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Prevalence of Atypical Radiographic Findings inBitewings of Class II Composite Restorations:

Detection and Assessment of Radiolucent Areas

Item Type dissertation

Authors Bazerbashi, Jood

Publication Date 2020

Abstract This retrospective study aimed to describe the prevalence ofradiographic abnormalities in bitewing radiographs of proximalclass II composite restorations. Bitewing radiographs of proximalcomposite restorations of adult patients who underwent resto...

Keywords dental adhesives; radiographs; radiolucency; Composite Resins;Dental Bonding; Dental Cements

Download date 15/09/2022 22:00:20

Link to Item http://hdl.handle.net/10713/13006

http://hdl.handle.net/10713/13006

Curriculum Vitae

Name: Jood Bazerbashi, DDS

Email address: [email protected]

EDUCATION

Degree And Date To Be Conferred:

Masters in Dental Biomedical Science May 2020

AEGD Certificate June 2020

University of Maryland School of Dentistry, Advanced Education in

General Dentistry, Baltimore, Maryland, USA

Major:

Doctor of Dental Medicine July 2014

Near East University Faculty of Dentistry, Lefkoşia, Cyprus

CLINICAL EXPERIENCE

Trainee at North Jeddah Specialty Dental Clinics Jan. 2018 – March 2018

North Jeddah Specialty Dental Clinics, Jeddah, Saudi Arabia

Shadowing at Dr. Mohammad H. Shahegh Clinic November 2017

Dr. Mohammad Shahegh Clinic, Clarksville, Maryland, USA

General Dentist Oct. 2016 – May 2017

Dental Pearl Clinic, Jeddah, Saudi Arabia

Shadowing at iSmile Specialists June 2016 – Aug.2016

iSmile Specialists, Houston, Texas, USA

COMMUNITY SERVICE

Volunteer Resident Sept.14, 2019

Mid- Maryland Mission of Mercy, College Park, Maryland, USA

Volunteer Resident April 6, 2019

Eastern Shore Mission of Marcy, Salisbury, Maryland, USA

Volunteer Resident July 28, 2018

Southern Maryland Mission of Mercy, Waldorf, Maryland, USA

Volunteer Dentist Feb.2016- May 2016

L- Medical Specialists Polyclinic Charity Clinic, Jeddah, Saudi Arabia

Volunteer at NEU Dental Public Health Program Feb. 2014 –May 2014

NEU Dental Public Health Program, Lefkoşia, Cyprus

Participant in NEU World Events Jan. 2013 - May 2014

Near East University World, cultural exchange event, Lefkoşia, Cyprus

Fundraiser coordinator Novmber 2010

Syrian Orphanage Charity Organization, Aleppo Syria

PROFESSIONAL LICENSE

Saudi Professional General Dentist License

ABSTRACT

Prevalence of Atypical Radiographic Findings in Bitewings of Class II Composite

Restorations: Detection and Assessment of Radiolucent Areas.

Jood Bazerbashi, General Dentist, 2020

Thesis directed by : Mary Anne S. Melo, Director of Operative Dentistry, Department of

General Dentistry

This retrospective study aimed to describe the prevalence of radiographic abnormalities

in bitewing radiographs of proximal class II composite restorations. Bitewing radiographs

of proximal composite restorations of adult patients who underwent restorative care at

predoctoral clinics at the University of Maryland School of Dentistry from August 2014

to July 2016 were identified. Atypical radiographic features were categorized by type of

material and location. The information recorded for patients included age, sex, tooth, and

restored surface. Out of the 669 examined restorations, 16.5% radiographs showed no

atypical radiographic findings and 83.5% restorations had unusual radiographic signs.

The types of atypical radiographic findings were distributed as 16.5% internal voids, 3%

overhang, 7.8% interlayer lines, 12.6% secondary caries, 20.7% interfacial gaps and

23.1% had multiple atypical findings. There is high prevalence of atypical radiographic

findings in class II composite restorations, particularly in the body of the composite,

premolars, and disto-occlusal restorations.

