2/11/23, 2:17 PM Comparison of the fracture resistance of three different recent composite systems in large Class II mesio-occlusal distal

distal cavities: An in…

J Conserv Dent. 2019 May-Jun; 22(3): 287–291. PMCID: PMC6632638

doi: 10.4103/JCD.JCD_225_18: 10.4103/JCD.JCD_225_18 PMID: 31367115

Comparison of the fracture resistance of three different recent composite systems

in large Class II mesio-occlusal distal cavities: An in vitro study
Yajuvender Singh Hada and Sumita Panwar

Department of Conservative Dentistry and Endodontics, Daswani Dental College and Research Centre, Kota,
Rajasthan, India
Address for correspondence: Prof. Yajuvender Singh Hada, Department of Conservative Dentistry and
Endodontics, Daswani Dental College and Research Centre, IPB-19, RIICO Institutional Area, Ranpur, Kota - 324
009, Rajasthan, India. E-mail: coolhadays@rediffmail.com

Received 2018 May 9; Revised 2018 Jun 15; Accepted 2019 Jun 6.

Copyright : © 2019 Journal of Conservative Dentistry

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-
NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-
commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Abstract

Background:

The present study was undertaken to evaluate the most suitable recent restorative material
for extensively mutilated teeth.

Aim:

This study aims to evaluate and compare the fracture resistance of maxillary premolars with
Class II mesio-occlusal distal (MOD) cavities restored with recent Ever X posterior, bulk-fill
composite, and Estelite sigma quick composite systems.

Materials and Methods:

Sixty human maxillary premolars were selected. Fifteen intact teeth served as positive control
(Group 1). MOD cavities were prepared in the remaining 45 teeth with standardized dimen‐
sions and were randomly divided into three experimental groups (Group 2, 3, and 4) (n = 15).
Teeth in Group 2, 3, and 4 were reinforced with 3M ESPE Filtek Bulk-fill posterior, GC Ever X
posterior, and Tokuyama Estelite sigma quick composites, respectively. Fracture resistance was
measured in Newton (N).

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Results:

Group 4 (1432.60 N) showed the highest mean fracture resistance followed by Group 3
(1326.20 N), Group 1 positive controls (1288.53 N), and Group 2 (946.66N), respectively. One-
way analysis of variance (ANOVA) test revealed a statistically significant difference between all
the groups (P = 0.005). Post hoc Tukey test revealed a statistically significant difference in
mean fracture resistance between the Group 2 and Group 4 (P = 0.004), as well as between
the Group 2 and Group 3 (P = 0.033). However, there were no significant differences among
the other groups.

Conclusion:

Among the experimental groups, Estelite sigma quick composite showed the highest fracture
resistance. Statistically, a significant difference was seen between all groups.

Keywords: Bulk fills, e glass fibers, fracture resistance, mesio-occlusal distal cavities, spherical
supranano fillers

INTRODUCTION

Restoration of extensively carious teeth is one of the biggest challenges in dentistry. Many
types of research and advancements on the molecular level are going on to overcome the
shortcomings such as polymerization shrinkage, microleakage, water sorption, and technique
sensitivity, leading to the evolution of composites with improved properties.[1]

Recent materials such as fiber-reinforced composites, bulk-fill composites, and higher filler
content composites are introduced with improved handling properties, reduced polymeriza‐
tion shrinkage, and increased fracture toughness.

Recently, time-saving composites are introduced which can be placed in 4–5 mm bulk and
cured in one step. Rheology of bulk fills is such that it allows better adaptation to the cavity
walls with self-leveling effect.[2]

Fiberreinforced Ever X posterior composite consists of the combination of Eglass fibers and
barium glass filler, fiber length in millimeter scale is 1–2 mm.[2] Within a tough polymer matrix
fibers helps in stopping the crack progression same as the function of dentine, rendering it a
perfect material of choice in large size cavities(MOD).[3] It is basically a dentine replacement
composite and needs to be covered proximally and occlusally with conventional composite
simulating enamel coverage.[4]

Group of new composites Estelite sigma quick with higher filler loading and spherical
supranano zirconia and silica fillers not just impart improved physical properties but also
made it esthetically demanding, quick curing time enhance the handling characteristics.[5]
Total filler content in Ever X posterior is 53.6% by weight.[21,23]

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Hence, this study aims to evaluate the fracture toughness of the recent composite materials in
severely weakened maxillary premolars with mesio-occlusal distal (MOD) cavities. The objec‐
tive of the study was to evaluate the fracture resistance of all the three materials and to find
which restorative material will provide maximum fracture resistance.

