Abstract
Objective
The aim of this in vitro study was to evaluate the bond strength of a resin composite fissure sealant to enamel which was pre-treated with different laser pulse modes and additional acid etching.
Materials and Methods
Forty-two healthy molars and premolars were collected for this study and randomly divided into 6 groups (n=7). Group 1: Quantum Square Pulse (QSP); Group 2: Medium-Short Pulse (MSP) mode; Group 3: Super Short Pulse (SSP) mode; Group 4: QSP + acid etching; Group 5: MSP + acid etching; Group 6: SSP + acid etching. The occlusal surfaces of the teeth were pre-treated according to the defined group. Laser conditioning of the enamel was performed using an Er:YAG laser Fotona Light Walker AT-S (Fotona, Ljubljana, Slovenia) with a wavelength of 2940 nm + acid etching (EN etch Ivoclar Vivadent AG, Schaan, Liechtenstein). Occlusal surfaces were sealed with a resin-based composite fissure sealant (Helioseal F, Ivoclar Vivadent AG, Schaan, Liechtenstein). Micro-tensile bond strength (μTBS) test and stereomicroscope evaluations of the failure mode were performed. The μTBS was tested using the Games-Howell method. The failure mode between groups was tested using the chi-square test. The significance level for all tests was set at p <0.05.
Results
The highest bond strength was measured using laser etching in MSP mode combined with acid etching (36.09 MPa). This combination showed a significantly higher bond strength than the other combinations (SSP + ETCH, p<0.001; QSP + ETCH, p<0.001).
Conclusion
The SP laser followed by acid etching of enamel yielded the highest bond strength. Thus, the MSP with a 140 µs pulse mode might be the preferred choice as a pre-treatment procedure for fissure sealing.
Key words: Enamel pre-treatment, Bond strength, Composite fissure sealant, Er: YAG laser
Keywords: MeSH terms: Dental Enamel, Pit and Fissure Sealants, Composite Resins, Bond Strength, Laser Therapy
Introduction
Dental caries is “a biofilm-mediated, diet-modulated, multifactorial, non-communicable, dynamic disease that results in net mineral loss of dental hard tissues” (1). Although smooth surfaces have benefited from caries-prevention protocols, the high prevalence of occlusal caries remains a challenge (2). This can be attributed to the complex pit and fissure morphologies, which are highly susceptible to caries development. Dental biofilms easily accumulate in these areas and cannot be effectively removed.
Dental fissure sealants prevent the pit and fissure caries. They provide a mechanical barrier to prevent dental plaque accumulation (3). Therefore, fissure sealant application is one of the most reliable and effective methods to prevent occlusal caries. The advantages of sealant application are significant caries risk reduction compared to non-sealed controls and lower biological ad economical cost compared to restoration placement (4). The success rate of fissure sealants depends on the quality of adhesion between the sealant material and the enamel (5). To enhance the bond strength between the composite fissure sealant and enamel, different pre-treatment techniques have been investigated. Each method aims to modify the enamel surface, creating micropores, increased surface roughness, or chemical interactions to facilitate mechanical or chemical bonding (6, 7).
Improving the bond and retention of the sealant material would increase the primary and secondary preventive benefits of sealants, as it has been reported that the loss of sealant is directly related to subsequent caries development.
Acid etching of the enamel with phosphoric acid at 30-40% concentration (8) is one of the most common procedures in resin-based pit and fissure sealant applications in clinical practice. Acid etching is a widely accepted and effective pre-treatment method that enhances sealant adhesion. Several studies have shown that acid etching significantly improves the bond strength. However, careful application and rinsing are required to avoid over-etching or enamel damage (9, 10). Over-etching or leaving acid on the enamel surface for an extended period can lead to excessive demineralization, enamel prismatic dissolution, or enamel surface roughness (11).
In addition to the conventional acid-etching method, laser etching has emerged as an alternative technique for enamel preparation before sealant placement. Pre-treatment of enamel with Er: YAG laser involves the use of laser energy to create micro texturing on the enamel surface, which can enhance the bond strength between the sealant material and the tooth. Some studies have demonstrated that the micro-roughened surface morphology after laser irradiation of permanent enamel is similar to that obtained with conventional acid etching (12, 13). Other studies reported that pre-treatment with Er: YAG laser alone prior to sealant application led to increased resin microleakage and lower bond strength of the sealant to enamel (14, 15).