Prevalence of Atypical Radiographic Findings in Bitewings of Class II Composite

Restorations: Detection and Assessment of Radiolucent Areas

by

Jood Bazerbashi

A thesis submitted to the Faculty of the Graduate School of the

University of Maryland, Baltimore in partial fulfillment

of the requirements for the degree of

Master of Science

2020

iii

Acknowledgments

The authors thank the staff of the IT at the University of Maryland School of Dentistry on

behalf of Christine Livesay for her assistance with the database settings.

iv

Table of Contents

Chapter Page

Acknowledgments …………………………………………………………………… iii

List of Tables ……………………………………………………………………..……v

List of Figures …………………………………………………………………….......vi

List of Abbreviations …………………………………………...................................vii

1. Introduction …………………………………………………………...………1

2. Methodology…………………………………………………………...............3

2.1 Study Design…………………………………………………………. 3

2.2 Eligibility Criteria……………………………………………………..4

2.3 Radiographic Assessment……………………………………………..7

2.4 Categorization of the Radiographic Findings…………………………7

2.5 Statistical Analysis…………………………………………………….8

3. Results ...……………………………………………………………………….11

4. Discussion ……………………………………………………………..............18

5. Conclusion.…………………………………………………………………….29

6. References.…………………………………………………………………….30

v

List of Tables

Table 1. Inclusion and Exclusion criteria applied to the selection of

radiograph images …………………………………………………………………….… 5

Table 2. Description of the categories for classification of findings……........................10

Table 3. The prevalence of radiographic abnormalities found in class II

composites restorations………………………………………………………………….13


composites restorations with secondary caries………………………………………….14


composites restorations among genders, age groups, tooth, and restoration surfaces…..15

Table 6. The prevalence of interface gap locations showing frequencies and

percentage among genders, age groups, tooth, and restoration surfaces……………….16

Table 7. The prevalence of secondary caries in class II expressed by frequencies

and percentage among genders, age groups, tooth, and restoration surfaces…………..16

Table 8. The prevalence of atypical radiographic findings with multiple

radiographic findings showing frequencies and percentages among genders, age

groups, teeth, and restoration surfaces………………………………………………….17

vi

List of Figures

Figure 1. Flow chart showing the selection criteria and categorization of the findings

used in this study………………………………………………………………………...6

Figure 2. Illustrative scheme of the classification criteria for radiographic findings

in class II composite restorations………………………………………………………..9

Figure 3. Radiographic image illustrating voids within the body of a composite of

the right maxillary second premolar………………………………………………….....19

Figure 4. Radiographic image showing interlayer lines within the body of composite

in the DO restoration of left maxillary first premolar…………………………………..20

Figure 5. A radiographic image representing overhang in the DO restoration first of

left maxillary premolar………………………………………………………………….21

Figure 6. Radiographic image showing an external bond interface gap in the DO

restoration of left mandibular premolar………………………………………………....22

Figure 7. Radiographic image illustrating internal interface gap in the DO restoration

of left maxillary premolar…………………………………………………………….....23

Figure 8. Radiographic image illustrating secondary caries MO restoration of right

maxillary premolar……………………………………………………………………...25

Figure 9. A radiographic image representing multiple radiolucent findings of body

void and external bond interface gap in the DO restoration of left maxillary premolar..27

Figure 10. Radiographic image illustrating various radiolucent findings of body

interlayer gap and external bond interface gap in the DO restoration of mandibular

right premolar…………………………………………………………………………...27

vii

List of Abbreviations:

BW Bitewing

F Female

M Male

PM Premolar

MO Mesio-occlusal

DO Disto-occlusal

MOD Mesio-occluso-distal

1

INTRODUCTION

About half of all restorations placed in adults in general dental practice are

replacements 1. Replacement restorations take up a substantial part of the tooth structure

as compared to the initial restorative treatment for the primary carious lesion. They are

very cost-intensive for patients and the health system 2, 3

. In addition to the financial burden

imposed on the patient, there are other reasons to avoid replacement, such as the risk of

pulp exposure and pulp irritation 4. Atypical radiographic findings such as voids and gaps

in the composite may result from several operator-related factors, such as poor placement

technique and entrapment of air within the composite or material-related factors such as

polymerization stress or radiopacity of the materials 5–7

.

