003ePaul, MN, USA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.271062271062272%\" valign=\"top\"\u003e\n \u003cp\u003e8934765\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.61538461538461%\" valign=\"top\"\u003e\n \u003cp\u003e10-MDP, HEMA, Dimethacrylate resins, Methacrylate-modified polyalkenoic acid copolymer, Filler, Ethanol, Water, Initiators, Silane\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.750915750915752%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e AFM, addition-fragmentation monomers, AUDMA, aromatic urethane dimethacrylate, HEMA 2-Hydroxyethyl Methacrylate, bisphenol A glycidyl methacrylate, TEGDMA, triethylene glycol dimethacrylate, UDMA, diurethane dimethacrylate.\u003c/p\u003e\n\u003cp\u003eFor total etch mode, 37% phosphoric acid (FineEtch, Spident Co., Ltd., Korea) was applied for 30 seconds (s) to enamel and 15s to dentine; for selective etch mode, acid was applied just enamel for 30s and rinsed for 15s and air dried for 5s. The Scotchbond Universal adhesive system was applied to the cavity according to manufacturers\u0026apos; instructions and light cured with Elipar (Elipar FreeLight S10, 3M ESPE, USA) to all specimens for 20s. All cavities were restored with Omnichroma and 3M Filtek Restorative according to their group and then light cured for 20s. Restorations were finished with fine needle-shaped diamond burs to obtain accurate marginal adaptation. A series of aluminum oxide-coated flexible discs (Sof-Lex Contouring and Polishing Disks, 3M ESPE) were used to polish the restorations (with medium grit for 10,000 rpm and with fine and super-fine grits for 30,000 rpm for 30s) by the same operator. All specimens were subjected to 500 cycles at 5-55 C0 with a dwell time of 15s for thermal aging (MTE-101, MOD Dental, Turkey). Then, two layers of nail varnish were applied on the remaining exposed area except for 1 mm away from the restoration margins, and the apical foramina was sealed with cyanoacrylate (BOSS 8.07, Boss Industrial, Turkey). The teeth were immersed in a %0.5 basic fuchsin dye solution at 37C\u003csup\u003e0\u003c/sup\u003e for 24 hours. And then removed from the solution and rinsed for 30 seconds with distilled water. The samples were sectioned mid-sagitally in the mesiodistal plane with a double-face diamond saw (Horico, Diamond Instruments, Germany). Each sectioned restoration\u0026apos;s surface was examined under a stereomicroscope with 40x magnification. Then, sections were photographed at 4x magnification with a digital camera (Canon Eos 600D, Canon, Taiwan) to evaluate the degree of dye penetration in gingival/cervical and incisal plane of restorations. Photographs were saved as TIFF images and transferred to Image Analysis software (ImageJ, National Institute of Health, Maryland, USA) at a resolution of 1280x1024. To calculate the percentage of microleakage, dye penetration measured as mm has been recorded and calculated as follows: Stained surface / Total surface of the restorative material (Fig1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe extension of dye penetration was also measured by following the ISO score system (ISO/TS 11405: 2003):\u003c/p\u003e\n\u003cp\u003eScore 0 = No dye penetration\u003c/p\u003e\n\u003cp\u003eScore 1 = Dye penetration into \u0026frac12; of the floor\u003c/p\u003e\n\u003cp\u003eScore 2 = Dye penetration of more than \u0026frac12; of the gingival floor\u003c/p\u003e\n\u003cp\u003eScore 3 = Dye penetration into the cervical and axial wall\u003c/p\u003e\n\u003cp\u003eTo compare the inter-examiner perceptibility of digital measurement and scoring, digital measurement values were converted into scores as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0% penetration = Score 0\u003c/p\u003e\n\u003cp\u003e1-50 % penetration = Score 1\u003c/p\u003e\n\u003cp\u003e51-99% penetration = Score 2\u003c/p\u003e\n\u003cp\u003e100% penetration = Score 3\u003c/p\u003e\n\u003cp\u003ePower analysis determined the number of test specimens by G*Power Ver. 3.1.9.4 (Franz Faul, Universit\u0026auml;t Kiel, Kiel, Germany) software; the level of significance (alfa) was set at 0.05 with %95 power, an effect size (d) 1.47.\u003c/p\u003e\n\u003cp\u003eThe kappa statistics were used to analyze the intra-examiner agreement and the agreement between the score-based and digital measurements. The resulting data recorded by Image J was statistically analyzed with one-way ANOVA analysis followed by Tamhane test at p = 0.05. Mann\u0026ndash;Whitney U and Chi-square tests were used to compare the differences in microleakage scores among different groups, comparisons between independent groups, respectively.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe intra- and inter-examiner agreement by visual scoring and image analysis was examined with Kappa. The intraclass correlation coefficient (ICC) test showed an excellent inter-examiner correlation (incisal 0.92, gingival 0.86).\u003c/p\u003e \u003cp\u003eIn the kappa analysis, where digital measurements and scores were compared, the agreement between the measurement methods was determined as substantial correlation κ\u0026thinsp;=\u0026thinsp;0.70 based on the gingival scores, while the agreement between the incisal measurements was determined as κ\u0026thinsp;=\u0026thinsp;0.64.