Clinical evaluation of three fissure sealants: 24 month follow-up.
Aim: This was to compare 3 different materials for fissure sealing (FS) after a clinical use during a 24 month period and to assess the use of flowable composite resins in combination with dentine adhesives as sealing materials. Study Design: There were 41 patients aged from 7-17 years, for whom 100 permanent molars were sealed with 3 different sealing materials. Methods: Group A, 33 teeth were sealed material Helioseal Clear Chroma (Vivadent, Schaan, Liechtenstein); Group B, 33 teeth were sealed with Teethmate F1 (Kuraray, Kurashiki, Japan), and in Group C, 34 teeth were sealed with the flowable composite Tetric Flow (Vivadent, Schaan, Liechtenstein). For the analysis of the degree of retention, the criteria used were: 0-complete retention, 1-loss of 1/3 of material, 2-loss of 2/3 of material, 3-complete loss of material. Clinical criteria for appearance of a new caries lesion included following values: Caries present (+) or caries absent (-). Statistics: Chi-Square test was used for statistical analysis of retention rates between groups. Results: After the 24 month period, the highest retention rate of complete retention was established for the material Tetric Flow of 76.5%, Helioseal Clear Croma 66.7%, and Teethmate F1 60.6%. The incidence of caries with Helioseal Clear Croma was 6.1%, for Teethmate F1 3%, with no statistically significant difference after the 24 months period (p=0.656). In the group of teeth sealed with Tetric Flow, there was not a single case of caries noted. Conclusions: The use of flowable composite resins as sealing materials is equal to other materials for fissure sealing.
Key words: fissure sealing, retention rate, flowable composite, adhesives
The use of fluorides has significantly decreased the incidence of caries on smooth surfaces of the teeth. According to recent studies, occlusal surfaces of the teeth are the most susceptible to dental caries development, so that 67% to 90% of all caries lesions in children aged from 5 to 17 are developed on the occlusal surfaces [Kaste et al., 1996; Brown et al., 1999; Meneghin et al., 1999]. Although 60% of all caries lesions comprise occlusal caries, these tooth surfaces constitute only 12.5% of all surfaces that can develop caries.
It has been more than 40 years since Buonocore  and later Takeuchi and Kizu  suggested the use of an organic plastic mass for use as a fissure sealant (FS). Since then, many new innovations and improvements in the production and use of sealing materials (cyanoacrylate, bisphenol A-glydicil methacrylate (Bis-GMA), methyl-methacrylate (MMA) and polyurethane) have occurred.
A sealing material works as an efficient mechanical barrier to plaque retention, which brings to the minimum dangerous action of the cariogenic microorganisms on the tooth enamel [Ripa, 1993]. Also, preventive success of a FS depends on its ability to close fissures, pits and other morphological defects to the full and to stay intact and attached to the enamel surface as long as possible [Ripa, 1993; Tulunoglu et al., 1999]. On the other hand, partial loss of a FS may lead-to marginal leakage resulting in caries development under the FS. The results of clinical studies have shown that the degree of retention of sealing material is essential for success [Simonsen, 1991].
The FS materials are completely successful if there is good retention. Studies have shown that yearly loss of FS is between 5-10% [Ismail and Gagnon, 1995; Simonsen, 1991]. Also, some more recent studies have shown yearly losses of up to 14% [Gungor et al., 2004], 15-25% [Pardi et al., 2005], 16-23% [Dukic and Glavina, 2006], and 45-55% [Yildiz et al., 2004].
The physical characteristics of FS, such as viscosity, flow ability and resistance to wear, are very important factors for retention and caries prevention. Loss of micro-mechanical retention on etched surface of the enamel, insufficient etching, contamination with saliva or moist air are reasons for loss of FS and caries development [Ripa, 1993; Lygidakis et al., 1994; Kanelis et al., 1997].
The aim of this study was to compare three different materials for FS over a 24 month period, and to assess the use of flowable composite resins in combination with dentine adhesives as sealing materials.
Materials and Methods
The study was carried out in Dept. Pedodontics, School of Dentistry, University of Zagreb. A total of 41 patients aged from 7-17 years were enrolled in the study using the criteria of maxillary and mandibular permanent molars which showed an absence of caries under standard dental lighting conditions. Any partially erupted molars or molars covered with operculeum were excluded from the study as in those cases a dry working field could not be obtained. By this selection, 100 permanent molars were sealed and divided into 3 groups:
* Group A, 33 teeth were sealed with Helioseal Clear Chroma[R] (Vivadent, Schaan, Liechtenstein);
* Group B, 33 teeth were sealed with Teethmate F1[R] (Kuraray, Kurashiki, Japan);
* Group C, 34 teeth were sealed with the flowable com posite Tetric Flow[R] (Vivadent, Schaan Liechtenstein).
