Accepted Manuscript

Title: Effect of a Broad-Spectrum LED Curing Light on the

Knoop Microhardness of Four Posterior Resin Based
Composites at 2, 4 and 6-mm Depths

Author: Maan M. ALShaafi Thomas Haenel Braden Sullivan

Daniel Labrie Mohammed Q. Alqahtani Richard B. Price

PII: S0300-5712(15)30069-5
DOI: http://dx.doi.org/doi:10.1016/j.jdent.2015.11.004
Reference: JJOD 2550

To appear in: Journal of Dentistry

Received date: 11-9-2014

Revised date: 16-11-2015
Accepted date: 18-11-2015

Please cite this article as: ALShaafi Maan M, Haenel Thomas, Sullivan Braden,
Labrie Daniel, Alqahtani Mohammed Q, Price Richard B.Effect of a Broad-
Spectrum LED Curing Light on the Knoop Microhardness of Four Posterior
Resin Based Composites at 2, 4 and 6-mm Depths.Journal of Dentistry
http://dx.doi.org/10.1016/j.jdent.2015.11.004

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 Effect of a Broad-Spectrum LED Curing Light on the Knoop Microhardness of

Four Posterior Resin Based Composites at 2, 4 and 6 mm Depths

Maan M. ALShaafi BDS, MSDa, Thomas Haenel MScb,c,d, Braden Sullivan BScb, Daniel
Labrie BSc, MSc, PhDe, Mohammed Q. Alqahtani BDS, MSDa, Richard B. Price BDS,
DDS, MS, PhD, FDS RCS (Edin), FRCD(C)b

a
King Saud University, Restorative Dental Sciences, PO Box 60169, Riyadh, 11545
Saudi Arabia
b
Dental Clinical Sciences, Dalhousie University, P.O. BOX 15000, Halifax (NS),
Canada, B3H 4R2
c
University of Bonn-Rhein-Sieg, Applied Sciences, Department of Natural Sciences,
von-Liebig-Strasse 20, 53359 Rhinebach, Germany
d
Tomas Bata University in Zln, Faculty of Technology, nmst T. G. Masaryka 275,
762 72 Zln, Czech Republic
e
Department of Physics and Atmospheric Science, Dalhousie University, P.O. BOX
15000, Halifax (NS), Canada, B3H 4R2

Corresponding author:

Richard B. Price

Department of Dental Clinical Sciences

Faculty of Dentistry, Dalhousie University

5981 University Ave., P.O. BOX 15000, Halifax (NS), Canada, B3H 4R2

Tel: (902) 494-1912

Fax: (902) 494-1662

Email: [email protected]
Abstract
Objective: To measure the Knoop microhardness at the bottom of four posterior resin-
based composites (RBCs): Tetric EvoCeram Bulk Fill (Ivoclar Vivadent), SureFil SDR
Flow (Dentsply), SonicFill (Kerr), and X-traFil (Voco).
Methods: The RBCs were expressed into metal rings that were 2, 4, or 6 mm thick with a
4 mm internal diameter at 30C. The uncured specimens were covered by a Mylar strip
and a Bluephase 20i (Ivoclar Vivadent) polywave LED light-curing unit was used in
high power mode for 20 s. The specimen was then removed and placed immediately on a
Knoop microhardness-testing device and the microhardness was measured at 9 points
across top and bottom surfaces of each specimen. Five specimens were made for each
condition.
Results: As expected, for each RBC there was no significant difference no significant
difference in the microhardness values at the top of the 2, 4 and 6-mm thick specimens.
SureFil SDR Flow was the softest resin, but was the only resin that had no significant
difference between the KHN values at the bottom of the 2 and 4-mm (Mixed Model
ANOVA p<0.05). Although the KHN of SureFil SDR Flow was only marginally
different between the 2 and 6-mm thickness, the bottom at 6-mm was only 59% of the
hardness measured at the top.
Clinical Significance: This study highlights that clinicians need to look at how the depth
of cure was evaluated when determining the depth of cure. SureFil SDR Flow was the
softest material and, in accordance with manufacturer's instructions, this RBC should be
overlaid with a conventional resin.