From a functional perspective, the presence of voids within restorations may

negatively affect the mechanical properties of the material over time 8. Reduced resistance

to fatigue and wear, due to their contribution to the initiation and propagation of cracks,

may lead to premature failure of the restoration when subjected to mechanical and external

loads 9, 10

. The presence of voids in the body of composite restorations has also been

reported as a detrimental factor for the clinical longevity of posterior composites 11

.

Secondary carious lesions are reported to be the most common reason to replace or

repair a defective dental restoration in general practice 1. If these gaps or voids are at the

margin, the risk of leakage and secondary caries is present. The detection of secondary

carious lesions or gaps at margins detected by explorer as well as pain and sensitivity

symptoms reported by patients led to a more precise diagnosis and decision to replace the

2

restoration12

. However, in the absence of clinical findings and the presence of atypical

radiographic findings, the diagnosis of caries can pose a challenge 13, 14

, leading to

uncertainty regarding the need to replace or repair existing restorations. Along with the

assessment of a patient’s caries risk status, radiographic interpretations are critical for new

patients who have received comprehensive treatment by another provider and are now

under periodic evaluation.

The American Dental Association (ADA) recommends posterior bitewing (BW)

exam for adults with high caries risk every six to 12 months, whereas for adults with low

caries risk exam can be done every two to three years 15–17

. From a radiographic point of

view, successful restorative treatment can be measured by the absence of radiographic

signs suggestive of underlining carious lesions, open margins, voids, or overhang 18, 19

.

However, when these radiolucent areas are mistakenly suspected to be caused by secondary

caries, there is a high likelihood that no lesion will be found after restoration removal. This

misdiagnosis leads to overtreatment and unnecessary replacement of the restoration.

Most of the atypical radiographic findings in the region of the bonding interface

between the restoration and the cavity walls directly influence secondary caries

formation20, 21

. Moreover, increased adhesive thickness layer or low adhesive opacity may

impose some difficulties in diagnosis 2, 22

. Another factor affecting radiographic evaluation

is the concentration of radiopacifiers in the composite. Low radiopacity constituents in the

resin-based material makes it hard to discriminate between composite and tooth structure

22.

3

The potential influence of recall BW findings related to class II composites on

outcomes of replacement remains controversial. This suggests that although significant

investigational and clinical, educational efforts are currently underway, mainstream

awareness and thorough quantification of these findings are still lacking. The purpose of

this study is to begin establishing a foundation of knowledge for the greater understanding

of influencing factors on the decision of replacement by identifying the prevalence of

radiographic abnormalities in class II composite restorations. F

MATERIALS AND METHODS

2.1. Study Design

This is a retrospective patient chart cohort study using charts for patients seen at the

predoctoral clinic at the University of Maryland, Baltimore, School of Dentistry. Bitewing

radiographs with Class II restorations were selected to quantify the prevalence of atypical

radiographic findings in composite restorations. The study was approved by the respective

Institutional Review Board (IRB) (HP-00084713).

A digital search was utilized using the Axium (Exan Group, Las Vegas, NV, USA)

Electronic Health Record (EHR). The search filtered patients between the ages 18-84 that

would qualify for the two following categories: 1) patients who had two or more surface

resin-based restorations placed by third and fourth year dental students on posterior teeth

from August 2014 to July 2016; 2) patients who had single, two- or four- horizontal or

vertical BW taken from August 2016 to July 2017. Data were extracted into a Microsoft ®

Excel file (Microsoft, Redmond, WA, USA).

4

2.2 Eligibility Criteria

Inclusion criteria included men and women between the ages of 18- 84 who

underwent Class II restorative treatment from August 2014 to July 2016 with BW

radiographs taken from August 2016 to July 2017. Only BW radiographs exposed with

XDR ® (XDR Radiology, Los Angeles, CA, USA) sensors, the available direct digital

sensor system at the university, were included.