All FS were placed by 3 dentists using a standardized procedure. Before sealing, each fissure system was cleaned of any plaque residue by bristle brush and prophylactic paste. Cleaning was followed by isolation with cotton rolls and saliva ejector, and by etching of the occlusal surfaces with 37% phosphoric acid solution for 40 secs. All surface for FS were then rinsed with water and dried with air blast for 20 secs until the enamel had a chalky white appearance. The FS materials were applied by cannullae. All FS were cured for 40 secs exposure with Elipar LED polymerizations lamp (3M ESPE).
In Group C (Tetric Flow[R]), after cleaning of fissures, as described above, the adhesive system Excite was applied by applicator brush into the fissure systems for 10 secs, followed by blowing with air, to provide a thin layer, and curing for 10 secs. Then, Tetric Flow[R] was applied by enclosed cannullae and cured for 40 seconds.
Sealing of the teeth was followed by a check for discontinuity and occlusion with articulation paper. Irregularities (bubbles of air, cracks or insufficient amount of material placed into the fissure) were corrected immediately with adding of a material or by adjusting high spots.
For the analysis of the degree of retention the method described by Dukic and Glavinia  was used as shown in Figure 1:
* complete retention,
* loss of 1/3 of material,
* loss of 2/3 of material,
* complete loss of material.
Clinical criteria for appearance of a new caries lesion included caries present (+) or caries absent (-). Chi-Square test was used for statistical analysis.
After the 24 month period, the best retention rate (complete retention) was for Tetric Flow of 76.5%. Helioseal Clear Croma had the retention rate of 66.7%, and Teethmate F1 had the complete retention rate of 60.6%. All materials show the highest partial loss of a sealant in the group of 1/3 of the sealant after 24 month period. Within the group, the highest partial loss was established for Teethmate F1 (30.0%), and the lowest for Helioseal Clear Chroma (18.2%). There was not a single case of loss of 2/3 material noted down in Tetric Flow group. There was no statistically significant difference in retention between these sealing materials after a 24 months period (p=0.656). The incidence of caries with Helioseal Clear Croma was 6.1%, with Teethmate F1 3%, with no statistically significant difference. In the group of teeth sealed with Tetric Flow, there was not a single case of caries noted down.
[FIGURE 1 OMITTED]
Only on three sealed teeth was a caries lesion detected after 24 months, one in the group sealed with Teethmate F1 and two in the group sealed with Helioseal Clear Chroma. At Tetric Flow material, there was no caries detected after 24 month period. The appearance of new caries lesions was related to a partial or complete loss of the material from the fissure.
The relatively new technique of flowable composite Tetric Flow[R] in combination with the adhesive system Excite, as a sealing material, was assessed its clinical success as a sealing material. Corona , in her study used the flowable composite Flow-It[R] in combination with the adhesive system Bond 1[R], and reported a retention rate of 100%, after 12 months. Also, Pardi et al,  showed complete retention rate of the flowable composite Revolution[R] in combination with the adhesive system Optibond Solo[R], of 84.4% after 12 months and 76.3% after 24 months. The present authors have previously reported a retention rate of the Tetric Flow[R] in combination with the Excite[R] adhesive of 84% after a12 month period [Dukic and Glavina, 2006] and now in this continued follow-up of 76.5%.
Other studies have shown extremely low retention rate values of 40% for the flowable composite Cu Ray-Match[R] as a sealing material, after a18 month period. And these low values were related to the fact that no adhesive system was used before placement of a flowable composite resin in the fissures [Autio-Gold, 2002]. The retention rate, besides the use of an adhesive system, can be affected by a working technique and the degree of viscosity of the material with a higher viscosity then there might be problems in a complete obturation of the depth of a fissure system. Also, the elasticity of a composite resin material and its durability with contraction and expansion characteristics relative to enamel, during mastication, can affect the retention rate. We recommend further research to confirm such statements. Also, they assume that dental adhesives have an impact on flowable composite resins as sealing materials, which has to be a subject of future studies. Clinical studies recommend the use of an adhesive system before placement of a flowable composite resin into fissures [Autio-Gold, 2002; Corona, 2005; Dukic and Glavina, 2006].
Many laboratory research's have confirmed good mechanical and chemical characteristics of flowable composite resins related to their penetration ability into the fissures [Kakaboura et al., 2002 ] and their ability of sealing deep fissures [Gillet et al., 2002]. Also, flowable composite resins show less surface porosity than the conventional sealing materials, which possibly affects the retention and long-term durability of the seal.