Pulse Duration and Laser energy influence enamel surface modification. Different pulse modes, such as long-pulse, short-pulse, and ultrashort-pulse lasers, can affect the interaction with enamel. Longer pulse durations allow for deeper penetration and more thermal effects, whereas shorter pulse durations provide more precise ablation with minimal thermal side effects (16). Regarding pulse shaping, three pulse-forming technologies are currently used in erbium dental lasers: Pulse-Forming Network (PFN), Variable Square Pulse (VSP), and the latest Adaptive Structured Pulse (ASP) technology (17). Adaptive Structured Pulsing (ASP) is a powerful technology enabling precise manipulation of the temporal envelope of laser pulses, transitioning from a simple square pulse shape to more complex forms. This includes breaking individual pulses in a train into multipulse burst sequences, with each pulse uniquely shaped. A notable example of this adaptive approach is the Quantum Square Pulse (QSP) modality, which optimizes Er: YAG laser performance by meeting the three fundamental requirements for dental tissue ablation: rapid ablation, minimal heat deposition, and reduced vibration (18, 19).
However, it should be noted that the optimal laser parameters for enamel etching may vary depending on the laser type, wavelength, energy density, and pulse duration. Further research is needed to determine the most effective laser parameters for sealant placement and evaluate the long-term clinical performance of laser-etched sealants. The aim of this study was to evaluate the bond strength of a composite fissure sealant to the enamel surface after pre-treatment with different laser pulse modes of an Er:YAG laser alone or using laser modes associated with acid etching, and to compare the results among all pre-treatment procedures. The null hypotheses were: H10 there is no difference in the bond strength whether the materials were applied to the enamel surface pretreated with Quantum Square pulse mode (QSP), Super Short Pulse (SSP mode), and Medium-Short Pulse mode (MSD); H20 there is no difference in bond strength of composite fissure sealant to enamel surface pre-treated with QSP, SSP, MSP laser mode with additional acid etching; H30 there is no difference in the failure mode among the groups.
Materials and Methods
The study was approved by the Ethics Committee of the University of Zagreb School of Dentistry and the University of Pristina “Hasan Pristina” Dental Faculty. A total of 42 noncarious human premolars and molars were collected for this study. Periodontal tissue remnants were cleanly removed. After disinfection with 0.5% chloramine solution for a week, the teeth were placed in distilled water and stored until sample preparation at 4 °C until use. All teeth were examined at 10X magnification using a stereomicroscope, and teeth with caries, cracks, and other enamel structure anomalies were excluded from the study.
Teeth were randomly divided into six groups, with seven specimens in each group (n=7) depending on the pre-treatment variety. These pre-treatments were performed on the occlusal surfaces of each tooth prior to fissure sealant application.
The groups were as follows:
Group QSP (Quantum Square pulse mode) Adaptive Structured Pulse (ASP) – QSP
Group MSP (Medium-Short Pulse mode) 140 µs pulse mode – MSP
Group SSP (Super Short Pulse mode) 50 µs pulse mode – SSP
QSP + Acid etching – QSP+ETCH
MSP + Acid etching – MSP+ETCH
SSP + Acid Etching – SSP+ETCH
After cleaning, rinsing, and drying, the specimens were conditioned with different laser modes, and acid etching was used for Groups 4, 5, and 6.
Laser conditioning of the enamel surface in all groups was carried out using the Adaptive Structured Pulse (ASP) mode with an Er: YAG laser device, the Fotona Light Walker AT-S (Fotona, Ljubljana, Slovenia) with a wavelength of 2940 nm, using a handpiece H14 with a conical sapphire fiber (13 up to 0.8/8 mm) tip. The power outputs were 120 mJ and 10 Hz, respectively. Additional acid etching was performed using orthophosphoric acid 37% (EN etch Ivoclar Vivadent AG, Schaan, Liechtenstein) for 20 s. After pre-treatment of the occlusal surface, the composite fissure sealant (Helioseal F, Ivoclar Vivadent AG, Schaan, Liechtenstein) was placed on the occlusal surfaces according to the manufacturer's instructions and polymerized in high-power mode at 1200 mW/cm2 (Bluephase Ivoclar Vivadent AG, Schaan, Liechtenstein) for 20 seconds. All teeth were placed in a self-curing acrylate to obtain a square surface so that cutting could be performed in a universal cutting machine (Isomet). All teeth were cut into 1-1.5 mm thick and at least 6 mm long beams. From each tooth we were able to obtain one or two beams making the total number of samples ten for each group.
