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Contents lists available at ScienceDirect

Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Effect of bulk-fill base material on fracture strength of root-filled teeth

restored with laminate resin composite restorations
⁎
N.A. Tahaa, , G.A. Maghaireha, A.S. Ghannama, J.E. Palamarab
a
Department of Conservative Dentistry, Jordan University of Science and Technology, Irbid, Jordan
b
Melbourne Dental School, The University of Melbourne, Melbourne, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: To evaluate the effect of using a bulk-fill flowable base material on fracture strength and fracture
Fracture strength patterns of root-filled maxillary premolars with MOD preparations restored with laminate restorations.
Root-filled teeth Methods: Fifty extracted maxillary premolars were selected for the study. Standardized MOD cavities with en-
Bulk-fill flowable bases dodontic treatment were prepared for all teeth, except for intact control. The teeth were divided randomly into
Laminate technique
five groups (n = 10); (Group 1) sound teeth, (Group 2) unrestored teeth; (Group 3) MOD cavities with Vitrebond
Resin based composite
base and resin-based composite (Ceram. X One Universal); (Group 4) MOD cavities with 2 mm GIC base (Fuji IX
GP) and resin-based composite (Ceram. X One Universal) open laminate, (Group 5) MOD cavities were restored
with 4 mm of bulk-fill flowable base material (SDR) and resin-based composite (Ceram. X One Universal). All
teeth were thermocycled and subjected to a 45° ramped oblique load in a universal testing machine. Fracture
load and fracture patterns were recorded. Data were analyzed using one-way ANOVA and Dunnett’s T3 test.
Results: Restoration in general increased the fracture strength compared to unrestored teeth. The fracture
strength of group 5 (bulk-fill) was significantly higher than the fracture strength of the GIC laminate groups and
not significantly different from the intact teeth (355 ± 112N, P = 0.118). The type of failure was unfavorable
for most of the groups, with the majority being mixed failures.
Conclusions: The use of a bulk-fill flowable base material significantly increased the fracture strength of ex-
tracted root-filled teeth with MOD cavities; however it did not improve fracture patterns to more favorable ones.
Clinical significance: Investigating restorative techniques that may improve the longevity of root-filled premolar
teeth restored with direct resin restorations.

1. Introduction The inherent problem with RBCs is polymerization shrinkage and its
associated stresses at the tooth restoration interface. Methods proposed
Loss of structural integrity of root-filled teeth by caries and re- to reduce these effects included the use of incremental placement
storative procedures makes them more vulnerable to fracture than technique, the use of low modulus liners or bases, modification of the
sound teeth. The choice of materials selected for intracoronal restora- light curing method, and the use of low shrink materials [6–8]. The use
tion of root-filled teeth plays an important role in tooth longevity. The of incremental techniques with conventional RBCs is time consuming
most commonly used direct restorative materials are, amalgam, resin- and may increase the risk of contamination and air entrapment between
based composites (RBCs) and glass ionomer cements (GICs). Adhesive increments [9], with reports of higher stresses induced at the interfacial
RBCs have considerable advantages in the treatment of weakened tooth margins [10]. The main concern in applying thicker increments of
structure. The good esthetic combined with the possibility of estab- conventional RBCs is to ensure adequate curing to obtain optimum
lishing adequate adhesion between tooth structure and restorations mechanical properties. Therefore; manufacturers have marketed bulk-
may eliminate the need for extending cavity preparations, to cover the fill RBCs, these can be placed in a single 4-mm increment and still have
cusps particularly in teeth with moderate loss of tooth structure [1–4]. adequate light polymerization [11], have low polymerization shrinkage
While the rationale for using GIC materials is based on their cariostatic compared to conventional composites, and reduced cuspal deflection
effect resulting from fluoride release and their ability to bond to tooth [12,13]. Bulk-fill RBCs are classified according to their rheological
structure; it’s use as a sole buildup material is not recommended due to properties either as a flowable base material to be covered with 2 mm of
moderate mechanical properties and high failure rates [5]. posterior hybrid composite, or as a final restorative composite that does

⁎
Corresponding author at: Jordan University of Science and Technology, Conservative Dentistry Department, P.O Box 3864, Irbid 21110, Jordan.
E-mail address: n.taha@just.edu.jo (N.A. Taha).

http://dx.doi.org/10.1016/j.jdent.2017.05.016
Received 6 April 2017; Received in revised form 23 May 2017; Accepted 24 May 2017
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not require an overlying occlusal layer [11].

