Direct Posterior Composite Restorations

with a New Adiiesive System:

One-Year Resuits
Martin Schoch^/Norbert Kramers/Roland FrankenbergerV
Anselm Petschelf^

Purpose: Syntac Sprint is a new one-bottie adhesive based on the total-etch and total-bond technique. The
aim of this study was to compare the new restorative system consisting of Syntac Sprint and the resin
composite Tetric Ceram with the clinically proven combination of the dentin adhesive Syntac Ciassic and
the resin composite Tetric.
Materials and Methods: In a controiied prospective clinical study, 47 cavities (36 premoiars, 11 molars;
29 maxillary, 17 mandibular; 6 occlusal, 33 occluso-approximal, 7 MOD, 1 > 3 surfaces) in 33 patients (17
female, 16 maie) were filled. Twenty-five fiiiings were placed with tlie combination Syntac Sprint/Tetric
Ceram under totai etching and totai bonding conditions, in thirteen restorations, Syntac Sprint was precured prior to tbe application of the resin composite; in the other twelve cases, restoration and adhesive
were cured simultaneously. The control group consisted of 22 cavities restored with Syntac Classic pius
the composite Tetric, At baseline and after 6 and 12 months, two calibrated investigators examined the
restorations with modified USPHS codes and criteria.
Results: The criteria marginal integrity and integrity ofthe tootb deteriorated significantiy between the
baseline and the 6- and 12- month investigations (Friedman 2-way ANOVA; p < 0.05). Mo differences were
found in the criteria surface rougbness, coior matching, anatcmic form, step forrnation, integrity of the filling, proximal contact, hypersensitivity, or satisfaction. After one year, aii fillings were in good condition.
There was no significant difference between the Syntac Sprint/Tetric Ceram and Syntac Classic/Tetric
groups for any criteNon Kruskai-Wallis; p > 0.05.
Conclusion: Within the limits of this study, Tetric Ceram fiiiings in combination with Syntac Sprint were
ciinicaiiy successfui after one year.
J Adhesive Dent 1999:2:167-173.

Submitted for pubiication.23.02.99:

accepted for pubiication:

25.03.99.

irect resin composite fillings are becoming more

Research Associate, Clinic or Operative Dentistry ana

ngy, University of Eriangen-Nuremberg, Germany

Periodontol-

Lecturer, Ciinic for Operative Dentistry and Periodontoiogy, University of Eriangen-Nuremberg, Gerrnany
Research Associate, Ciinic for Operative Dentistry and
iogy, University of Eriangen-Nuremberg,
Germany

Periodonto-

Professof, CIIDJC for Operative Dentistry and Periodontoiogy,

"ersity of Eriangen-Nuremberg,
Germany

Uni-

Reprint requests: Dr. Martin Schoch, DMD, Clinic for Operative Dentistry and Periodontoiogy, University of Eriangen-Nuremberg, GluecHstrasse I I , D-91054 Erlangen, Germany. Tei: +49-9131-853-4203.
Faj; +49-9131-853-3603, email;schocit@clent.uni-eriangen.de

Vol 1, No 2, 1999

Dcommon as an aiternative to amaigam restorations, ^s:"-' Despite reservations about using resin
composites in the posterior region, promising longterm ciinicai resuits have been reported, even with
older materiais.I'lois-^^
While effective adhesion to enamel using the
acid-etch technique has been known to dentistry for
decades, effective bonding to dentin has been deveioped oniy in recent years. To become a standard
in dental practice, the dentin bonding procedure
should not require lengthy application times or sev167

