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Operative Dentistry, 2011, 36-3, 326-334

Comparison of Premolar
Cuspal Deflection in Bulk
or in Incremental
Composite Restoration
Methods
ME Kim  SH Park

Clinical Relevance
For class II composite restorations, choosing composites with a low shrinkage value and
elastic modulus, applying an incremental filling technique of more than three layers, and
polymerizing them with sufficient curing time are needed to reduce the cuspal deflection,
which is induced by the polymerization shrinkage stress of composites.

SUMMARY
Objectives: This study examined the cuspal
deflection of maxillary premolars when either
a bulk filling or incremental filling technique
was employed using a range of composites
with different elastic moduli.
Methods: Four brands of composite materials,
Heliomolar (HM, Ivoclar Vivadent, Schaan,
Liechtenstein), Heliomolar HB (HH, Ivoclar
Vivadent, Schaan, Liechtenstein), Filtec Supreme XT (FS, 3M Dental Product, St Paul,
Myeung-Eun Kim, DDS, PhD, Department of Conservative
Dentistry, Yonsei University, Seoul, Korea
*Sung-Ho Park, DDS, PhD, professor, Department of Conservative Dentistry, Yonsei University, Seoul, Korea
*Corresponding author: Department of Conservative Dentistry, Yonsei University, 134, Shinchon-Dong, Seodaemun-Gu, Seoul, Korea, 120752; e-mail: sunghopark@
yuhs.ac
DOI: 10.2341/10-315-L

MN, USA), and Renew (RN, Bisco Inc, Schaumburg, IL, USA), as well as three filling techniques, bulk filling, two-layer incremental
filling, and three-layer incremental filling
methods, were used. One hundred twenty
caries-free human premolars were collected
and divided into four groups according to the
filling material used. Each of these four groups
was then subdivided into three groups according to filling method. In group 1, a bulk filling
of 0.15 g of each resin was inserted and lightcured with LED light from the occlusal, mesial,
and distal surfaces for 60 seconds each. Group
2 was given two horizontal increments, 0.08 g
and 0.07 g, with each increment light-cured
from the occlusal, mesial, and distal surfaces
for 30 seconds each. In group 3, three horizontal increments of 0.05 g were used, each of
which was light-cured from the occlusal, mesial, and distal surfaces for 20 seconds each. The
cuspal deflection was measured using a cus-

Kim & Park: Cuspal Deflection in Bulk or Incremental Methods

tomized cuspal deflection measuring machine


for 10 minutes after initiating light polymerization. The elastic modulus of each composite
resin material was measured using a threepoint bending test. Two-way analysis of variance (ANOVA) with a Dunnet test was used to
examine the effect of the two variables (curing
methods, materials) on the amount of cuspal
deflection at the 95% confidence level. In each
material, groups 1, 2 and 3 were compared
using one-way ANOVA and a Dunnet test at the
95% confidence level. The elastic moduli of HM,
HH, FS, and RN were compared using one-way
ANOVA and a Tukey test at the 95% confidence
level. The relationship between the amount of
cuspal deflection in each group and the elastic
modulus of the composite was analyzed using a
Pearson correlation test.
Results: The amount of cuspal deflection in HH
was larger than in the other materials (HM, FS,
and RN; p,0.05). There was no significant
difference between HM, FS, and RN. The
amount of cuspal deflection was greatest in
group 1, followed in order by groups 2 and 3
(p,0.05). The amount of cuspal deflection was
in the following order: group 123 in HM, and
1.2, 3 in HH, FS, and RN. The elastic modulus
was HH.RN.FS.HM (p,0.05). There was a
positive correlation between the cuspal deflection and the elastic modulus of the composite.
Conclusions: The incremental filling techniques reduced the amount of cuspal deflection in all composite groups with different
elastic moduli. The amount of cuspal deflection showed a positive correlation with the
elastic modulus of the composite.
INTRODUCTION
Resin-based dental composite materials exhibit a
1%-3% decrease in volume during polymerization.1,2
Polymerization shrinkage stresses can initiate failure of the composite-tooth interface, which can cause
postoperative sensitivity, microcracks, microleakage, and secondary dental caries.3 It was reported
that placing a composite into class II cavities can
lead to the inward deformation of the cusp, with the
amount of deformation varying from 15 to 50 lm.4-15
Many factors affect the level of cuspal deflection,
such as the size and shape of the cavity,16,17 Youngs
modulus of the composite resin,18 amount of polymerization shrinkage,8,11 use of an intermediary
flowable liner,10 type of curing light,12 and placement techniques.9,15,19-22