The null hypothesis tested will be that there will be no difference in the fracture resistance of
intact teeth and those restored with different composite materials.

MATERIALS AND METHODS

Sixty human maxillary premolars collected from department oral and maxillofacial surgery
which was extracted for orthodontic reason, were used in the study. Power and the sample
size of the study were calculated by IBM® SPSS® 21 SOFTWARE (IBM, Hong Kong). All the
specimens were scaled to remove the adhering soft tissue and calculus and were stored in
physiologic saline. Fully erupted teeth with mature apices, intact enamel and dentine without
any carious lesion, restorations, and developmental defects were included. Teeth with open
apices or resorption, previous restorations, or with any anatomical variation were excluded
from the study.

Fifteen intact teeth were used as positive controls (Group 1). Standardized MOD cavities was
prepared using a tungsten carbide straight fissure bur (FG 172, KERR Haw, Canada) in high-
speed water-cooled hand piece, bur was changed after every 10 cavity preparations.
Dimensions were 2 mm ± 0.2 mm pulpal width, 1.5 mm ± 0.2 mm gingival width, and 2 mm ±
0.2 mm buccolingual width and are verified using periodontal probe.[6] Facial and lingual
walls of the occlusal segment were prepared parallel to each other with the cavosurface angle
at 90° [Figures 1 and 2].

Prepared cavities were air-dried, and COLTENE Swiss Tec etchant was used for 10 s, and cavi‐
ties were rinsed for 30 s and air-dried.

3M ESPE Single Bond Universal bonding agent was applied and cured for 20 s with Dentsply
Spectrum curing light. Tofflemire matrix band was applied for a further composite restoration.

Subsequently, teeth were randomly divided into three groups (n = 15).

Group 2: Teeth restored with Filtek 3M ESPE bulk fill

Bulk-fill posterior composite was placed in bulk without any incremental technique and cured
for 30 s [Figure 3].

Group 3: Teeth restored with fiber-reinforced composite GC Ever X posterior

In this case, walls of the MOD cavities were built by microhybrid Coltene Swiss Tec composite
followed by placement of Ever X posterior composite in the core. The restoration was com‐
pleted by placing a 0.5 mm layer of microhybrid composite on the occlusal surface[4] [
Figure 4].

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Group 4: Teeth restored with TOKUYAMA Estelite sigma quick

Estelite sigma quick composite was placed by incremental technique and cured for 10 s for
each increment [Figure 5].

Manufacturer's instructions were followed while placing and curing the composites.

Thermocycling (SD Mechatronik, Germany thermocycler) was carried out 500 cycles at 5°C ±
2°C–55°C ± 2°C with 30 s dwell time and 5 s transfer time. Then, the specimens were stored in
an incubator (Bioline technology, India) at 37°C and 100% humidity for 24 h. Teeth were
mounted in square blocks of cold cure acrylic resin 2 cm in dimensions up to 1.5 mm apical to
the cement–enamel junction. A layer of light body elastomeric impression material was applied
around the root surface to simulate the periodontal ligament. The fracture resistance of the
teeth was measured using an Instron India universal testing machine (model 1011). Each spec‐
imen was subjected to compressive loading using a 5 mm round diameter stainless steel ball at
a strain rate of 2 mm/min. The ball should contact the inclined planes of the facial and palatal
cusps beyond the margins of the restoration, which will simulate the tendency of the mastica‐
tory forces deflecting the cusps under stress. The force necessary to fracture the specimen
was recorded in Newton (N), and data obtained were tabulated and subjected to the statistical
analysis using IBM SPSS Statistics professional software.