Schoch et ai

erai different application steps. Therefore, the trend

toward easy handiing and growing user-friendliness
in developing dentin bonding agents (DA) is enormous. The latest generation of tiiese agents, consisting of only one materiai, can be subsumed
under the catchword "one-bottle adhesives." In addition to the time-consuming application procedure,
anotiier problem is dentin moisture controi as a
cruciai factor in dentinal adhesion,
Syntac Sprint (Vivadent, Schaan, Liechtenstein)
is a new one-bottle adhesive, which can be applied
in oniy one layer and need not be light-cured prior
to the application of the resin composite. Additionally, the manufacturer promises the adhesive's tolerance of different ciinical moisture conditions of
the dentin, including contamination with saliva, as
previously reported for other dentin bonding
The predictive value of in vitro studies is often
limited; therefore, controlied prospective clinical
studies are necessary for definitive assessment of
dental materials,^'^
The aim of the present study was to evaiuate the
ciinical behavior of the one-bottle adhesive Syntac
Sprint in combination with the resin composite material Tetric Ceram (Vivadent), To draw a comparison to a more estabiished DA,^ the dentin adhesive
Syntac Classic (Vivadent) was used with the resin
composite Tetric (Vivadent). In supplementary tests,
Syntac Sprint was precured with light (contrary to
manufacturer's recommendations) to determine
whether this improved the clinical performance of
the restorations.

MATERIALS AND METHODS

Study Design
From iWarch to August 1997, six experienced dentists piaced 46 restorations (36 premoiars, 1 1 molars; 30 maxillary, 17 mandibular; 6 occlusal, 33
occluso-approximal, 7 iViOD, 1 > 3 surfaces: see
Table 1) in 33 patients (17 female, 16 maie; average age 29 years, range 19 - 4 1 years).
After wooden wedges were placed, the cavities
were prepared as conservatively as possible, unless
the repiaced restorationsas in the majority of
caseshad been prepared according to Biack's
rules. Inner angies o f t h e cavities were rounded,
but the enamel margins were not beveied. All cavities were isolated with a rubber dam.
168

Only presumed caries profunda areas close to

the pulp were covered with a calcium hydroxide material (Reocap, Vivadent), followed by a zinc phosphate cement (Harvard, Richter & Hoffmann Harvard, Beriin),
In order to protect the neighboring teeth and to
form the proximal areas, transparent plastic matrix
bands (Moiarbands Transparent, Hawe-Neos, Bioggio, Switzerland) were cervicaily adapted witin
wedges (Sycamore interdental wedges, Hawe-Neos),
Twenty-two filiings were placed using the resin
composite Tetric in combination with the DA Syntac
Ciassic. Therefore, the enamei was selectively
etched with 37% phosphoric acid gei (Email Preparator GS, Vivadent) for 60 s, rinsed for 60 s, and
dried with compressed air. After applying with a
brush, Syntac Ciassic Primer was left for 15 s on
the dentin before it was dried thoroughly with compressed air. The second layer on the primed dentin
consisted of Syntac Classic Adhesive, which was
dried after 10 s. Finally, Heliobond was painted on
both enamel and dentin, and iight-cured for 40 s
after excess resin had been blown thin with compressed air.
Twenty-five cavities were filled with the resin
composite Tetric Ceram bonded with the DA Syntac
Sprint. Foiiowing the principies of totai etching and
totai bonding. Email Preparator GS was applied to
enamel and dentin from the peripheral to central
parts of the cavity and left on for 15 to 20 s. Subsequentiy, the surface was washed for 30 s and carefully dried according to the wet bonding technique.
Syntac Sprint was gently brushed into the conditioned dentin for 10 s. After a waiting period of 20
s, the excess was blown off. In 13 of these 25
restorations, Syntac Sprint was precured for 40 s
prior to the application of the resin composite. In
the other 12 cavities, the DA was light-cured simultaneously with the first layer of resin composite.
In five patients, it was possibie to use both procedures in a split-mouth design. No split-mouth design was used for the two different dentin bonding
agents.
The resin composite was incrementally applied
with a syringe, starting in the proximal boxes. Each
iayer, with a maximum thickness of 2 mm, was
iight-cured for 40 s. After appiying and modeiiing
the last layer, the resin composite was covered with
a glycerine gel, Finaiiy, each filling surface was
iight-cured for 60 s.
The finishing was carried out with diamond burs,
poiishing disks (Sof-Lex, 3M-Dental, St. Paui, MN,
The Journal of Adhesive Dentistry

Tabie 1 Number of evaiuated restorations by iocation and extension

divided into the different dentin adhesive systems

Syntac Classic
Cavities
Premolars
Molars
One surface
Two surfaces
Three surfaces
> Three surfaces
Caries profunda
Dentinal margin

22
18
4
o
18
3
1
9
1

USA] and strips (Compostrip, Premier, King of Prussia, PA, USA), and the Occlu-Brush (Hawe-Neos).