The microtensile bond strength (μTBS) of the samples was tested using a Bisco Microtensile tester (Bisco, Schaumburg, Illinois, USA). Each sample was fixed at both ends to microtensile device test jaws using cyanoacrylate glue (Zapit, Dental Ventures of America, and Corona, CA, USA). The force was applied at a crosshead speed of 1 mm/min until the failure of the sample. The force obtained at the moment of sample failure was recorded. The microtensile bond strength values (MPa) were calculated as the ratio of the applied force (N) at the moment of sample failure to the cross-sectional bonding area (mm2) of the sample. The cross-sectional bonding area was determined by measuring the width of the sample. The type of failure of the sample was classified as adhesive, cohesive, or mixed using a stereomicroscope at 40× magnification.
Statistical analyses were performed using the statistical software SPSS version 20 (IBM, New York, USA). Individual entities obtained by μTBS analysis were described with two independent nominal variables and one dependent continuous variable: three different pulse modes, with and without additional acid etching treatment, and μTBS. The answer to the hypotheses was determined using two-way analysis of variance (ANOVA). The significance of the effects was determined by hypothesis testing using F-tests.
The normality of the distribution of the dependent variables was tested using the Kolmogorov-Smirnov test. Because the equality of error variances condition was not met for multiple comparisons, the μTBS was tested using the Games-Howell method.
The failure mode between groups (three without etching and three with etching) was tested using the chi-square test. The significance level for all tests was set at p <0.05.
Results:
Group SSP (24.79 MPa ±3.92) had the lowest bond strength, followed by QSP + ECTH (27.92 MPa ±2.24), and SSP + ECTH (28.16MPa ±3.69). The highest bond strength was achieved in the MSP + ECTH group (36.09 MPa ±4.42), while almost the same bond strength was achieved in the MSP and QSP (32.42 ±5.91 and 32.03 MPa ±6.13 respectively). The bond strength dispersion, expressed by the standard deviation, was the highest in the QSP group (6.13 MPa) and almost the same in the MSP group (5.91 MPa). The other groups showed less bond strength dispersion, especially in the QSP + ETCH group (2.24 MPa), Figure 1.
Figure 1.
_339-347-f1.jpg)
Box and whisker plot microtensile bond strength (MPa) by the group
The above results of the μTBS analysis using two-way analysis of variance contradict hypotheses H01 and H02; namely, there are statistically significant differences among the SSP, MSP, and QSP groups regarding μTBS, despite the fact that etching alone was not a statistically significant factor. A statistically significant difference was found in the interaction between the studied groups, Figure 2.
Figure 2.
_339-347-f2.jpg)
Average values of microtensile bond strength without and with the etching procedure in the groups (with associated 0.95 confidence intervals
Multiple comparisons of the μTBS test with the Games-Howell method are shown in Table 1. The method enables mutual comparison of all six groups (SSP, MSP, QSP, SSP + ETCH, MSP + ETCH, and QSP + ECTH), pair by pair.
Table 1. Multiple comparisons microtensile bond strength (MPa) with Games-Howell method.