The exclusion criteria included posterior BW radiographs showing

superimpositions on the restoration, poor image quality, or the use of different restorative

material other than composite resin. At the predoctoral clinic of the University of Maryland

School of Dentistry, in the lack of suspicion of caries, overlap less than one-third the width

of interproximal enamel would categorize as clinically acceptable BW. However, in this

study, BWs with any overlap of the restoration were excluded.

Excluded radiographs displaying objects or restoration interfered with the

visualization of the Class II composite restoration, such as orthodontic brackets, Class V

restoration, or crown. Also, radiographs that did not show the assigned tooth due to

extraction or BWs that show the teeth on the contralateral side were excluded (Table 1).

5

Table 1. Inclusion and Exclusion criteria applied to the selection of radiograph images.

Inclusion Criteria Exclusion Criteria

BW radiographs taken at the

University of Maryland School of

Dentistry for adult patients seen at

predoctoral clinics

BW radiographs with the presence of

superimpositions or poor image quality

Radiographs taken between August

2016 to July 2017

Presence of superimpositions from class V

restorations, orthodontic bracket, or crowns

Class II composite restorations

completed between August 2014 to

July 2016

Radiographs showing radiopacity of other

restorative material such as core build-up

material or amalgam

Taken with a direct digital sensor

Radiographs that do not have the assigned

tooth due to extraction, BW captured to the

contralateral side, or restorative surface is not

fully shown on the radiograph.

6

Figure 1. Flow chart showing the selection criteria and categorization of the findings used

in this study

7

2.3 Radiographic Assessment

Digital radiographs were assessed by two examiners (general dentists). In cases of

disagreement, a consensus was obtained. Reliability tests were performed for the

radiographic assessment (kappa= 0.72). After three months, approximately 50% of the

radiographs were re-evaluated under the same settings to calculate the intra-examiner

reproducibility.

Six hundred sixty-nine images from 351 patients were assessed using MiPACS

software (Medicare Imaging, Charlotte, NC, USA) displayed on ViewSonic VX3276-

MHD 32” high definition light-emitting diode backlit display monitor (native resolution

1535x2048) in a view distance of 70 cm in dim lighting. Radiographic filters were applied

to adjust sharpness and brightness. Three hundred thirty-five radiographs were excluded

following the exclusion criteria ( Figure 1).

2.4 Categorization of the Radiographic Findings

Three hundred thirty-four included images were transferred to PowerPoint

(Microsoft) on slides with a black background. Slides were labeled with the sample

number, tooth number, and restoration surface. PowerPoint slides and Excel spreadsheets

were both linked with a numeric coding system for each sample. A classification was

designed to codify the radiographic findings and used for screening. The classification

consists of a written description of each category intended to reduce ambiguity. Figure 2

illustrates the description used for classification in a radiographic image.

8

From the pool of 334 included x-rays, 55 BWs showed no atypical radiographic

findings, and 279 BWs demonstrated atypical radiolucency/radiopacity findings. This set

of radiographs provides examples of appearances classifiable as standard and normal. This

category refers to radiographs, where there are no large areas of radiolucency. Those

divisions are defined by the standard radiographs, together with the written description.

For assessment of the bonding interface, the presence or absence of a radiolucent halo

adjacent to the gingival, mesial, distal, and pulpal walls was considered.

The 279 BWs were categorized according to the type of material (composite or

adhesive) and location (internal or external) (Table 2). The information recorded for each

patient included age, sex, tooth, and restored surface.

Guidelines were placed to avoid misinterpretation of bond interface radiolucency

and secondary caries. Radiolucent areas that are detected at the cavity preparation walls

were considered as interfacial gaps. Large radiolucent regions that are not bound to the

preparation structure and are extending into the dentine were interpreted as secondary

caries.

2.5 Statistical Analysis

The radiographic prevalence of atypical findings was presented as frequencies and

percentages, whereas demographic variables were presented as frequencies and

percentages, when appropriate.

9

Figure 2. Illustrative scheme of the classification criteria for radiographic findings in class

II composite restorations.

10

Table 2. Description of the categories for classification of findings.

