ADA
PROFESSIONAL
PRODUCT
REVIEW
EXECUTIVE
SUMMARY
A Publication of the Council on Scientific Affairs EXECUTIVE SUMMARY Read full report at www.ADA.org/ppr Section editor’s note: The ADA Professional Product Review is an online publication, with an executive summary that appears in The Journal of the American Dental Association. For the online version of Volume 8, Issue 3, containing the full text of articles summarized here as well as additional content, please visit www.ada.org/ppr. —David C. Sarrett, DMD, MS, editor, ADA Professional Product Review, and JADA section editor, ADA Professional Product Review Executive Summary A Laboratory Evaluation of Bulk-fill vERSUS Traditional Multi-increment– Fill Resin-BASED Composites
Amer Tiba, PhD; Gregory G. Zeller, DDS, MS; Cameron G. Estrich; Albert Hong
A
n emerging product in the dental materials marketplace is the bulk-fill resinbased composite. Unlike traditional composites, which typically are placed in maximum increments of 2 millimeters, the bulkfill composite is designed to be placed in increments measuring 4 mm or sometimes greater. Provided that the quality of the resulting restoration is comparable with or surpasses that of a traditional composite restoration, the bulk-fill composite would seem to provide a faster option for restoring teeth. But some questions exist regarding bulk-fill composites. For example, adequate depth of cure is an important consideration when resin-based composites are used. Does a bulk-fill composite allow the curing light to penetrate to the material farthest from the light source? Minimizing shrinkage and shrinkage-induced stress associated with polymerization also are key performance considerations. In this article, we describe a study in which we evaluated several physical and mechanical properties of currently marketed bulk-fill materials, comparing the materials with one another as well as with traditional multi-increment–fill resinbased composites. For this evaluation, the ADA Laboratory purchased 12 resin-based composites: Filtek Su-
preme Ultra Universal Restorative (3M ESPE, St. Paul, Minn.), Heliomolar HB (Ivoclar Vivadent, Amherst, N.Y.), Alert Condensable Composite (Pentron, Orange, Calif.), HyperFIL (Parkell, Edgewood, N.Y.), QuiXX Posterior Restorative (Dentsply Caulk, Milford, Del.), SonicFill (Kerr, Orange, Calif.), Tetric EvoCeram Bulk Fill (Ivoclar Vivadent), x-tra fill (VOCO, Briarcliff Manor, N.Y.), Filtek Bulk Fill Flowable Restorative (3M ESPE), SureFil SDR flow (Dentsply Caulk), Venus Bulk Fill (Heraeus, South Bend, Ind.) and x-tra base (VOCO). This included nine bulk-fill composites, two multi-increment–fill resin-based composites and one that could be placed in either fashion. In laboratory tests, we measured depth of cure, Knoop hardness, volumetric shrinkage, polymerization shrinkage stress, flexural strength and flexural modulus, fracture toughness and fracture work, water sorption and solubility, shade color and stability, and radiopacity. Evaluation summary. In most cases, the bulk-fill composites were comparable to the traditional multi-increment–fill resin-based composites. When measured against an international standard,1 all but three products (SonicFill, Tetric EvoCeram Bulk Fill, and Alert Condensable Composite) achieved an acceptable depth of cure; however, when we conducted a Knoop hardness test, only one of the bulk-fill composites continued to fail (Alert Condensable Composite). We also used performance values stated in the standard1 to gauge flexural strength, water sorption and solubility; all products performed within the standard’s parameters for these properties. For the remaining properties, we rated per-