RESULTS

Highest mean fracture resistance was observed with Group 4 Estelite sigma quick (1432.60 N)
followed by Group 3 Ever X posterior (1326.20 N), Group 1 Intact teeth (1288.53 N), and
Group 2 bulkfill posterior composite (946.66N) [Figure 6]. One-way ANOVA test [Tables 1 and
2] revealed a statistically significant difference (P = 0.005) between the groups. On intergroup
comparisons, Post hoc Tukey test [Table 3] revealed that there is a statistically significant dif‐
ference in mean fracture resistance between the Group 2 and Group 4 (P = 0.004), as well as
between the Group 2 and Group 3 (P = 0.033). However, there were no differences between
the other groups.

DISCUSSION

Tokuyama Estelite sigma quick is the preferred material for restoring extensive cavities with
the highest mean fracture resistance (1432.60 N) followed by Ever X Posterior (1326.20 N),
positive controls (1288.53 N), and Bulk-fill group (946.66N). Hence, our null hypothesis has
got rejected.

Fracture is a complete or incomplete break in a material resulting from the application of ex‐
cessive force.[7] Fracture resistance is directly related to the stoppage of the crack propaga‐
tion. Masticatory forces have a tendency to deflect cusps, and composites decrease the defor‐
mation of the cusps under masticatory load.[8,9]

The variation in strength between different composites may be explained due to the differ‐
ences in the chemical composition of their matrix, filler content, filler size, and distribution.
[9,10] Thus, a reduction in size and increase in the volume of fillers are directly proportional

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to an increase in compressive strength and surface hardness.[10,11]

High filler loading increases the physical and handling properties of the composites, new adhe‐
sive materials not only seal the margin but also increase the retention and resistance proper‐
ties of the restored tooth.[12] Recent nanofiller technology with nanometric fillers impreg‐
nated in nanoclusters leads to high filler loading resulting in an increase in high compressive
strength and flexural strength.[13,14]

Bulk filling all of the tooth preparation with a composite at one time has obvious advantages
for both patients and practitioners. The manufacturers claim that the bulk-fill materials can
achieve a depth of cure of 6 mm.[15,16] Bulk-fill technology not only results in fewer voids in
the mass of the material since all of it is placed at one time but also would be faster than plac‐
ing numerous increments.

Filtek™ Bulk Fill Posterior contains two novel methacrylate monomers that, in combination, act
to lower polymerization stress. A high molecular weight aromatic urethane dimethacrylate de‐
creases the number of reactive groups in the resin. This helps to moderate the volumetric
shrinkage. The addition–fragmentation monomers contain a third reactive site that cleaves
through a fragmentation process during polymerization. This process provides a mechanism
for the relaxation of the developing network and subsequent stress relief. The fragments, how‐
ever, still retain the capability to react with each other or with other reactive sites of the devel‐
oping polymer.[17]

Radical-amplified photopolymerization initiator (RAP technology) is used in Estelite sigma

quick. The initiator balances the high polymerization activity needed to cure the resin with
short exposure times (one-third of that required by conventional composites) and requires
exposures of 10 s or less. To achieve high esthetic qualities, it has a suprananofillers 0.2-μm
mono-dispersing spherical filler (Si-Zr). Particle diameters of 0.2 μm are known to produce the
best balance of material properties and esthetics. Estelite sigma quick itself resists wearing
without causing unusual wear in opposing teeth. It resists absorbing stains from substances
such as coffee better than conventional products.[19] It is 82% filled by weight, which allows it
to have excellent strength and durability to withstand the demands of the posterior dentition
and the harsh environment of the oral cavity.[18]

Fibers incorporated into a composite material greatly enhances its mechanical property. The
fibers present helps in stopping crack propagation when the stress is transferred from the ma‐
trix to the fibers.[20] Ever X posterior containing E-glass fibers of 1–2 mm in length impreg‐
nated within the nanohybrid composite could be used in 4 mm increment. The difference in
fracture toughness between materials may be due to the inorganic filler loading – 76.5% by
weight in bulk-fill composites, 53.6% in Ever X posterior, and 82% in Estelite sigma quick. The
highest filler loading in Tokuyama Estelite sigma quick provides excellent strength and
durability.