CoHection of Data
After 24 h, a clinical check limited to the parameter
"postoperative sensitivity" was performed as part of
modified USPHS codes and criteria.^^ii-is The patients were asked whether they felt "no pain," "occasional," "constant but tolerable," or "unbearable"
paih from the new restorations.
After approximately 2 weeks (baseline), 6 months,
ahd 12 months, two calibrated investigators evaluated the restorations Independently of each other
according to modified USPHS codes and criteria7,9,ii-i3 as follows; surface roughness, color
matching, anatomic form, step formation, marginal
adaptation, integrity of the tooth, integrity of the filling, proximal contact, sehsitivity, hypersensitivity,
and satisfaction. These parameters were scored
with the following ratings: excellent/good ("alpha"),
sufficient ("bravo"), insufficient ("chariie"), and poor
("delta"]. In the event of a disagreement in evaluation, the ultimate decision was made by consensus
ofthe two examiners.
Replicas (Epoxy Die, Vivadent) of the prepared
cavities ahd the restored teeth and their antagonists were made with a polyether impression material (Impregum, Espe, Seefeld, Germany] at baseline
and after six and twelve months. These replicas will
be used for a future study quantitatively measuring
wear and marginal adaptation.
Vol 1, No 2 , 1 9 9 9

Dentin adhpiivo
Syntac Sprint
light-cured
separate y

not liglit-cured

13
g
4
3

0
5
0

Color photographs were taken of the initial situation and of the prepared cavities. At the recall appointments, photos were taken of the restorations
and the antagonists with and without marked occlusal contact points.

Statisticai Analysis
The consensus scores regarding the modified
USPHS criteria were analyzed using the software
package SPSS for Windows 95 (version 7.5.2). To
compare the different DA groups at a certain investigation, the Kruskal-Wallis test was applied. Changes over time within an individual DA group could
be verified using the Friedman 2-way ANOVA test.

RESULTS
All patients were very content "alpha") with all
restorations at the recall appointments, with the exception of one patient who suffered from "occasional" (category "2", ie, "alpha") hypersensitivity
24 hours postoperatively. This occurred in the Syntac Sprint group when the adhesive was cured separately. Within the next twelve months of clinical
service, no complaints were registered. After one
year, all restorations were still in place. None of
them needed replacement, and ho tooth required
endodohtic treatment.
All composite fillings were rated not worse than
"bravo" in all modified USPHS criteria. Conse-

169

Schoch etal
Tabie 2 Percentage of the "aipiia" ratings for the modified USPHS
criteria

Syntac Classic
Criteria
Surface roughhess
Color matchihg
Anatomic form
Step formation
IVlarginal integrity
Integrity tooth
Integrity fiiiing
Prosimai contact
Sensitivity
24h-checkup
Satisfaction

Baseline

lYear

Baseline

lYear

Syhtac Sprint
not iight-cured
separately
Baseiine

lYear

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

95

82

100

92

100

92

100

95

100

100

100

100

100

100

100

100

100

100

95

95

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

quently, all restorations were in "exceiient/good" or

at ieast "sufficient" condition. Table 2 shows the
percentage of "aipha" ratings in the different criteria. Some fiiiings received "bravo" scores for the integrity of the tooth (only Syntac Classic/Tetric),
proximal contact (oniy Syntac Classic/Tetric), and
marginai integrity (all groups). There were no statistically significant differences for any criterion between the three DA groups. There were also no
obvious differences between the various filling locations, or margins located above or below the cemento-enamel junction.
One restoration (Syntac Classic/Tetric) showed a
proximal distance wider than 100 pm and was
therefore rated "bravo" for the oriterion proximai
contact. Four proximal contacts were rated too
weak ("good"/"alpha") and two were slightly too
strong in this group ("good"/"alpha"). Within the
Tetric Ceram fiiiings, six contacts received oniy a
"good" score, because three cases were rated as
siightiy too weak and three as somewhat too strong.
Significant changes over time within individuai
DA groups were oniy obvious among the criteria
marginai integrity (Figs 1 and 3) and integrity ofthe
tooth (Figs 2 and 3),
At baseline, only two teeth within the Syntac
Classic group showed an enamel crack which was
visible but could not be probed ("alpha"). The others exhibited no enamel cracks whatsoever. After 6
months, enamel cracks occurred in more than half
170