LOCATION CATEGORY DESCRIPTION

No atypical

radiographic

finding

No radiolucent or radiopaque results

suggesting atypical radiographic findings

in composite restoration

BODY OF THE

RESTORATION

Mass of composite

constituting the

restoration

Internal

Void/Porous

Void =pore Circular volumetric (2D)

empty radiolucent spaces located at the

body

Interlayer line Lack of continuity between the

composite layers characterized by a thin

radiolucent line

Overhang Excess radiopaque composite in the

interproximal area

BONDING

INTERFACE

Surface (Line)

between tooth and

composite

Internal gap–not

gingival margin

Lack of continuity, radiolucency between

the composite and tooth NOT involving

gingival margins

External gap –at

the gingival

margin

Radiolucency, lack of continuity between

the composite and tooth involving

gingival margins: usually “notch” shape.

Secondary caries Presence of radiolucency in dentine

indicating recurrent caries

Other More than one radiographic finding

indicating multicategory

11

RESULTS

Table 3 summarizes the results of the radiographic findings. Out of 669 BW

radiographs, 335 were excluded for meeting the exclusion criteria; therefore, 334 BWs

were used in the current study. A total of 55 (16.5%) BW did not show any atypical

radiographic findings. 279 (83.5%) radiographs showed radiolucent or radiopaque areas in

the restoration, suggesting atypical radiographic findings.

There were 91 of 279 (27.2%) restorations that had at least one atypical finding in the

body of the composite recorded and were classified as follows: 55 (16.5%) presented with

internal body voids, 26 (7.8%) interlayer lines, 10 (3%) demonstrated radiopacity

suggesting overhang.

Sixty-nine (20.7%) restorations showed a discontinuity in the adhesive bond area,

leaving a gap between the tooth structure and the composite. Thirty-seven (53.6%) of these

restorations had a notch-like appearance suggesting a noticeable gap at or around the

gingival margin, and 32 (46.4%) out of the 69 had an internal inconsistency between tooth

structure and resin-base material not involved with the exogenous seal of the restoration.

Secondary carious lesions were in a total of 42 (12.6%) restorations. Out of the 42

restorations suggesting secondary caries, 20 (47.6%) had other radiographic findings, and

22 (52.4%) did not present with any additional radiographic finding other than secondary

caries (Table 4).

12

Furthermore, 77 (23.1%) of restorations presented with multiple radiolucencies or

mixed radiolucency and radiopacity abnormal radiographic findings. 11(3.3%) BW’s

indicate the tooth bond interface gap and interlayer gaps between the body of composite

layers. Remaining BW radiographs with multiple radiolucent findings were classified as

follows: 58 (17.4%) restorations presented with voids within the composite and bonding

interface, 2 (0.6%) restorations had void interlayer radiolucencies, and 3 (0.9%) BW’s

revealed radiolucencies of interlayer lines and voids within composite with the interface.

Three BWs presented heterogenous radiographic findings composing radiopaque

and radiolucency areas. Out of the three, 1 (0.3%) restoration had radiolucent composite

body pore and radiopaque excess composite, indicating overhang on the gingival margin.

The other 2 (0.6%) BW’s showed radiolucent lines withing the composite body and

radiopaque overhang. Table 5-8 explains the information recorded for each patient

included age, sex, tooth, and restored surface.

13

Table 3. The prevalence of radiographic abnormalities found in class II composites

restorations.

Radiographic Finding Frequency/ total Percentage %

No atypical findings 55/334 16.5%

Atypical findings 279/334 83.5%

Bonding interface 69/334 20.7%

External bonding interface 37/334 11.1%

Internal bonding interface 32/334 9.6%

Body of composite 91/334 27.2%

Internal Void 55/334 16.5%

Interlayer lines 26/334 7.8%

Overhang 10/334 2.9%

Secondary caries 42/334 12.6%

With other radiographic findings 20/334 6.0%

Without other findings 22/334 6.6%

Other findings 77/334 23.1%

Interlayer/ interface 11/334 3.3%

Void/ interface 58/334 17.4%

Void/ overhang 1/334 0.3%

Void/ interlayer 2/334 0.6%

Void/interlayer/ interface 3/334 0.9%

Interlayer/ overhang 2/334 0.6%

14

Table 4: The prevalence of radiographic abnormalities found in class II composites

restorations with secondary caries.