The earliest approach to apply RBCs in thicker layers was in-
troduced as a high translucent composite, followed by materials with
modification in the monomers, or the addition of a polymerization
modulator embedded in the resin as in the bulk-fill flowable materials
marketed as the stress decreasing resin (SDR). This modulator has vis-
coelastic behavior that results in polymerization stress values up to
60–70% less than methacrylate and nano-hybrid flowable RBCs [14].
The use of a flowable bulk-fill base in class II cavities significantly
reduced cuspal deflection with adequate marginal seal compared to the
incremental layering technique [13,15]. Acceptable clinical results si-
milar to the conventional layering technique over a 3-year evaluation
period were also reported for bulk-fill materials including; good surface
characteristics, marginal adaptation, color stability, low frequency of
secondary caries and lower fracture rates [16,17].
Generally positive effects have been reported by using flowable
composites as stress decreasing intermediate layers in class II restora-
tions [8,18]. The bulk-fill flowable liners combine the advantages of
Fig. 1. A schematic diagram of the MOD cavity preparation for prepared groups; (A)
low stress, low shrinkage values and adequate mechanical properties, Occlusal isthmus width, (B) Gingival floor width, (C) Intercuspal width, and (D)
which is particularly important in restoration of root-filled teeth. The Buccopalatal width.
aim of this study was to evaluate a flowable bulk-fill base material for
restoring root-filled maxillary premolars compared to laminate tech- 2.3. Restoration of teeth
nique using both conventional and resin modified GICs in association
with RBCs. The null hypothesis was that the bulk-fill base material will 2.3.1. Group 2
not improve the fracture resistance and fracture patterns of root-filled Teeth were left unrestored to act as a negative control group.
maxillary premolars restored with direct resin composite.
2.3.2. Group 3
2. Materials and methods A layer of resin modified GIC (Vitrebond; 3 M ESPE, MN, USA) was
packed into the canals above the gutta percha to the level of the canal
2.1. Teeth selection orifice and light cured for 30 seconds using a LED light curing source at
1,000mw/cm2 intensity (Translux Power Blue; Heraeus kulzer, Hanau,
Fifty non-carious sound maxillary premolars with mature apices Germany). Both enamel and dentine were etched with 36% phosphoric
were used in the study. Teeth were measured from both intercuspal, acid etchant (DeTrey Conditioner 36; Dentsply DeTrey, Konstanz,
bucco-lingual and mesiodistal directions to standardize the size, al- Germany) for 15 seconds, and rinsed thoroughly with air-water spray. A
lowing a maximum deviation of 10% from the determined mean. Teeth transparent polyester matrix (TDV Polyester Matrix; TDV Dental Ltda.,
were stored in 1% chloramine T solution in distilled water (pH 7.8) Pomerode, SC, Brasil) was placed on each tooth, then a universal total-
(Sigma- Aldrich Co., St. Louis, MO, USA) until use. etch adhesive system (Prime & Bond XP; Dentsply DeTrey, Konstanz,
Germany) was applied according to manufacturer's instructions then
2.2. Cavity preparations and root filling light cured for 10 seconds. The MOD cavity was then restored in-
crementally (1.5–2 mm) with shade A2 nano-ceramic composite resin
Teeth were randomly divided into 5 groups (n = 10) using a (Ceram.X one UNIVERSAL; Dentsply DeTrey, Konstanz, Germany) and
random sequence number generator. each increment was light cured for 20 seconds.

2.2.1. Group 1 2.3.3. Group 4

Sound teeth were left intact as a positive control group. The cavity was conditioned using 10% polyacrylic acid (Dentin e
conditioner, GC Corporation, Tokyo, Japan) for 10 seconds and a GIC
2.2.2. Groups 2, 3, 4 and 5 base (Fuji IX, GC Corporation, Tokyo, Japan) was placed above the
A standardized mesio-occlusal-distal (MOD) cavity was prepared on gutta percha and in the proximal boxes to a thickness of 2 mm (open
all teeth in these groups using tungsten carbide high speed fissure bur laminate). Both enamel and dentine were etched with 36% phosphoric
(DIA-BURS; MANI, Tochigi, Japan) with water coolant so that the acid etchant (DeTrey Conditioner 36; Dentsply DeTrey, Konstanz,
buccopalatal width of the occlusal isthmus was one third of the inter- Germany) for 15 seconds, and rinsed thoroughly with air-water spray.
cuspal width, and the proximal box width was one third of the bucco- Resin composite was then incrementally placed as in group 3.
palatal width of the crown. The gingival floor was located 1 mm above
the cemento-enamel junction (CEJ) and the cavity floor was prepared 2.3.4. Group 5
with no gingival step (no axial walls). The total depth of the cavity was After acid etching with 36% phosphoric acid etchant (DeTrey
between 5 and 6 mm. All internal angles were rounded and the cavo- Conditioner 36; Dentsply DeTrey, Konstanz, Germany) for 15 seconds,
surface margins were at 90 ° (Fig. 1). the cavity was rinsed thoroughly with air-water spray and then a uni-
Root canals were prepared using the ProTaper rotary nick- versal total-etch adhesive system (Prime & Bond XP; Dentsply DeTrey,
el–titanium system (Dentsply, Maillefer, Ballaigues, Switzerland) to a Konstanz, Germany) was applied according to manufacturer's instruc-
standard apical size up to F2 file and canals were filled using gutta tions then light cured for 10 seconds, a bulk-fill flowable base (SDR;
percha and AH Plus root canal sealer (Dentsply, Maillefer Detrey, Dentsply DeTrey, Konstanz, Germany) was applied above gutta percha
Konstanz, Germany). Gutta percha was removed to 2 mm below the and light cured for 20 seconds and then in the cavity up to 4 mm
CEJ. The access cavity was cleaned with a cotton pellet moistened with thickness, and then light cured for 20 seconds. The remaining 2 mm
alcohol. The sealer cement was allowed to set for 7 days at 37 °C and were then restored with one increment of Ceram. X one universal as in
100% relative humidity. group 3 and 4.