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Penetration percentage\u003c/h2\u003e \u003cp\u003eThe mean percentage microleakage values of the test groups are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All test materials exhibited dye penetration along the tooth-restoration interface. The highest amount of microleakage was observed on the gingival site enamel of the Omnichroma group, where universal adhesive was used in self-etch mode. The statistical analysis showed no significant difference between the incisal site and gingival site enamel margins (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) for all tested materials and adhesive modes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMicroleakage Penetration Percentages (%)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOmnichroma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFiltek Universal Restorative\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-Etch\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eİncisal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e36.07\u0026thinsp;\u0026plusmn;\u0026thinsp;22.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e27.75\u0026thinsp;\u0026plusmn;\u0026thinsp;24.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGingival\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e41.52\u0026thinsp;\u0026plusmn;\u0026thinsp;30.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e34.93\u0026thinsp;\u0026plusmn;\u0026thinsp;31.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Etch\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eİncisal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e28.84\u0026thinsp;\u0026plusmn;\u0026thinsp;15.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e24.41\u0026thinsp;\u0026plusmn;\u0026thinsp;24.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGingival\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e32.09\u0026thinsp;\u0026plusmn;\u0026thinsp;28.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e26.05\u0026thinsp;\u0026plusmn;\u0026thinsp;23.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelective Etch\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eİncisal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e26.73\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e25.36\u0026thinsp;\u0026plusmn;\u0026thinsp;19.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGingival\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e40.77\u0026thinsp;\u0026plusmn;\u0026thinsp;35.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e30.183\u0026thinsp;\u0026plusmn;\u0026thinsp;25.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Scoring\u003c/h2\u003e \u003cp\u003eThe frequency of the different scores is shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. In the study, the results of the Kruskal Wallis test showed that 62.4% of teeth showed microleakage (scores 1, 2 and 3) in the gingival site enamel margins. In comparison, 75.6% had microleakage (scores 1, 2 and 3) in the incisal site enamel margins, with 37.5% and 34.16% of teeth showing no microleakage (score 0) in the respective sites. The Kruskal Wallis test showed no statistical difference between the microleakage scores regardless of application mode or composite brand on both side enamel margins. Examination of the adhesive application modes using both scoring and penetration techniques revealed that the total etch method exhibited the least microleakage, even though the difference between the application modes was not statistically significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMicroleakage Penetration Scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eOmnichroma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003eFiltek Universal Restorative\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScore 0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eScore 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-Etch\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eİncisal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGingival\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Etch\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eİncisal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGingival\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelective Etch\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eİncisal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGingival\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eToday's resin composite restorations are widely utilized in various applications ranging from anterior aesthetic restorations to wider posterior restorations, and are predominantly limited by microleakage, attributed to material shrinkage during polymerization reactions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsistent adhesion between the tooth-restoration interface is crucial for protecting restorations from the negative effects of polymerization reactions and the oral cavity's mechanical and thermal stresses [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Accordingly, one of the most critical considerations in the evolution of a novel resin restorative material is to extensively examine and minimize the potential for microleakage.