1182 JADA 144(10) http://jada.ada.org October 2013 Copyright © 2013 American Dental Association. All Rights Reserved.
ADA
PROFESSIONAL
PRODUCT
formance on a relative scale. For example, to reduce the risk of marginal gaps, shrinkage and shrinkage stress should be kept to a minimum. VOCO’s x-tra fill, which is a bulk-fill composite, showed the lowest volumetric shrinkage value, and the high-viscosity SonicFill and flowable SureFil SDR flow (both bulk fills) had the lowest value for polymerization shrinkage stress as compared with the other resin-based composites. In contrast with the lower values preferred for polymerization shrinkage and shrinkage stress, higher values are preferred for fracture toughness (the ability to resist fracture) and fracture work (the ability to resist growth of a crack), both of which give an idea of the product’s durability. VOCO’s x-tra fill had a high fracture toughness. That product rated similarly to the others in terms of fracture work. Venus Bulk Fill had the highest fracture work measurement. Color stability is an important feature for resin-based composites. We tested these restoratives to ensure that they maintained their color in wet and dry environments. Two products—Tetric EvoCeram Bulk Fill and x-tra fill—showed variation in color after 30 days’ storage in water. All other products maintained color according to visual inspection by three independent observers (A.T., G.G.Z., A.H.). In addition to the previously described properties, we measured radiopacity as part of our laboratory evaluation. The average radiopacity of dentin is equivalent to 1.11 mm of aluminum (Al) and of enamel is equivalent to 2.05 mm Al.2 All tested products exhibited a radiopacity value greater than 1 mm Al, which is required by the standard.1 Conclusions. In this evaluation, we compared several properties of bulk-fill versus multiincrement–fill resin-based composites and found performance of restoratives in both categories to be acceptable according to an international standard,1 with the exception of depth of cure and hardness. Three of the bulk-fill resin-based composites (SonicFill, Tetric EvoCeram Bulk Fill and Alert Condensable Composite) did not achieve adequate depth of cure when tested according to the standard. All products but one (Alert Condensable Composite) demonstrated adequate hardness after curing in a subsequent test (Knoop hardness test). With the exception of depth of cure and Knoop hardness, we found the laboratory performance of bulk-fill resin-based composites to be comparable to that of traditional multi-increment–fill resinbased composites. n Dr. Tiba is a research associate, Division of Science, American Dental Association, Chicago.
REVIEW
EXECUTIVE
SUMMARY
Dr. Zeller is a senior director, ADA Research Laboratories and Practice Institute, American Dental Association, Chicago. Ms. Estrich is a research analyst, Department of Scientific Information, Division of Science, American Dental Association, Chicago. Mr. Hong is a fourth-year student, School of Dentistry, A.T. Still University, Mesa, Ariz. Address reprint requests to ADA Professional Product Review, 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail [email protected]. Disclosure. None of the authors reported any disclosures. 1. International Organization for Standardization. ISO 4049:2009, Dentistry: Polymer-based Restorative Materials. Geneva: International Organization for Standardization; 2009. 2. Dukic W, Delija B, Derossi D, Dadic I. Radiopacity of composite dental materials using a digital X-ray system. Dent Mater J 2012;31(1):47-53.
Evaluation of Four Dental Clinical Spectrophotometers Relative to Human Shade ObservaTION
Terence A. Imbery, DDS; Marc Geissberger, DDS, MA; Foroud Hakim, DDS, MBA; Shaman Al-Anezi, DDS; Sorin UramTuculescu, DDS, MS, PhD; Riki Gottlieb, DMD; Cameron G. Estrich
O
ne of the most challenging tasks in dentistry is selecting a shade for a restoration in a single maxillary central incisor. From a functional aspect, the correct shade of a crown has little importance in the success of the restoration, but it often is the foremost factor in patient acceptance. More than 80 percent of patients with an anterior metal ceramic restoration were aware of a shade mismatch relative to the adjacent natural tooth.1 Restoration remakes owing to shade mismatches can be a financial burden to all involved. Shade selection normally is accomplished by means of visual comparison of the selected tooth with shade tabs from commercially available shade guides. This process usually is quick and cost effective. Also, the clinician’s ability to discriminate tooth color can be improved with training and experience.2,3 However, shade selection is limited in part to the clinician’s understanding of color science and is more subjective than objective. Color perception varies between people and within a person over time.4-7 Approximately 8 percent of men and 0.5 percent of women have a color-vision defect or difficulty differentiating reds and greens.1 Our purpose in this study was to evaluate the accuracy of four commercially available dental clinical spectrophotometers in comparison with the accuracy of human evaluators. Additionally, we investigated the influence of ambient lighting and the evaluator’s color acuity in shade selection. We addressed four investigative questions in this study: JADA 144(10) http://jada.ada.org October 2013 1183
Copyright © 2013 American Dental Association. All Rights Reserved.