Dentih adhesive
Syntao Sprint
Light-cured
separsteiy

of all restored teeth, and one was even detectable

with a probe ("bravo"). This situation remained stable up to the one-year recall at the end of the study.
A simiiar deterioration in tooth integrity was obvious in both Syntac Sprint groups, although no tooth
had to be scored "bravo." Slight chipping was detected in one oase, leaving a defect which could be
eiiminated by polishing ("alpha"). The lower frequency of enamel cracks in these two groups was
not found to be statistioally significant (p < 0.05).
The restorations' marginal integrity not only
showed deterioration overtime but also a change in
the quality of fiaws. In only two restorations (one
Syntac Classic, one Syntac Sprint "polymerized") at
baseline was gap formation (< 100 pm = "alpha")
detectable. Another filling of the Syntac Classic
group showed a discoloration of the margin which
was not removable by polishing ("bravo"). In a total
of 29 restorations, marginal overhangs scored as
"good" ("alpha") were observed.
After one year, the number of restorations without any detectable deficiencies ("excellent*') declined from 14 to 8. This was chiefly due to more
gap formation and marginal discolorations. Four
cases of gap formation exhibited widths of more
than 100 |jm (3 Syntac Classic, 1 Syntac Sprint "not
polymerized") resulting in "bravo" scores. The dominant baseline probiem of marginal overhangs was
thus pushed into the background somewhat.
The color matching was "excellent" in almost all
The Journal of Adhesive Dentistry

Schoch et ai

restorations. In only one Tetric and two TetrJc Ceram fillings was a minor oolor deviation obvious
While the polish of seven Tetric fillings was rated
as "good" after one year, only two Tetric Ceram
restorations had to be scored as "good" because of
slight surface roughness.
The assessment of filling integrity revealed minor
wear on two restorations in each DA group (2 Tetric,
4Teric Ceram) after 12 months, mainly located on
lateral ridges.
Concerning the anatomical form of the surface of
the fillings, some differences between the two composites were observed. In both groups, four restorations were considered "overcontoured," while
twelve Tetric, but only four Tetric Ceram fillings were
rated as slightly "undercontoured," There were no
obvious changes over time.
Step formation was rated quite similarly in both
composite groups. In 50% of all restorations, a positive step formation was detected, but only four
restorations within the Tetrio group and two within
the Tetric Ceram group showed a negative step formation.

100%

Base 6 M 12 M Base 6 M 12 M

75%
50%
25%

Synlac Sprint
light-cured
separately

Syntac Sprint
not light-cured
separately

Base 6 M 12 M Base 6 M 12 M

Base 6 M 12 M

Syntac Classic

Fig 1

Marginal integrity.

100%'
75%'
50%'
25%'

Syntac Classic

DISCUSSION
All fillings were still in place after one year, and received exclusively "alpha" and "bravo" scores for all
modified USPHS codes and criteria. This indicates
an acceptable in vivo performance. The high incidence of "alpha" scores is comparable to most of
the studies using USPHS codes and criteria.i-2.i3
Compared with Scheibenbogen's results of up to
84% "bravo" after one year for the anatomical form
of restorations placed by student operators.i'^ the
high percentage of "alpha" scores in the present
study must be ascribed to the greater experience of
the research assistants placing the adhesive restorations.
Within the course ofthe first year, there were no
statistically significant differences between the
three DA groups and the two resin composite
groups for any of the criteria. The question must
therefore be posed as to the advantages and disadvantages of Syntac Sprint in combination with the
resin composite Tetric Ceram,

Base 6 M 12 M

Fig2

Syntac Sprint
light-cured
separately

Syntac Sprint
not light-cured
separately

integrityoftooth.

Modified USPHS ratings

1 alpha- excellent
2 alpha- good
3 bravo-sufficient I

Fig 3

Key to Figs l a n d 2.