\u003c/p\u003e \u003cp\u003eDifferent methodologies are available in the literature to evaluate microleakage \u003cem\u003ein vitro\u003c/em\u003e and \u003cem\u003ein vivo\u003c/em\u003e [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. I\u003cem\u003en vitro\u003c/em\u003e methods make it possible to detect the movement of molecules, bacteria, and radioactive materials between the restoration-tooth interface[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Traditionally and as a most widely accepted method, evaluation of microleakage with a conventional scoring system is used to rate the degree of dye penetration [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, examination with dye penetration alone is a conventional method of which does not yield quantitative results, and intermediate intervals can be attributed to the same score [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. As can be seen from the kappa analysis used in our study, microleakage scores evaluated with dye penetration by more than one person have different results than 10\u0026ndash;20% of the rest [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In line with this approach, in the current study, image analysis was used with Image J software in addition to the dye penetration scoring method, and the two methods were compared for reliability. Digital imaging has been suggested as a suitable method for identifying minor endodontic filling abnormalities, early stages of caries lesions, periodontal bone defects, and marginal microleakage [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Comparison of the results showed that the two different microleakage measurement methods used were 'substantially' correlated. Contrary to expectations, although 'no agreement' was detected between the microleakage values evaluated by digital and scoring in our study, 'perfect agreement' was not detected either.\u003c/p\u003e \u003cp\u003eWhile \u003cem\u003ein vivo\u003c/em\u003e studies are considered the best method for evaluating dental materials, \u003cem\u003ein vitro\u003c/em\u003e simulations help to predict the longevity of mechanical and structural behaviors of the composites despite some limitations [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In the present study, thermocycling with a range of 5\u0026ndash;55\u0026deg;C and a dwell time of 15 seconds, totaling 500 cycles, was used to evaluate microleakage. This approach was chosen as it closely mimicked clinical conditions, although there is no standard methodology for thermal cycling in such studies, as observed in most research [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRestoration of Class V lesions is challenging, and the optimal restoration technique is still controversial among clinicians due to the presence of oblique dentin tubule morphology at the marginal edges, the difficulty of isolation, adhesion, finishing, and polymerization pattern of resin composites [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The preparation of Class V cavities with incisal margins produces stronger coherence bonds and poses unique challenges in the cervical surface bond due to the structure of the cement substrate [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlso, the high configuration factor (C-factor: 5) in Class V cavities influences the polymerization stress that occurs within the restoration during the photopolymerization of the resin and may result in microleakage. Due to the morphological differences observed in the incisal and gingival margins, these two margins were compared separately in the current study. Although more microleakage is expected to be observed due to the more significant number and diameter of dentinal tubules in the cervical region, no statistically significant difference was detected due to the contribution of current materials to successful restorations.\u003c/p\u003e \u003cp\u003eIn order to manage the polymerization kinetics in clinical conditions, the chemical components of restorative materials, primarily filler distribution and shape, have been improved [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Filtek Universal and Omnichroma resin composites contain nanofillers to increase the filler ratio and improve the aesthetic properties of the material [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. While these fillers are in the form of homogeneous nano-fillers in the structure of Omnichroma composites, patented TRUE nanofiller technology is used in the structure of Filtek Universal composites, according to the manufacturer's claim. These newly developed TRUE-type fillers comprise sub-100 nm particles and clusters, providing increased filler ratio and mechanical properties. The increased filler ratio also reduced the polymerization shrinkage of the material and may explain the reduced microleakage values of the composites in the current study [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNew resin composite materials, Filtek Universal and Omnichroma, were released to the market to overcome aesthetic issues on the anterior