Radiographic Atypical Findings Frequency/total Percentage %

Body of composite

Voids 7/20 35.0%

Interlayer gap 3/20 15.0%

Overhang 2/20 10.0%

Bonding Interface

External Interface 3/20 15.0%

Void/ interface 3/20 15.0%

Interlayer/ interface 2/20 10.0%

15

Table 5: The prevalence of radiographic abnormalities found in class II composites

restorations among genders, age groups, tooth, and restoration surfaces

16

Table 6: The prevalence of interface gap locations showing frequencies and percentage among

genders, age groups, tooth, and restoration surfaces.

Table 7: The prevalence of restorations suggesting secondary caries in class II showing

frequencies and percentage among genders, age groups, tooth, and restoration surfaces

17

Table 8: The prevalence of atypical radiographic findings presenting multiple radiographic

findings expressed by frequencies and percentages among genders, age groups, teeth, and

restoration surfaces.

18

DISCUSSION

The goal of this study was to establish the previously undefined prevalence of

radiographic abnormalities in class II composite restorations. The prevalence rates and data

obtained in this radiographic analysis dramatically illustrates that the prior comprehended

notion that radiographic assessment, class II composite, in particular, continues to be

underrecognized. The prevalence rates of radiographic abnormalities were significantly

higher than anticipated by the authors.

Voids within the body of the restoration are also referred to as porosities or bubbles.

Here, referred to as internal voids, they represented a large subset of these atypical findings,

affecting 16.5% (55/334) of performed restorations (Figure3) (Table 3). These results are

less compared to the 70% voids found in the examined samples in the light microscope in

vitro study 5. However, the higher incidence of voids results in the current study brings into

question the causes of these alterations. Voids are caused by air entrapment and can be

incorporated into composites during their manipulation when performing a restorative

procedure or even while being manufactured 23. Here, all the restorations were assumed to

be performed by an incremental technique using low-viscosity or high viscosity universal

hybrid composites TPH Spectra ST (Dentsply, Milford, DE, USA) since this the employed

restorative method and the material available in the predoctoral clinics. However, definitive

conclusions cannot be made, as this information was not collected in our study.

19

Figure 3. Radiographic image illustrating voids within the body of a composite of the

right maxillary second premolar

Since, in the present study, all the restorations were placed by the provider under

training (juniors and senior dental students), the operator’s ability may have influenced this

outcome. Sixty-five percentage of voids were found in restored premolars, and 69% were

accounted by two-surface (disto-occlusal) restorations (Table 5). Cavity preparations in

premolars are very often conservative and represented by slot preparations compromising

the proximal lesions and occlusal access. This type of preparation may offer challenges for

incremental placement of the composite. Furthermore, in certain clinical scenarios, the

distal box of the preparation can be more difficult for visualization and adaptation of the

material.

Voids between the layers of class II composite was another subset from our study

(Figure 4). In the previously mentioned in vitro study, nearly 63% of the examined samples

had voids between the layers 5. These results were substantially higher compared to 7.8%

20

examined radiographically in the present study (Table 3). Premolars and disto-occlusal

restorations had a high rate in this radiographic condition (Table 5). The appearance of

interlayer gaps is frequent in incremental techniques if the layers were not adapted properly

24. These interlayer gaps affect the physical properties of the restoration 5.

Figure 4. Radiogr aphic image showing interlayer lines within the body of composite in

the DO restoration of left maxillary first premolar

Three percent of the examined restorations had an overhang (Figure 5). Sixty

percent of overhangs were identified in restored premolars and (mesio-occlusal)

restorations (Table 5). A previous study found similar rates of 4% of prevalence overhang

25. The positive ledge at the margins is an iatrogenic factor for gingivitis through

mechanical irritation. Studies have shown that there is higher radiographic attachment loss

with the presence of marginal overhangs in periodontally involved patients 26. In addition

to the contribution in degrading local periodontal health, it also promotes secondary caries

21

formation 27. The irregular rough surface of overhang acts as the perfect area for bacterial

plaque accumulation.