Considering the retention of other FS, this study recorded retention of 60.6% for Teethmate F1[R] and 66.7% for Helioseal Clear Croma[R] after a 24 months period. Similar results over the same period of time, were described by Autio-Gold  for Delton[R] (64.6% after 18 months). Numerous studies report complete retention rates of 50.8% over a 24 months period for Concise White Sealant[R] and 42.6% for Helioseal F[R] [Yildiz, 2004], other studies report retention rates of 71.4% for Delton FS+[R] and of 80% for Dyract Seal[R] [Gungor et al., 2004]. Low rates of 22% were recorded for FluoroShield[R] and 20% for Compoglass[R] [Puppin-Rontani et al., 2006], but medium to high of 47.4% for Vitremer[R]; 76.3% for Revolution[R] and of 58.4% for Dyract Flow[R] [Pardi et al, 2005]. The latter study also showed better retention results after a 24 month period for the flowable composite resin Revolution[R] compared with Dyract Flow[R] and resin-modified GIC Vitremer[R] [Pardi et al., 2005].
Longer term studies, over a 36 month period, on retention of a FS report complete retention rates of 95.8% for the Helioseal F[R] [Vrbic, 1999], and of 70% for the Fluoroshield[R] [Rock et al., 1996]. Studies over 48 months showed a complete retention rate of 77% for Fluoroshield[R] and of 89% for Delton[R] [Lygidakis and Oulis, 1999]. A very long-term study over 84 months showed a complete retention rate of 45% for Delton[R] [Forss and Halme, 1998].
It is important to point out that there are no two identical clinical studies concerning the retention rate of FS. Studies differ in methods of evaluation of the retention of FS, pretreatments of enamel, selection of FS, experience of the operator(s) and in other technical and physical parameters. All of these influence the final results of the retention of FS.
In this study of 100 FS over 24 months only 3 cases of caries lesions were recorded, 1 for Teethmate F1[R], and 2 for Helioseal Clear Chroma[R]. These records report efficiency of FS as a preventive procedure for the protection of an occlusal surface. These results correspond with those of other studies where the incidence of caries was established at 4.3% for the flowable composite Revolution[R] and 6.7% for the Dyract Flow[R], which confirms a low incidence of caries [Pardi et al., 2005].
Laboratory studies indicate possible problems when using a self-etching adhesive before application of the flowable composite resins in FS. The main problems are a lower adhesive strength, high rate of microleakage and lower etcing ability [Kanemura et al., 1999; Perry and Rueggeberg, 2003; Hannig et al., 2004]. The enamel in the fissure system is more resistant to etching because of its anatomic and physical characteristics, which is explained by its complex system of prismless enamel between the entrance and the walls of the fissure. Tay et al.  also showed that self etched adhesives do not penetrate deep enough into the enamel fissure, so that penetration is restricted only to the prismless enamel. The reduction of caries development in the fissures is more related to the quality of FS retention, rather than the content of the material and to the type of the material [Yildtz et al., 2004].
The use of flowable composite resins as sealing materials is comparable to other materials for fissure sealing. Flowable composite resin as sealants should be used in combination with a dentine bonding agents as they can improve the strength of the adhesive bonding to the enamel of the fissures and to reduce marginal microleakage, which should lead to an increased of the retention rate.
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W. Dukic, D. Glavina
Dept. Paediatric dentistry, School of Dental Medicine, University of Zagreb, Croatia
Postal address: Dr. W. Dukic., Dept. Paediatric Dentistry, School of Dental Medicine University of Zagreb, Gunduliceva 5, Zagreb 10000, Croatia
Table 1. Retention rates for three different fissure sealing materials assessed after 24 months. Sealant retention Teethmate F1 (0) Complete retention % (n) 60.6% (20) (1) Loss of 1/3 % (n) 30.3% (10) (2) Loss of 2/3 % (n) 3% (1) (3) Complete loss % (n) 3% (1) (+) Caries present % (n) 3% (1) Total n=100 33 Chi-square 5.919 Helioseal Clear Sealant retention Chroma Tetric Flow (0) Complete retention 66.7% (22) 76.5% (26) (1) Loss of 1/3 18.2% (6) 20.6% (7) (2) Loss of 2/3 3% (1) 2.9% (1) (3) Complete loss 6.% (2) 0% (+) Caries present 6.1% (2) 0% Total 33 34 df = 8 p = 0.656
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|Author:||Dukic, W.; Glavina, D.|
|Publication:||European Archives of Paediatric Dentistry|
|Date:||Sep 1, 2007|
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