regions with color adjustment potential ability and new chemical composition [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Microleakage comparison of the two new composites yielded that both groups exhibited a low level of microleakage. However, the group where Omnichroma resin composites were applied to the cavity using the self-etch method showed a slightly higher incidence of microleakage, even though not statistically significant. Filtek Universal composites contain newly released Aromatic urethane dimethacrylate (AUDMA) and addition-fragmentation monomers (AFM), which reduce polymerization shrinkage during photopolymerization and may minimize the gaps between tooth-restoration interfaces [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFiltek Universal and Omnichroma, which have the blending effect feature, provide color adjustment by reflecting light from neighboring hard tissues with increased translucency by the manufacturers [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Omnichroma manufacturers claim that sufficient polymerization can be achieved even in deeper cavities due to increased translucency. These materials may also have provided reduced microleakage by increasing the degree of conversion with increased translucency [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough it is known that the etch and rinse systems achieved higher bond strength than the self-etch systems, the formulation of the adhesives and application methods are constantly changing [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. It is necessary to identify the optimal etching mode in order to reduce microleakage in current composite resins.\u003c/p\u003e \u003cp\u003eEtching the dental hard tissue aims to increase the surface roughness by dissolving the hydroxyapatite minerals in the structure to eliminate the smear plugs in the dentinal tubules and to achieve adequate adhesion. Moreover, phosphoric acid etching dissolves enamel rods, creating a porose surface where the adhesive can diffuse [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Aside from its benefits, dentin etching could potentially result in reduced interfibrillar space, inducing a collapse in collagen fibril structure and consequently restricting the extent of monomer penetration and low quality hybrid layer [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSelf-etch adhesives dissolve the smear layer and the underlying dentin structure with the acidic monomers in their structure, eliminating the need for a separate acid application [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although they are user-friendly with these features, their adhesion success is controversial because they cause superficial demineralization of the dentin, and the dentinal tubules are partially occluded by the smear [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Furthermore, having low acidity may cause low bond strength at the tooth restoration interface, which may be responsible for the higher rates of marginal discoloration of cervical lesions [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to the advantages of roughening the surfaces by etching on the inorganic structures in the enamel, the disadvantages of the organic structure were evaluated, and the concept of separate etching of enamel (selective etching) was developed to be applied with multipurpose (universal) or self-etch adhesives [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Although there are few results in the literature regarding the clinical outcomes of selective etching techniques, studies pointed out that the selective etching of enamel creates a more durable marginal integrity [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study, the difference between the adhesive methods applied in different modesis not statistically significant. Similar to our results, Perdiago et al. evaluated the application of Scotchbond Universal adhesive with multi-modes \u003cem\u003ein vivo\u003c/em\u003e and did not detect a significant difference between the application methods during the 18-month follow-up period [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. That can be explained by the fact that Scotchbond Universal adhesive, unlike conventional self-etch adhesives, causes deeper demineralization with reduced acidity (pH\u0026thinsp;\u0026gt;\u0026thinsp;2.5) with acidic monomers [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In addition to these innovations, the adhesives used in this study contain hydroxyethyl methacrylate (HEMA) and Methacryloyloxydecyl dihydrogen phosphate (MDP) monomers. 10-MDP monomers interact with calcium without deep demineralization on the dentin and enamel surface, and by providing the formation of MDP-Ca salts, it aims to increase the bond strength [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. At the same time, the HEMA molecule in the adhesive interacts chemically with hydroxyapatite and increases the adhesion to dental tissues by increasing the wettability of dentin with its hydrophilic character [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, the consistent performance of the Scotchbond Universal adhesive across different groups suggests its versatility and reliability. These findings highlight the potential of this adhesive in various applications within the field of dentistry.