The application of Syntac Sprint in only one layer

is fast and easy. Only one material and no intermediary steps are necessary, so that the user-friendliness is increased and technique sensitivity may be
Vol 1, No 2 . 1 9 9 9

171

reduced. Aithough none of the dentists in this study

reported considerabie time savings, the described
good handiing properties could heip to raise the acceptance of dentin bonding agents in gnerai dental practices.
Because it is often very difficult to ciinicaiiy monitor the moisture content of dentin, a special soivent has been deveioped for Syntac Sprint.''
According to the manufacturer's descriptions, it toierates contamination with saliva and the different
moisture conditions occurring in vivo because its
aqueous components help to rhydrate the desiccated collagen network. Since ail of the dentists in
this study appiied rubber dams and used the same
wet bonding technique, a smali range of moisture
conditions was present, but not contamination with
saliva. Under these conditions, Syntac Sprint's performance was similar to Syntac Ciassic after one
year.
The manufacturer's recommendation to simultaneously iight-cure the Syntac Sprint layer and the
first portion of composite wouid signify a further
simplification of the appiication protocol. Since
there were no significant differences between the
two Syntac Sprint groups, this study did not provide
any arguments against the shortened application
mode. On the other hand, it shouid be borne in
mind that the layer's thickness will vary from dentist to dentist, regardless of method.
Sensitivity plays a major role in the subjective
satisfaction of the patient, and is therefore potentially crucial for acceptance of the restoration.^
Compared to data from the literature^'' and the control groups, the rate of postoperative discomfort observed in this study can be considered acceptable.
The moment of photopoiymerization had no influence on the development of hypersensitivity.
The adhesion of Syntac Sprint to dentin and
enamel seems to be similar to other dentin bonding
agents. In a Syntac Sprint manufacturer's brochure,
shear bond strengths of non-precured Syntac Sprint
to dentin were given as 23 MPa on extremely desiccated or contaminated dentin and 24 iViPa on normai or wet d e n t i n . Twenty-four iViPa was also
achieved on dentin when Syntac Sprint was precured for 10 s. The shear bond strengths of nonprecured agent to enamei ranged from 2 1 MPa on
desiccated enamei, to 22 MPa on contaminated or
wet enamei, and on to a maximum of 24 MPa on
normai enamei. Precuring for 10 s provided a shear
bond strength on enamel of 22 iViPa. in contrast,
Frankenberger et ai^ reported a dentin push-out

172

bond strength of 27 MPa with precuring for 10 s.

Bond strength was significantly inferior without precuring (22 MPa) or on contaminated dentin [20
MPa). Based on these in vitro results, the use of a
rubber dam, the wet bonding technique, and precuring with iight for at least 10 s are recommended.
Ferrari et al" carried out SEM evaluations of the
bonding mechanism of Syntac Sprint, which exhibited a hybrid layer of about 3 to 7 ym thickness,
resin tags, and adhesive iaterai branch formation.
They strongly recommend the use of Syntac Sprint
according to manufacturer's instructions.''
The two restorations with proximal margins
below the cemento-enamei junction did not perform
differentiy from the fillings with all margins located
in enamel. Differences between premoiars and molars and between large and small cavities could not
be found after tweive months.
The handiing properties of Tetric Ceram do not
seem to be inferior to those of conventionai Tetric.
Tetric Ceram actually received better ratings for
some criteria, such as surface roughness and
anatomicai form at the restoration surface, although these differences were not statistically significant. The results of the present study ciearly
indicate that marginal overhangs of well-matching
fine-hybrid resin composites are a persistant problem, at least within the observed 12 months of ciinicai service.

CONCLUSIONS
After 12 months of clinical service, aii Tetric/
Syntac Ciassic and all Tetric Ceram/Syntac Sprint
restorations were in place and ciinicaiiy acceptable.
In terms of the modified USPiHS codes and criteria, there were no significant differences between
the different dentin bonding agent systems or between the resin composites.
Light-curing of Syntac Sprint prior to the application ofthe resin composite did not have any impact
on the clinical performance.
Due to its simpiified application protocoi, Syntac
Sprint may help to increase the acceptance of
dentin bonding agents and lower the technique sensitivity.
The future results of this prospective long-term
ciinicai study will facilitate a final evaluation of this
new one-bottle adhesive.

Tbe Journal of Adhesive Dentistry

Schoch et al

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173