| First group | Second group | Mean Difference | Std. Error | p |
|---|---|---|---|---|
| SSP | QSP | -7.24* | 1.615 | 0.001 |
| MSP | -7.63* | 1.573 | <0.001 | |
| SSP+ETCH | -3.37 | 1.202 | 0.079 | |
| QSP+ETCH | -3.13* | 0.997 | 0.039 | |
| MSP+ETCH | -11.30* | 1.306 | <0.001 | |
| QSP | SSP | 7.24* | 1.615 | 0.001 |
| MSP | -0.39 | 1.903 | 1.000 | |
| SSP+ETCH | 3.87 | 1.611 | 0.187 | |
| QSP+ETCH | 4.11 | 1.464 | 0.090 | |
| MSP+ETCH | -4.06 | 1.690 | 0.183 | |
| MSP | SSP | 7.63* | 1.573 | <0.001 |
| QSP | 0.39 | 1.903 | 1.000 | |
| SSP+ETCH | 4.26 | 1.568 | 0.100 | |
| QSP+ETCH | 4.50* | 1.417 | 0.041 | |
| MSP+ETCH | -3.67 | 1.649 | 0.252 | |
| SSP+ETCH | SSP | 3.37 | 1.202 | 0.079 |
| QSP | -3.87 | 1.611 | 0.187 | |
| MSP | -4.26 | 1.568 | 0.100 | |
| QSP+ETCH | 0.24 | 0.990 | 1.000 | |
| MSP+ETCH | -7.93* | 1.301 | <0.001 | |
| QSP+ETCH | SSP | 3.13* | 0.997 | 0.039 |
| QSP | -4.11 | 1.464 | 0.090 | |
| MSP | -4.50* | 1.417 | 0.041 | |
| SSP+ETCH | -0.24 | 0.990 | 1.000 | |
| MSP+ETCH | -8.17* | 1.114 | <0.001 | |
| MSP+ETCH | SSP | 11.30* | 1.306 | <0.001 |
| QSP | 4.06 | 1.690 | 0.183 | |
| MSP | 3.67 | 1.649 | 0.252 | |
| SSP+ETCH | 7.93* | 1.301 | <0.001 | |
| QSP+ETCH | 8.17* | 1.114 | <0.001 |
*The mean difference is significant at the 0.05 level.
For example, SSP showed significantly lower bond strength compared to QSP and MSP, but it did not increase significantly by etching (SSP + ETCH); it was also lower than those in the other two groups with ECTH. Neither the QSP, nor MSP changed significantly with etching, Table 1
Failure mode analyses showed 100% success of sealing (adhesive) outcomes in the SSP, MSP, and MPS + ETCH groups. In the QSP group, the success rate was 87% (three failed sealing outcomes), whereas in the same group with etching, the success rate was 90.5% (two failed sealing outcomes). In the SSP group, one failed experiment was registered in the case of etching, which reduced the success rate by 5%, Table 2.
Table 2. Stereomicroscope analysis results.
| Pulse mode | Stereomicroscope analysis | |||||
|---|---|---|---|---|---|---|
| Adhesive | Cohesive-material | Cohesive-teeth | Pretest Failure-Adhesive | Total | ||
| SSP | n | 21 | 0 | 0 | 0 | 21 |
| rp | 100.0% | 0.0% | 0.0% | 0.0% | 100.0% | |
| QSP | n | 20 | 0 | 1 | 2 | 23 |
| rp | 87.0% | 0.0% | 4.3% | 8.7% | 100.0% | |
| MSP | n | 20 | 0 | 0 | 0 | 20 |
| rp | 100.0% | 0.0% | 0.0% | 0.0% | 100.0% | |
| SSP+ETCH | n | 19 | 1 | 0 | 0 | 20 |
| rp | 95.0% | 5.0% | 0.0% | 0.0% | 100.0% | |
| QSP+ETCH | n | 19 | 2 | 0 | 0 | 21 |
| rp | 90.5% | 9.5% | 0.0% | 0.0% | 100.0% | |
| MSP+ETCH | n | 20 | 0 | 0 | 0 | 20 |
| rp | 100.0% | 0.0% | 0.0% | 0.0% | 100.0% | |
| Total | n | 119 | 3 | 1 | 2 | 125 |
| rp | 95.2% | 2.4% | 0.8% | 1.6% | 100.0% | |
*Legend: n – number of cases, rp – row percentages
Discussion
The aim of this study was to test and compare the bond strength of composite fissure sealant to enamel after pre-treatment with QSP, SSP, and MSP laser pulse modes and additional acid etching. The results have shown that SSP had the lowest bond strength (24.79 MPa ±3.92), followed by QSP + ETCH (27.92 MPa ±2.24), SSP + ETCH (28.16 MPa ±3.69), and MSP + ETCH (36.09 MPa ±4.42).