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eAccording to the results, it can be concluded that:\u003c/p\u003e\n\u003cp\u003e1. There is no statistically significant difference between the microleakage values of Omnichroma and Filtek Universal resin composites.\u003c/p\u003e\n\u003cp\u003e2. The microleakage of the gingival and incisal margins is statistically similar, regardless of the composite brand and the universal adhesive\u0026apos;s application method.\u003c/p\u003e\n\u003cp\u003e3. Resin composites with color adjustment potential are suitable for use in class V cavities while being easy to handle, providing aesthetics and reduced microleakage.\u003c/p\u003e\n\u003cp\u003e4. Evaluation of microleakage \u003cem\u003ein vitro\u003c/em\u003e can be done by conventional or quantitative methods.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding statement:\u0026nbsp;\u003c/strong\u003eNo funding was obtained for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest disclosure:\u0026nbsp;\u003c/strong\u003eThe authors deny any conflicts of interest related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval statements:\u003c/strong\u003e This study was conducted according to stipulations of the Helsinki Declaration (2000) and previously approved by the Research Ethics Committee of the Gazi University under protocol number E-21071282-050.99-60064.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consents statements:\u003c/strong\u003e No references from previously published articles were used in the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePermision to reproduce materials from other sources:\u003c/strong\u003e No published material (including figures/diagrams, or short extracts, or content taken from websites) from previously published articles were used in the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eNone declared\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution:\u003c/strong\u003e\u0026nbsp; \u003cem\u003eCeyda SARI:\u003c/em\u003e Formal analysis, investigation, resources, writing, visualization, project administration, funding; \u003cem\u003eSinem AKGUL:\u003c/em\u003e Writing, conceptualization, methodology, investigation, resources, supervision; \u003cem\u003eOya BALA\u003c/em\u003e: Conceptualization, methodology, validation, resources, funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent statements:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGolbari N, Kasraei S, Afrasiabi A, Mostajir E, Mojahedi SM (2019) Effect of diode laser (810 nm) irradiation on marginal microleakage of multi-mode adhesive resins in class V composite restorations. 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Dent Mater 24(10):1412-1419. https://doi.org/10.1016/j.dental.2008.02.018\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Composite, ImageJ, Microleakage, Universal adhesive","lastPublishedDoi":"10.21203/rs.3.rs-3660696/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3660696/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThe aim of this \u003cem\u003ein vitro\u003c/em\u003e study was to evaluate the levels of microleakage of different modes of the Scotchbond Universal (3M ESPE, St. Paul, MN, USA) and the two novel resin composites.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eSixty-six freshly extracted sound human central incisors of the similar size were randomly assigned to 2 groups (n:33 per group) according to the brand of resin composite. Each group was further divided into 3 subgroups based on the universal adhesive application protocol used: (a) total etch, (b) self-etch and (c) selective etch. Each tooth was immersed in a 0.5% basic fuchsin dye solution at 37C\u003csup\u003e0\u003c/sup\u003e for 24 hours. After dye penetration, teeth were sectioned and evaluated with conventional (scoring) and digital methods (Image J). The intra- and inter-examiner agreement was estimated according to the Kappa statistics and the results were analyzed with the one-way ANNOVA and the Kruskal Wallis statistical tests (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe microleakage of the gingival and incisal margins are statistically similar, regardless of the composite brand and the method of application of the universal adhesive.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe microleakage exhibited by current adhesives and resins is independent of the adhesive application mode and measurement method.\u003c/p\u003e\u003ch2\u003eClinical relevance:\u003c/h2\u003e \u003cp\u003eEvaluation of microleakage in Class V cavities using novel universal composites (Omnichroma and 3M Filtek Universal) with Scotchbond Universal adhesive, providing essential insights for clinicians grappling with challenges in adhesive restorations, such as aesthetic outcomes, polymerization stresses, and optimal adhesive protocols.\u003c/p\u003e","manuscriptTitle":"Does Different Application Modes of Universal Adhesives with Universal Resin Composites Affect the Microleakage in Class V Cavities? 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