PROFESSIONAL
PRODUCT
REVIEW
EXECUTIVE
SUMMARY
A Publication of the Council on Scientific Affairs EXECUTIVE SUMMARY Read full report at www.ADA.org/ppr Section editor’s note: The ADA Professional Product Review is an online publication, with an executive summary that appears in The Journal of the American Dental Association. For the online version of Volume 8, Issue 3, containing the full text of articles summarized here as well as additional content, please visit www.ada.org/ppr. —David C. Sarrett, DMD, MS, editor, ADA Professional Product Review, and JADA section editor, ADA Professional Product Review Executive Summary A Laboratory Evaluation of Bulk-fill vERSUS Traditional Multi-increment– Fill Resin-BASED Composites
Amer Tiba, PhD; Gregory G. Zeller, DDS, MS; Cameron G. Estrich; Albert Hong
A
n emerging product in the dental materials marketplace is the bulk-fill resinbased composite. Unlike traditional composites, which typically are placed in maximum increments of 2 millimeters, the bulkfill composite is designed to be placed in increments measuring 4 mm or sometimes greater. Provided that the quality of the resulting restoration is comparable with or surpasses that of a traditional composite restoration, the bulk-fill composite would seem to provide a faster option for restoring teeth. But some questions exist regarding bulk-fill composites. For example, adequate depth of cure is an important consideration when resin-based composites are used. Does a bulk-fill composite allow the curing light to penetrate to the material farthest from the light source? Minimizing shrinkage and shrinkage-induced stress associated with polymerization also are key performance considerations. In this article, we describe a study in which we evaluated several physical and mechanical properties of currently marketed bulk-fill materials, comparing the materials with one another as well as with traditional multi-increment–fill resinbased composites. For this evaluation, the ADA Laboratory purchased 12 resin-based composites: Filtek Su-
preme Ultra Universal Restorative (3M ESPE, St. Paul, Minn.), Heliomolar HB (Ivoclar Vivadent, Amherst, N.Y.), Alert Condensable Composite (Pentron, Orange, Calif.), HyperFIL (Parkell, Edgewood, N.Y.), QuiXX Posterior Restorative (Dentsply Caulk, Milford, Del.), SonicFill (Kerr, Orange, Calif.), Tetric EvoCeram Bulk Fill (Ivoclar Vivadent), x-tra fill (VOCO, Briarcliff Manor, N.Y.), Filtek Bulk Fill Flowable Restorative (3M ESPE), SureFil SDR flow (Dentsply Caulk), Venus Bulk Fill (Heraeus, South Bend, Ind.) and x-tra base (VOCO). This included nine bulk-fill composites, two multi-increment–fill resin-based composites and one that could be placed in either fashion. In laboratory tests, we measured depth of cure, Knoop hardness, volumetric shrinkage, polymerization shrinkage stress, flexural strength and flexural modulus, fracture toughness and fracture work, water sorption and solubility, shade color and stability, and radiopacity. Evaluation summary. In most cases, the bulk-fill composites were comparable to the traditional multi-increment–fill resin-based composites. When measured against an international standard,1 all but three products (SonicFill, Tetric EvoCeram Bulk Fill, and Alert Condensable Composite) achieved an acceptable depth of cure; however, when we conducted a Knoop hardness test, only one of the bulk-fill composites continued to fail (Alert Condensable Composite). We also used performance values stated in the standard1 to gauge flexural strength, water sorption and solubility; all products performed within the standard’s parameters for these properties. For the remaining properties, we rated per-