Comparisons between the groups revealed significant differences. The SSP exhibited lower bond strength than both the QSP and MSP modes (p=0.001), with MSP showing the highest overall strength (p<0.001). However, no significant difference was observed between the QSP and MSP modes (p =1.000). This confirms that SSP results in lower bond strength, while the QSP and MSP modes provide higher strength, refusing the first hypothesis that there is no difference between the SSP, MSP and QSP bond strength
The impact of acid etching in combination with laser modes was further examined. Although SSP + ETCH showed higher bond strength than SSP alone, the difference was not statistically significant (p=0.079). The combination of MSP + ETCH resulted in the highest bond strength (36.09 MPa±4.42), thus showing that etching with MSP improves adhesion, while QSP + ETCH decreases the bond strength compared to QSP alone.
The analysis rejected the null hypothesis and confirmed the significant effect of the laser pulse mode on the bond strength, particularly when combined with etching. A post-hoc analysis using the Games-Howell method showed that MSP + ETCH had a significantly higher bond strength than the other groups, suggesting that the MSP was the preferred pre-treatment mode.
Stereomicroscope analysis found that the MSP and SSP groups showed 100% success in sealing outcomes, whereas the QSP group had a higher failure rate, further supporting MSP as the best pre-treatment option. This study aligns with and expands upon the findings from previous research on bond strength using laser pre-treatment techniques. Previous studies have reported varying results depending on the laser type and parameters used. For example, AlHumaid et al. (20) demonstrated similar bond strengths for Er, Cr: YSGG laser pre-treatment compared to traditional acid etching. In contrast, Drummond et al. (21) and Shahabi et al. (22) observed that acid etching generally provided superior bond strength compared with laser treatment. However, Wanderley et al. (23) found that Er: YAG lasers can achieve bond strengths comparable to or even exceeding those of acid etching.
In this study, MSP + ETCH provided the highest bond strength, supporting the notion that combining laser etching (particularly the MSP mode) with acid etching improves bond strength. This finding aligns with the research by Borsatto et al. (24, 25), who showed that combining etching methods, that is laser and acid method, can enhance the tensile strength and reduce microleakage. However, unlike AlHumaid’s results, which indicated that higher laser power settings (3.5 W) are required to match the acid etching bond strengths, our study found that the MSP mode provided superior bond strength even without a particularly high laser power setting. This suggests that the laser pulse mode (e.g., MSP) may play a critical role in achieving high bond strength, rather than just the laser power output.
While some studies indicate that lasers can negatively affect bond strength owing to enamel surface irregularities, our findings contrast with this by showing that the MSP, in particular, significantly enhances bond strength. Additionally, the stereomicroscope analysis used in this study indicated high success rates for the MSP and SSP groups in sealing, further reinforcing MSP's reliability as a pre-treatment method, which contrasts with findings in studies using lasers such as Er, Cr:YSGG, where surface damage reduced bond strength (26, 27).
Although this study offers valuable insights, several limitations must be acknowledged. First, the relatively small sample size may have reduced the statistical power and generalizability of our results. Future research with a larger sample size would strengthen the reliability of these findings. Second, this study focused exclusively on the μTBS without evaluating other important factors, such as retention rates or clinical performance. Including these additional parameters in future studies would provide a more complete picture of the effectiveness of laser etching as a pre-treatment for fissure sealants. Third, the study did not directly compare laser etching with conventional acid etching; instead, it compared different laser modes and the combination of laser and acid etching, which means that the conventional method was not used as a reference.
Thus, this study adds to the existing body of literature by demonstrating that the MSP mode combined with acid etching provides the highest bond strength, reinforcing the findings of previous studies while offering a new perspective on the effectiveness of specific laser modes in improving composite bond strength.
Conclusion
These findings contribute to the growing body of literature on pre-treatment methods for fissure sealants and emphasize the potential benefits of alternative approaches, such as the QSP and MSP laser enamel pre-treatment. Future studies with larger sample sizes and comprehensive evaluations are warranted to elucidate the role of laser etching in enhancing the effectiveness of fissure sealant placement.
Footnotes
Conflict of Interest
The authors declare no conflict of interest.
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