327

Although the incremental filling technique is


preferred over the bulk filling method, it is unclear
if the incremental filling technique can reduce the
amount of cuspal deflection compared with the bulk
filling technique. Some studies reported that the
amount of cuspal deflection was reduced when the
cavities were restored with a composite placed in
multiple but small increments,3,13,15,19 whereas
others claimed that there was no evidence of
incremental filling with an advantage in cuspal
deflection over bulk filling.9,20,23-25 Lee and others13
reported that incremental filling and indirect restoration decreased the amount of cuspal deflection by
34% and 32.2%, respectively, compared with a bulk
filling. Park and others15, in their in vitro study
using an aluminum block to minimize the substrate
variations inherent with the use of natural teeth,
reported that the bulk filling technique produced
significantly more cuspal deflection than the incremental techniques, whereas there was no significant
difference between the horizontal and oblique incremental methods. This should be confirmed using a
tooth substrate. On the other hand, Versluis and
others23, in their finite element study, reported that
incremental filling techniques increased the amount
of cuspal deflection more than the bulk filling
technique. This was attributed to the incremental
deformation of the preparation, which effectively
decreases the total amount of composite needed to
fill the cavity. The finite element method can
integrate the parameters for geometry and material
properties but cannot simulate the transitional
change in resin flow during polymerization precisely.23 Abbas and others,9 in their in vitro study using
premolars, reported that cuspal deflection was
increased significantly with an incremental cure
compared with a bulk cure but the level of microleakage was higher in the bulk cure. They suggested
that the bulk cure regimen induced an incomplete
cure that resulted in low cuspal deflection and
higher microleakage. It is important to determine
whether the lower cuspal deflection in bulk cure is
due to an incomplete cure or to another reason, as
Versluis and others23 indicated. If it is due to
incomplete cure, it would have different results
when the curing time is extended or curing lights
with a high-power density are applied.
Another issue in cuspal deflection is the elastic
modulus of the composites. Ausiello and others,18,26
in their finite element method study, reported that
the cusp displacement was affected by the elastic
modulus of the composites. They reported that a less
rigid restoration can reflex the applied stress

Operative Dentistry

328

through greater elastic deformation, which is transferred to the lower levels of cusp deformation.
However, Lee and Park,27 in their in vitro study in
which the amount of polymerization shrinkage and
cuspal deflection was measured using composites
with a known elastic modulus and filler content,
reported that even flexible composites could lead to
greater cuspal deflection than rigid composites. They
suggested that this was possible because both the
amount of polymerization shrinkage and elastic
modulus appeared to affect the cuspal deflection.
The incorporation of less inorganic fillers and
flexible monomers into the composites could help
decrease the elastic modulus but might increase the
amount of polymerization shrinkage significantly.
Therefore, selecting composites with different elastic
moduli but a similar amount of shrinkage would be
needed to examine the influence of the elastic
modulus on cuspal deflection.
The cuspal deflection might be affected differently
in composites with different moduli when a bulk
filling or incremental filling technique is applied.
Rees and others25 and Hyun and Park20 reported no
difference in cuspal deflection between the bulk and
incrementally filled composites. Interestingly, they
used Heliomolar as a filling material, which has a
low elastic modulus.28 A comparison of the cuspal
deflection of a bulk filled or incrementally filled tooth
in which composites with different elastic moduli are
used might provide an answer to this controversy.
This study compared the cuspal deflection of the
maxillary premolars when a bulk filling and incremental filling technique were employed using composites with different elastic moduli. In this study,
sufficient light-curing time was applied to prevent
incomplete cure of the composites. In addition,
composites with a similar amount of polymerization
shrinkage but different elastic moduli were selected.

Table 1: Restorative Materials Used in This Study


Materials

Code

Manufacturer

Volumetric
shrinkage (%)

Heliomolar

HM

Ivoclar Vivadent,
Schaan, Liechtenstein

3.2

Heliomolar HB

HH

Ivoclar Vivadent,
Schaan, Liechtenstein

3.3

Filtec supreme
XT

FS

3M Dental Products, St
Paul, Minn, USA

2.8

Renew

RN

Bisco Inc,
Schaumburg, IL, USA

3.1

the filling method: group 1, bulk placement; group 2,


horizontal placement of two layers; and group 3,
horizontal placement of three layers (Table 2). For
all groups and subgroups, there was no significant
difference in the dimensions of the tooth specimens.
Preparation of a Modified MOD Cavity and
Adhesive Application
Before preparing the teeth, an outline of the cavity
was drawn with a lead pencil, and a parallel-sided
mesio-occlusodistal (MOD) cavity, 3.5 mm in width
and 3 mm in depth, without buccal or lingual
extension was prepared using diamond burs with
water spray cooling (Figure 1). The dimensions were
confirmed using a prefabricated hexahedral resin
block, which had the same size as the cavity
dimensions. The block was placed into the cavity,
and the preparation was adjusted until it fit the
prepared cavity.