The presence of overhang is mainly caused by incorrect proximal matrix placement.

Prior studies have pointed out that the application of low viscosity composites may increase

the presence of an overhang 28. Proximal restorations involve restoring the anatomical

structure of the tooth, which could be challenging for students. The correct matrix system

should be adapted to restore the unique anatomy of every tooth, which varies from case to

case.

Figure 5. A radiographic image representing overhang in the DO restoration first of left

maxillary premolar

Twenty-one percent of the radiographs examined had an abnormal adhesive

interface, implying the presence of radiolucent areas between the restoration and tooth

structure (Table 3). 11.1% of this radiographic condition is present as an external bonding

interface and 9.6% as an internal interface gap. This result is consistent with previously

22

published findings for a 14% (111/770) bond layer interface and 11.8% (91/770) lack of

adaptation, which includes both external interface gap and overhang 29.

Our data indicated that there is a higher prevalence of external gap at the gingival margin

11.1% represented by radiolucency between the composite and tooth involving gingival

margins, usually “notch” shape (Figure 6). This result is less, compared to other studies

of 33 % underfilled restorations 25. Gaps at the gingival margins are a dilemma for class

II composites. The presence of gingival interfacial gap at the enamel level suggests

weaker bonds and higher microleakage potential at the dentine level 30. The gingival

interface is the most common zone for secondary caries development. Several studies

showed that there is a correlation between the depth of the ditched margins and the

demineralization process 31, 32.

Figure 6. Radiographic image showing an external bond interface gap in the DO

restoration of left mandibular premolar

23

Internal interface gaps can be caused by moisture contamination that reduces the

adaptability of material on the prepared tooth surface (Figure 7). This contamination would

manifest as post-operative pain sensitivity due to fluid and bacterial movement 20.

Figure 7. Radiographic image illustrating internal interface gap in the DO restoration of

left maxillary premolar

Every so often, this interface can be generated by the adhesive layer. The

insufficient radiopacity of bonding agents can assist in radiographic misdiagnosis of the

tooth- restoration interface 17. Replacement decisions based on radiographic assessment

can be commonly affected by the composition of the adhesive system.

Other technique related factors can create radiolucent halos 33. Thick adhesive layer

functions as elastic buffer underneath the restoration, absorbing stress 34. Therefore

applying a thicker adhesive layer contributes to a more apparent radiolucent zone that gives

rise to the misdiagnosis and retreatment 2.

24

The most used adhesive system at the predoctoral clinic is OptiBond® Solo Plus™

(Kerr, Orange, CA, USA). In a study comparing adhesive systems and their radiopacity,

OptiBond Solo Plus shows the most radiopaque effect 35. However, the enamel is more

radiopaque than OptiBond Solo Plus. Different radiodensity can influence the diagnosis of

secondary caries 36. In addition to this, the application of the adhesive system is technique

sensitive and, if not appropriately blown after application, will exhibit pooling. Although

this acts in return as an elastic buffer, it also contributes to a high number of false

replacement decisions 34.

Both gaps at the gingival margin and the internal interface showed similar results

toward pre-molars, 65% and 63% consequently. However, there was a higher rate of

prevalence, according to restoration surfaces. Seventy percent of the external interface gaps

were in disto-occlusal restorations, and fifty percent of the internal interface gaps were in

mesio- occlusal restorations (Table 6).

Secondary caries was detected in the screened BWs at 12.6 % (Table 3) (Figure 8).

A study evaluating radiographs had consistent findings of 15% (119/770) 29. In another

study, secondary caries was diagnosed radiographically in 14% of restoration 37.

Examination of BWs for radiolucent secondary caries is a diagnostic challenge.

Many different factors can influence the ability to detect these alterations accurately. These

may be exposure parameters, type of image receptor, image processing, display system,

viewing conditions, and ultimately, the training and experience of the clinician. Moreover,

various morphologic phenomena, such as pits and fissures, cervical burnout, mach band

effect, and dental anomalies, such as hypoplastic pits and concavities, can mimic the

25

appearance of a carious lesion. The radiolucent thick adhesive material and residual caries

underneath the restoration cause a halo mimicking caries, which makes it tricky to diagnose

32.