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After restoration, teeth were stored in an incubator at 37 °C in 100% supracrestal. Unrestored teeth with cavity preparations demonstrated
humidity for 24 h, and then subjected to thermocycling in water (5000 consistent patterns of fracture of the buccal cusp, extending sub-
cycles between 5 and 55 °C, a dwell time of 20 s and a transfer time of crestally.
10s). Teeth were mounted vertically in a self-cure acrylic resin (Denture In teeth restored with GIC (group 3, 4) inconsistent patterns of
Base material, Self-cure (type 2), Jiading, Shanghai, China) within fracture occurred in almost 50% of the teeth; cohesive fractures within
nylon mounting rings. The teeth were then subjected to a ramped load the buccal cusp without debonding were common (5/10 in Vitrebond
at a rate of 0.5 mm/min until fracture. The load was applied at 45° to group, and 4/10 in the Fuji IX group). Further investigation of the
the long axis, on the palatal incline of the buccal cusp, using a rounded debonded surfaces in teeth with adhesive failure (4 teeth in the
steel loading tip 3.9 mm in diameter in a computer controlled electro- Vitrebond group, 6 in the Fuji IX group) under stereomicroscope and
mechanical universal testing machine (WDW-20 Model; Jinan testing SEM showed mixed failures with wide areas of cohesive failure within
equipment IE Corporation, China). The force required to fracture each the adhesive.
tooth was recorded in Newtons and data were analyzed using one-way Most of restored teeth in the SDR group (7/10) fractured at the
ANOVA and Dunnett T3 test for multiple comparisons at the 5% sig- buccal proximal line angle and propagated obliquely to the buccal root
nificance level. surface, while only 1 tooth fractured within the buccal cusp and 2 teeth
Fracture patterns were evaluated under a stereomicroscope and had atypical horizontal root fracture. 9/10 teeth had subcrestal fracture
categorized according to location, the restoration–tooth interface where level. Debonding of the restorations was more at the buccal interface,
fracture occurred, severity of the fracture and mode of failure (ad- investigation of the fractured surface showed mixed patterns of cohe-
hesive, cohesive, mixed) at a magnification of 20×. Representative sive failures within adhesive and patches of cohesive within composite.
samples were also gold sputtered for studying the fracture surface under
the scanning electron microscope (SEM). 4. Discussion