MATERIALS AND METHODS


One hundred twenty intact human maxillary premolars were collected after extraction and stored
immediately in a saline solution. The dimensions of
the teeth were strictly controlled: the buccolingual
dimension was between 9.6 and 9.7 mm, and the
mesiodistal dimension was between 7.6 and 7.7 mm.
From the internal data bank, which records the
volumetric shrinkage of composite resins that have
been previously measured using AcuVol (Bisco Inc,
Schaumburg, IL, USA), four different composites
with an A2 shade and ,0.5% difference in volumetric shrinkage were selected (Table 1). Each material
group was subdivided into three groups according to

Table 2:

Cavity-Filling Methods and Curing Times in Each


Group
Method

Composite, g

Curing time, s

Group 1

Bulk filling

0.15

606060

Group 2

Two-layer
increments

0.80.7

(303030)
(303030)

Group 3

Three-layer
increments

0.50.50.5

(202020)
(202020)
(202020)

Kim & Park: Cuspal Deflection in Bulk or Incremental Methods

329

two measuring pins in contact with the cusp tips of


the buccal and lingual surfaces. The point where the
pin was positioned on the tooth surface was
controlled through the specimens. To minimize any
tooth mobility, a specimen stabilizer made from
putty impression material was used to sustain the
specimen (Figure 3).

Figure 1. Schematic diagram of the parallel-sided, tunnel-shaped


MOD cavity.

The cavities were flushed with copious amounts of


water, and the enamel was then etched with 37%
phosphoric acid (Total Etch, Ivoclar Vivadent,
Schaan, Liechtenstein), rinsed with water, and dried
completely. AdheSE (Ivoclar Vivadent) was then
applied according to the manufacturers instructions
and lightcured for 20 seconds using a Bluephase
LED curing light (Ivoclar Vivadent).
Measurement of Cuspal Deflection
The specimen was positioned in a custom-made
cuspal deflection measuring system (Figure 2)
(R&B Inc, Daejon, Korea) using the screw and pin
in the system. The system was designed to detect
any cusp deflection during polymerization from the

Figure 2. Schematic diagram of the custom-made cuspal deflection


measuring system.

In group 1, a 0.15-g bulk filling was used. The


amount of resin material was weighed on an
electronic balance and placed into the cavities (Table
2). Before light-curing, the initial distance sensed by
the two crossheads was set to the baseline value of 0.
All specimens in group 1 were light-cured from the
occlusal, mesial, and distal surfaces for 60 seconds
each using the LED curing light (Bluephase, Ivoclar
Vivadent) with a power density of 900 mW/cm2,
when measured using a Coltolux Light Meter
(Coltene, Altstatten, Switzerland), making a total
curing time of 180 seconds. The tip of the curing light
was kept within 2 mm of the tooth specimen. As
light-curing began, the degree of inward cuspal
movement was measured and recorded using the
system. The inward cuspal movement altered the
position of the measuring pin and floating lever,
which was detected using a linear scale sensor (Lie 5,
Numeric Jena Gmbh, Jena, Germany). The data
were stored in a computer simultaneously every 0.5
seconds for 10 minutes (Table 2).
In group 2, two separate increments, 0.08 g and
0.07 g, were placed into the cavity. Each layer was
light-cured from the occlusal, mesial, and distal
surfaces for 30 seconds, resulting in a total curing
time of 180 seconds (Table 2). In group 3, each
increment was light-cured at the occlusal, mesial,

Figure 3. Specimen placed in the cuspal deflection measuring


system.

Operative Dentistry

330

and distal surfaces for 20 seconds. Therefore, the


total curing time was 180 seconds in all three groups
(Table 2). In groups 2 and 3, the cuspal deflection
was measured in the same way as reported for group
1. In groups 2 and 3, the cuspal deflection measurement was continued without stopping while the
second or third fillings were placed on the top of the
previous filling.
Elastic Modulus Measurement
A test specimen, 253232 mm in size, was prepared
using a stainless-steel mold according to ISO 4049.
The flexural strength test apparatus was calibrated
to provide a constant crosshead speed of 0.75 mm/
min. The apparatus consisted of two rods (2 mm in
diameter) mounted parallel to each other with a 20mm distance between centers. A third rod (2 mm in
diameter) was centered between and parallel to the
other two so that the three rods in combination could
be used to give a three-point reference to the
specimen. The displacement of the resin specimen
at a 10N load was measured. The elastic modulus
was calculated using the following formula:
E