Figure 8. Radiographic image illustrating secondary caries MO restoration of right

maxillary premolar

Furthermore, the illusory optical effect of each band appears when there is a vast

difference between the radiopacity of the tooth structure and restorative material 38. The

mach band effect causes a dilemma on the misdiagnosis and, consequently, false-positive

retreatment 39. In the present study, we have managed to cover up the restoration (less

radiopacity) with a black square filter on MiPacs during radiographic evaluation to inhibit

the false effect on optical receptors.

26

About forty-seven percent of restorations that are suggesting secondary carious

presented with other radiographic conditions. Eight out of twenty of these restorations

exhibit an external interfacial gap as one of the other radiographic findings (Table 4). The

exposed margins of the external interface may explain the reason for the secondary caries

progression. The other radiographic conditions associated with secondary caries were

found within the body of composite.

It is also worth mentioning that a higher rate of secondary caries was found in class

II distal restorations (Table 5) (Table 7). This leads to the question if caries excavation

was completed properly or the patient’s oral hygiene is the reason behind these results.

Cavity preparation in a distal box and indirect vision through the mirror are both a

challenge to providers that would affect caries excavation. A patient’s oral hygiene is the

primary factor that determines the progression of secondary caries. Although flossing is

important, many patients find it difficult to access posterior interproximal surfaces. The

difficulty of access to some interproximal areas facilitates plaque accumulation and

consequent secondary caries progression.

As a combination of the previously discussed finding, multiple radiographic

findings detected in the examined sample at 23.1% (Table 3) (Figure9) (Figure 10). This

category was further assessed in detail in Table 6. Some of these conditions can be

interpreted as imperfections that genuinely affects the longevity of the restorations. To also

determine the diagnosis of repair versus replacement, minor imperfections should not be

the reason to intervene. The difference between genders is not well understood at this time.

27

Figure 9. Radiographic image illustrating multiple radiolucent findings of body void and

external bond interface gap in the DO restoration of left maxillary premolar

Figure 10. Radiographic image illustrating various radiolucent findings of body

interlayer gap and external bond interface gap in the DO restoration of mandibular right

premolar

28

Limitations

We acknowledge several limitations of our study. First, it is a database review and

was limited by the number of patients with adequate radiographs. The radiographs that

were excluded were not indicative of clinically unacceptable radiographs. The BW

radiographs exclusion was based on parameters that would affect the accurate detection

and calculation of the prevalence of atypical radiographic abnormalities. The 83.5%

prevalence of atypical findings is an aggressive estimate of the restorative practice because

this percentage was based on patients who had restorative treatment provided by dental

students. Dental students are providers under training, and their performance may differ

from general dentists with years of experience. Published results in the previous study

showed that there is a difference in the resulting restorations between operators5. Many

studies discussed the presence of atypical radiographic findings in BWs. However, these

variables were discussed separately, and there was limited research on the prevalence of

radiographic interlayer gaps 5, 25, 29, 37.

Second is the subject-defined parameters for assessing the adhesive interface. We have

not measured the thickness of adhesive space and did not include a quantitative reference

for it. Thus, we may have underestimated the number of adhesive interfaces that are

atypical. Likewise, not much information was provided in records to know if there were

any liners applied underneath the restoration. Liners would contribute to the

radiolucency. Third, our study does not include clinical data such as the presence of the

pain or sensitivity on oral examination, analysis of the interpretation of radiographs by

oral care providers, or assessment patients’ restoration complaints.

29

CONCLUSION

The prevalence of atypical radiographic findings in class II composite restorations

is considerable, particularly in the body of the composite followed by the bonding interface.

Within the body of composite internal voids were in the highest percentage. The overall

results have shown a higher prevalence of abnormal radiographic findings in both pre-

molars and (disto-occlusal) restorations. Dental practitioners should be aware of the

inadequate bonding, and inappropriate placement of posterior restorations could impart

increased premature composite replacement.

30

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