The teeth used in this study were extracted for orthodontic reasons,
3. Results
but were limited to teeth with fully formed apices and therefore com-
plete primary dentine deposition. These teeth were chosen for con-
3.1. Fracture strength
sistency and ease of collection, and because older teeth will have a
highly variable history of tooth stress, wear, caries and restoration and
Group 1 (Sound teeth) was significantly stronger than all other
hence large variations in the quantity of secondary and tertiary dentine.
groups (564 ± 207 N, P < 0.05) except group 5 (SDR) (355 ± 112N,
Despite attempts at standardization of the size of used teeth and the
P = 0.118). Group 2 (Unrestored teeth) showed the lowest fracture
random allocation of samples, variations still exist in terms of cusp
load (118 ± 31 N, P < 0.05). Restoration in general increased the
inclines, remaining cusp thickness and diameter at the cervical region.
fracture strength compared to unrestored teeth. The fracture strength of
This is reflected in high standard deviation with a wide range of values
group 5 (SDR) was significantly higher than groups 2, 3, 4 (Fig. 2) and
within each group, similar to what have been commonly reported and
not significantly different from intact teeth. However; there was no
making statistically significant differences difficult to achieve.
significant difference in fracture strength between group 3 (Vitrebond)
The use of bulk-fill flowable composite base (SDR) has significantly
and Group 4 (Fuji IX base) (P = 0.999) which were weaker than the
improved the fracture strength of root-filled teeth compared to other
intact control.
laminate restorations and unrestored teeth; however it did not improve
the fracture patterns to more restorable ones, which partly accepts the
3.2. Fracture patterns null hypothesis of the study.
Polymerization shrinkage induces tensile stresses within the cusp,
A summary of the fracture patterns is presented in Table 1. Sound which causes cuspal deflection in an inward direction. The cusps may
teeth fractured mostly within buccal cusp and most fractures were return to the original position if the bonding allows this, among the
factors that influence the extent of cusp recovery are flow and creep of
the material, hygroscopic expansion and fracture within the tooth
structure [19]. If the bond to tooth structure is stronger than poly-
merization shrinkage stress, strain within the tooth will occur, on the
other hand if the bond is weaker then gap formation and subsequent
leakage will occur [20]. It has been reported that large restorations
results in higher stress in the tooth structure rather than at the tooth
restoration interface which could induce cracking of the tooth or even
fracture from excessive flexure or flexural fatigue [21,22]. The bulk-fill
flowable material SDR has previously shown lower polymerization
stress [13,14,23], lower cuspal deflection [13,15], lower flexural
modulus [13,14] and slower contraction rate [8]. El-Damanhory and
Platt found a significant correlation between stress and the flexural
modulus [12]. The use of a material with low modulus of elasticity in
load bearing areas allows higher deformation under occlusal stresses,
which may dissipate the stress and improves the fracture strength.
However; it is not easy to predict the effect of these factors on inter-
facial stress buildup and subsequent fracture patterns; furthermore long
term follow-up has shown only a weak correlation between interfacial
stress and clinical outcomes [16].
In an experimental study by Soares et al. [24], it was concluded that
Fig. 2. A box and whisker plot showing the distribution of fracture load values in dif-
ferent groups. The plot illustrates a summary of the fracture load based on the median,
the higher the elastic modulus of the restorative material when the
quartiles and extreme values. The median of each group (2nd quartile) is shown by the junction of restorative material/dental structure is stressed, the lower
line that divides the box into two parts. The box represents the interquartile range which the deformation of dental structures. In contrast, a low elastic modulus
contains 50% of the values; the whiskers represent the highest and lowest values. of the material promoted lower restoration stiffness and a greater


N.A. Taha et al. -RXUQDORI'HQWLVWU\[[[ [[[[ [[[²[[[

Table 1
Fracture patterns for test groups.

Goup (n = 10) Level Pattern Margin

Supra-crestal Sub-crestal Within cusp From line angle Other Buccal Palatal None

(1) Sound Teeth 8 2 8 – 2 – – –

(2) Unrestored 1 9 – 10 – – – –
(3) Vitrebond 1 9 5 4 1 6 1 3
(4) Fuji IX 2 8 4 6 0 0 6 4
(5) SDR 1 9 1 7 2 6 1 3

Subcrestal: Fracture below the acrylic mounting level. Suprarestal: Fracture at or above acrylic mounting level. Within cusp: Fracture within the cusp itself. From line angle: Fracture
propagated from buccal-proximal line angle, towards the buccal root surface obliquely. Other: A more complex fracture pattern (Root Fracture). Margin: The cavity margin (either buccal
or palatal) at which debonding between the restoration and tooth structure occurred.

distribution of stresses produced by the compression test to adjacent laminate restorations has improved the fracture strength of extracted
tooth structure which resulted in catastrophic type of fracture. Frac- root-filled maxillary premolar teeth with moderate loss of tooth struc-
tures in the SDR group in this study were mostly subcrestal fracture of ture. However; more investigations are required with different bulk-fill
the buccal cusp with intact restoration, which is in disagreement with materials and variable thickness in addition to clinical studies on the
other studies [13,25,26]. Atalay et al. [25], reported more favorable survival of these teeth.
forms of cusp fracture leaving intact restoration, this could be related to
the difference in loading pattern; in their study an 8 mm sphere verti- Acknowledgment
cally contacting the inclines of both cusps was used compared to the
simulation of nonfunctional side contacts at 45° in this study. Fur- This study was support by research grant number 466/2015 from
thermore; in their study the fracture strength of teeth restored with Sure Deanship of Research at Jordan University of Science and Technology.
fil SDR (micro hybrid flowable) was not superior to conventional nano-
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