F1l3
;
4bh3 d

where E is the elastic modulus, F1 is the load (in


Newtons) at a convenient point (10N) in the straightline portion of the tract, d is the deflection (in
millimeters) at load F1, l is the distance (in
millimeters) between the supports (20 mm), b is
the width (in millimeters) of the specimen measured
immediately before testing, and h is the height (in
millimeters) of the specimen measured immediately
before testing.
Statistical Analysis
The amount of the cuspal deflection in the four filling
materials and three curing methods were analyzed
by two-way analysis of variance (ANOVA) with a
Dunnet test at the 95% confidence level. The amount
of cuspal deflection in the three curing methods was
compared using one-way ANOVA with a Tukey test
in each composite material at the 95% confidence
level. The correlation between the amount of cuspal
deflection and the elastic modulus of the composite
was analyzed using a Pearson correlation test.
RESULTS
Table 3 summarizes the amount of cuspal deflection.
The amount of cuspal deflection differed according to
the material and curing method used (p,0.05).

Table 3: Mean Value of Cuspal Deflection (lm) (n10)a


Group 1

Group 2

Group 3

Heliomolar

14.56 6 1.52a 12.42 6 1.82ab 10.41 6 1.97b

Heliomolar HB

19.33 6 3.48a

16.17 6 1.37b

14.33 6 1.92b

Filtec supreme 15.22 6 1.49a


XT

12.45 6 1.07b

11.58 6 2.27b

Renew

12.02 6 2.37b

10.33 6 1.65b

14.43 6 0.56a

a
Small letters a, b beside figures represent the results of statistical analysis
of one-way analysis of variance with a Tukey test in each material. a and b
are different at the p0.05 level.

There was no correlation between the materials


and curing methods (Table 4). The Dunnet test
revealed the amount of cuspal deflection in Heliomolar HB (HH, Ivoclar Vivadent, Schaan, Liechtenstein) to be larger than the other materials,
Heliomolar (HM, Ivoclar Vivadent), Filtec Supreme
XT (FS, 3M Dental Product, St Paul, MN, USA), and
Renew (RN, Bisco Inc); p,0.05). There was no
significant difference between HM, FS, and RN.
The amount of cuspal deflection was in the following
order: group 1.group 2.group 3 (p,0.05).
The amount of cuspal deflection was group 123
in HM and 1.2, 3 in HH, FS, and RN (p,0.05; Table
3). Figure 4 (a-d) shows the amount of cuspal
deflection as a function of time. The elastic moduli
listed in Table 5 was HH.RN.FS.HM (p,0.05).
Statistical analysis revealed a positive correlation
between the cuspal deflection and elastic modulus of
the composite. The Pearson correlation coefficient in
groups 1, 2, and 3 was 0.619, 0.665, and 0.528,
respectively.
DISCUSSION
In this study, the cuspal deflection of the bulk or
incrementally filled cavity ranged from 10.33 to
19.33 lm, which is similar to that found in other
studies.8,21,25,29
The cuspal deflection observed was in the order of
group 1.group 2.group 3. There was no correlation
between the materials and curing methods. These
results suggest that the reported lower cuspal
deflection in the bulk cure compared with the
incremental cure appears to be due to incomplete
cure of the composites.
In a light-curing composite, most of the polymerization shrinkage occurs in a short period of time,

Kim & Park: Cuspal Deflection in Bulk or Incremental Methods

Table 4:

331

Results of Two-Way Analysis of Variance

Source
Corrected model

df

Type III sum of squares

Significance

11

67.501

14.264

0.000

22,222.136

22,222.136

4695.995

0.000

Material

371.934

123.978

26.199

0.000

Method

362.830

181.415

38.337

0.000

7.742

1.290

.273

0.949

Error

511.072

108

4.732

Total

23,475.714

120

1253.578

119

Intercept

Material3method

Corrected total

742.506(a)

Mean square

particularly with a highpower-density curing light,


where approximately 85%-90% of polymerization
shrinkage occurs within 20 seconds of light curing,
even though a slight increase continues.8,30,31 However, Figure 4 shows that cuspal deflection was
much slower and longer than polymerization shrinkage of the composites. During the dark polymerization period, more cuspal deflection may be induced,
even though the absolute amount of polymerization
shrinkage was smaller because the material is stiffer
in this period than in the light-curing period.8 It is
also possible that the remaining tooth structure
appears to resist flexure in the early phase of the
polymerization process.8 Versluis and others23 assumed that the reason for the greater cuspal
deflection in an incrementally filled cavity versus a
bulk filled cavity was due to the incremental
deformation of the preparation, which effectively
decreases the total amount of composite required to
fill the cavity. However, considering the speed of
cuspal deflection in the present study, the amount of
incremental deformation would be so limited as to
have very limited influence.
In this study, the cuspal deflection of the incrementally filled group was lower than that of the bulk
filled group in all composite groups with different
elastic moduli. However, there appeared to be some
differences according to the elastic moduli. In HM,
which had the lowest elastic modulus, the cuspal
deflection was group 123, whereas it was group
1.2, 3 in HH, FS, and RN. Interestingly, there was