The present results were obtained in optimized laboratory settings; however, clinical condi‐
tions are not similar and the aspects such as insertion and handling could have a potential ef‐
fect on the mechanical properties of the materials and their performance.

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Maxillary premolars were chosen as they are more prone to fracture due to the anatomical
shape with steep cuspal inclines which leads to cuspal separation during mastication.[4] MOD
cavities were prepared in the teeth as these are considered to be the worst in terms of frac‐
ture resistance.[22]

Any relevant study could not be found comparing bulk-fill posterior composite, Ever X poste‐
rior along with Estelite sigma quick, and hence, the results of the study cannot be substantiated
with those of any other studies.

CONCLUSION

Within the limitations of this study, maximum fracture resistance is shown by the Tokuyama
Estelite sigma quick composite.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

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morphological and mechanical characteristics. Dent Mater. 1992;8:310–9. [PubMed: 1303373]

14. Bremer BD, Geurtsen W. Molar fracture resistance after adhesive restoration with ceramic inlays or resin-based
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16. de Moraes RR, Gonçalves Lde S, Lancellotti AC, Consani S, Correr-Sobrinho L, Sinhoreti MA, et al. Nanohybrid resin
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Figures and Tables

Figure 1

Cavity preparation mesial review

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Figure 2

Cavity preparation occlusal view

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Figure 3

Restoration with bulk-fill posterior

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Figure 4

Restoration with Ever X posterior

Figure 5

Restoration with Estelite sigma quick

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Figure 6

Graphical representation of comparison of mean fracture resistance of composites

Table 1

Mean fracture resistance in Newton (N) in all four groups

n Mean Standard Standard 95% confidence Minimum Maximum

deviation error interval for Mean

Lower Upper
bound bound

Control 15 1288.5333 236.67575 61.10942 1157.4667 1419.6000 885.00 1675.00

Bulk-fill 15 946.6667 179.83630 46.43353 847.0766 1046.2567 684.00 1417.00

Composite

Ever X 15 1326.2000 452.28092 116.77843 1075.7352 1576.6648 965.00 2873.00

Posterior

Estelite 15 1432.600 503.26432 129.94229 1153.9015 1711.2985 870.00 2791.00

Sigma Quick

Table 2

Fracture resistance analysis of variance test

Sum of squares Degree of freedom Mean square F Sig

Between Groups 1989541.933 3 663180.644 4.857 0.005

Within Groups 7646653.067 56 136547.376

Total 9636195.000 59

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Table 3

Multiple comparisons using post hoc Tukey test

Reference Comparison Mean Difference Standard Significance 95% Confidence

Group (RG) Group (CG) (RG-CG) error Interval

Lower Upper
Bound Bound

Control Bulk-fill 341.86667 134.93079 0.066 -15.4149 699.1482

composite

Ever x posterior -37.86667 134.93079 0.992 -394.9482 312.6149

Estelite sigma -144.06667 134.93079 0.710 -501.3482 213.2149

quick

Bulk-fill Control -341.86667 134.93079 0.066 -699.1482 14.4149

Composite Ever x posterior -379.53333 134.93079 0.033 -736.8149 -22.2518

Estelite sigma -485.93333 134.93079 0.004 -843.2129 -128.6518

quick

Ever X Posterior Control 37.86667 134.93079 0.992 -319.6149 394.9482

Bulk-fill 379.53333 134.93079 0.033 22.2518 736.8149

composite

Estelite sigma -106.40000 134.93079 0.859 -463.6815 250.8815

quick

Estelite Sigma Control 0.06667 134.93079 0.710 -213.2149 501.3482

Quick Bulk-fill 485.93333. 134.93079 0.004 128.6518 843.2149
composite

Ever x posterior 106.40000 134.93079 0.859 -250.8815 463.6815

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