1182 JADA 144(10) http://jada.ada.org October 2013 Copyright © 2013 American Dental Association. All Rights Reserved.
ADA
PROFESSIONAL
PRODUCT
formance on a relative scale. For example, to reduce the risk of marginal gaps, shrinkage and shrinkage stress should be kept to a minimum. VOCO’s x-tra fill, which is a bulk-fill composite, showed the lowest volumetric shrinkage value, and the high-viscosity SonicFill and flowable SureFil SDR flow (both bulk fills) had the lowest value for polymerization shrinkage stress as compared with the other resin-based composites. In contrast with the lower values preferred for polymerization shrinkage and shrinkage stress, higher values are preferred for fracture toughness (the ability to resist fracture) and fracture work (the ability to resist growth of a crack), both of which give an idea of the product’s durability. VOCO’s x-tra fill had a high fracture toughness. That product rated similarly to the others in terms of fracture work. Venus Bulk Fill had the highest fracture work measurement. Color stability is an important feature for resin-based composites. We tested these restoratives to ensure that they maintained their color in wet and dry environments. Two products—Tetric EvoCeram Bulk Fill and x-tra fill—showed variation in color after 30 days’ storage in water. All other products maintained color according to visual inspection by three independent observers (A.T., G.G.Z., A.H.). In addition to the previously described properties, we measured radiopacity as part of our laboratory evaluation. The average radiopacity of dentin is equivalent to 1.11 mm of aluminum (Al) and of enamel is equivalent to 2.05 mm Al.2 All tested products exhibited a radiopacity value greater than 1 mm Al, which is required by the standard.1 Conclusions. In this evaluation, we compared several properties of bulk-fill versus multiincrement–fill resin-based composites and found performance of restoratives in both categories to be acceptable according to an international standard,1 with the exception of depth of cure and hardness. Three of the bulk-fill resin-based composites (SonicFill, Tetric EvoCeram Bulk Fill and Alert Condensable Composite) did not achieve adequate depth of cure when tested according to the standard. All products but one (Alert Condensable Composite) demonstrated adequate hardness after curing in a subsequent test (Knoop hardness test). With the exception of depth of cure and Knoop hardness, we found the laboratory performance of bulk-fill resin-based composites to be comparable to that of traditional multi-increment–fill resinbased composites. n Dr. Tiba is a research associate, Division of Science, American Dental Association, Chicago.
REVIEW
EXECUTIVE
SUMMARY
Dr. Zeller is a senior director, ADA Research Laboratories and Practice Institute, American Dental Association, Chicago. Ms. Estrich is a research analyst, Department of Scientific Information, Division of Science, American Dental Association, Chicago. Mr. Hong is a fourth-year student, School of Dentistry, A.T. Still University, Mesa, Ariz. Address reprint requests to ADA Professional Product Review, 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail [email protected]. Disclosure. None of the authors reported any disclosures. 1. International Organization for Standardization. ISO 4049:2009, Dentistry: Polymer-based Restorative Materials. Geneva: International Organization for Standardization; 2009. 2. Dukic W, Delija B, Derossi D, Dadic I. Radiopacity of composite dental materials using a digital X-ray system. Dent Mater J 2012;31(1):47-53.
Evaluation of Four Dental Clinical Spectrophotometers Relative to Human Shade ObservaTION
Terence A. Imbery, DDS; Marc Geissberger, DDS, MA; Foroud Hakim, DDS, MBA; Shaman Al-Anezi, DDS; Sorin UramTuculescu, DDS, MS, PhD; Riki Gottlieb, DMD; Cameron G. Estrich
O
ne of the most challenging tasks in dentistry is selecting a shade for a restoration in a single maxillary central incisor. From a functional aspect, the correct shade of a crown has little importance in the success of the restoration, but it often is the foremost factor in patient acceptance. More than 80 percent of patients with an anterior metal ceramic restoration were aware of a shade mismatch relative to the adjacent natural tooth.1 Restoration remakes owing to shade mismatches can be a financial burden to all involved. Shade selection normally is accomplished by means of visual comparison of the selected tooth with shade tabs from commercially available shade guides. This process usually is quick and cost effective. Also, the clinician’s ability to discriminate tooth color can be improved with training and experience.2,3 However, shade selection is limited in part to the clinician’s understanding of color science and is more subjective than objective. Color perception varies between people and within a person over time.4-7 Approximately 8 percent of men and 0.5 percent of women have a color-vision defect or difficulty differentiating reds and greens.1 Our purpose in this study was to evaluate the accuracy of four commercially available dental clinical spectrophotometers in comparison with the accuracy of human evaluators. Additionally, we investigated the influence of ambient lighting and the evaluator’s color acuity in shade selection. We addressed four investigative questions in this study: JADA 144(10) http://jada.ada.org October 2013 1183
Copyright © 2013 American Dental Association. All Rights Reserved.