no significant difference in cuspal deflection between


the two layer incremental techniques and the bulk
placement technique in HM, which is consistent with
the results reported by Hyun and Park. 20 A
significant difference was only found between the
bulk placement and three layer incremental placement technique. More increments might be needed
in HM on account of its lower elastic modulus than
the other materials.
HH, which has the highest elastic modulus,
showed the largest cuspal deflection. Heliomolar
HB falls into the category of what is known as a
packable or condensable resin composite. This
material is less sticky due to a slight modification
of the proportional composition of the monomer
mixture.
A comparison of the amount of cuspal deflection
between groups 1, 2, and 3 revealed a larger
difference between groups 1 and 2 than between
groups 2 and 3 in all materials. In particular, in HH,
FS, and RN, there was no significant difference in
the amount of cuspal deflection between groups 2
and 3, even though the value was slightly lower in
group 3 (Table 3; Figure 4). Based on this limited
information, it is possible that the amount of cuspal
deflection did not decrease lineally with the number
of increments, and the effect appears to decrease
with the increments. However, more research will be
needed.
The Pearson correlation test revealed a positive
correlation between the elastic modulus of the

Operative Dentistry

332

Figure 4. Change in the amount of cuspal deflection as a function of time in (a) HM, (b) HH, (c) FS, and (d) RN.

composite and amount of cuspal deflection. HH,


which had the highest elastic modulus, showed a
greater amount of cuspal deflection than the other
materials. However, the Pearson correlation coefficient was in the moderate range. More factors, such
as the amount of polymerization shrinkage, should
be considered in a future study to develop a study
Table 5:

Result of Elastic Modulusa


F1, N

D, mm

E, GPa

Heliomolar

10

0.44 6 0.03

2.81 6 0.23a

Heliomolar HB

10

0.16 6 0.01

7.76 6 1.00d

Filtec supreme XT

10

0.34 6 0.03

3.64 6 0.41b

Renew

10

0.29 6 0.02

4.32 6 0.37c

a, b, c, and d are different at the p0.05 level.

model with greater accuracy. In this study, as the


four different composites showed a ,0.5% difference
in volumetric shrinkage, its effects on cuspal
deflection were minimized.
Figure 4 shows that there was a slight increase in
cuspal deflection in all groups when the light was
turned off. For example, there was an increase in the
graph at 180 seconds in group 1 in all composites.
The light-curing process increased the temperature
in the tooth by more than 108C when high-powerdensity curing light was used.32,33 Considering that
the linear coefficient of thermal expansion for the
tooth and composites is 8.3-11.4 PPM/8C and 26.543.4 PPM/8C, respectively,34 several additional micrometers of linear contraction might have occurred
in the tooth and composites when the light was
turned off after 180 seconds of light activation.8
CONCLUSION
The incremental filling techniques reduced the
amount of cuspal deflection in all composite groups

Kim & Park: Cuspal Deflection in Bulk or Incremental Methods

with different elastic moduli. The amount of cuspal


deflection has a positive correlation with the elastic
modulus of the composite.
Acknowledgements

333

ite using an LED light curing unit Journal of Dentistry


35(2) 97-103.
13. Lee MR, Cho BH, Son HH, Um CM & Lee IB (2007)
Influence of cavity dimension and restoration methods on
the cusp deflection of premolars in composite restoration
Dental Materials 23(3) 288-295.

This work was supported by a faculty research grant of Yonsei


University College of Dentistry for 2006 (6-2006-0018) and the
Korea Science and Engineering Foundation (KOSEF) grant
funded by the Korea government (MEST) (No. R13-2003-01305002-0).

14. Palin WM, Fleming GJ, Nathwani H, Burke FJ & Randall


RC (2005) In vitro cuspal deflection and microleakage of
maxillary premolars restored with novel low-shrink
dental composites Dental Materials 21(4) 324-335.

(Accepted 8 February 2011)

15. Park J, Chang J, Ferracane J & Lee IB (2008) How should


composite be layered to reduce shrinkage stress: incremental or bulk filling? Dental Materials 24(11)
1501-1505.

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