1. INTRODUCTION
Photo-polymerizable resin-based composites (RBCs) have become a material of
choice for direct restorations.1 Historically RBCs would be light cured in 2-mm thick
increments of material, but there exists a demand to bulk cure RBCs in 4 to 6-mm
increments to reduce clinical procedure times. Given the widespread use of RBC
restorations and with over 260 million restorations placed worldwide,1 anything that
could cause premature failure of resin restorations has both health and financial
implications. There is good indirect evidence that undercured resins are a significant
cause of restoration failure due to a greater chance of fracture, secondary caries, or
excessive wear of the restoration.2 Additionally, when dental RBCs are not optimally
cured, they are more likely to leach greater amounts of chemicals into the body.3
Arbitrarily increasing exposure times in an effort to prevent under-curing may damage
the pulp and surrounding tissues since light curing can create a temperature increase in
the tooth and surrounding oral tissues.4-6 Thus, both dentists and the manufacturers of
LCUs need to know how well curing lights can polymerize dental resins using clinically
relevant exposure times and RBC thickness.

Two common methods for determining how well a resin is cured are: 1) Degree of
Conversion (DC) using Fourier transform infrared radiation (FTIR) spectroscopy7, 8; and
2) Microhardness testing.7-22 Most publications report a good correlation between the DC
and microhardness testing.19, 22, 23 Knoop microhardness testing is a relatively simple test
that provides an accurate, reproducible assessment of how well a RBC is cured and a
linear relationship has been reported between Knoop microhardness, Youngs modulus
and the viscosity of the RBC24 and the Knoop microhardness measurements can be used
as an alternate method for describing the curing characteristics.23

The Knoop microhardness test uses a low load on a rhombohedral-shaped

diamond indenter with a longer and a minor diagonal. When the Knoop indenter is
removed from the test material, elastic recovery dimensional change mostly occurs in
the minor diagonal leaving the longer diagonal virtually unchanged.25 Due to the shape of
the Knoop indenter, this elastic recovery of the specimen has a greater effect on the
length of the Vickers indent than on the length of the Knoop indent. Thus the Knoop
indenter shape is ideal when testing dental resins because they can exhibit elastic recoil
when the load is removed from the indenter. This visco-elastic recovery of the resin
materials can have a very significant effect on the outcome of the hardness tests of
denture teeth.26 In addition, the narrow width of the Knoop indenter footprint means that
the indentations can be spaced closer together, or nearer the edge of the sample than
when the Vickers indenter is used. Martens hardness testing eliminates subjective bias
and may overcome problems due to elastic recovery because the test measures the depth
of the loaded indentation under dynamic loading conditions.26 However, despite previous
positive results, 19, 22, 23 the appropriateness of using micromechanical properties of RBC
materials determined using a microhardness indenter has been questioned,8, 27 especially
since it has been reported that there is no correlation between Martens hardness and the
flexural strength of composite resins.28

The depth of cure (DOC) is often described as the thickness of the RBC that is
adequately cured, or as the depth to where the microhardness equals the surface value
multiplied by an arbitrary ratio, usually 0.8 (80% of the top).16, 29 However, this 80%
value is RBC specific. A recommended lower limit of acceptably polymerized values in
one RBC was reached at 80% of the maximum degree of conversion, 73% of maximum
Knoop microhardness, and approximately 70% of maximum flexural strength and
modulus.30 But is has also been questioned whether a 20% hardness drop-off compared
with a samples surface is sufficient polymerization in deeper layers,16 and maybe this
value should be 90% of the maximum top hardness value.31

Recently, bulk fill RBCs were introduced that allow larger increments to be
adequately cured in just one light exposure, thus reducing placement time.7, 8, 10, 12, 32
Some investigators have found that although there were significant differences between
resins, curing RBCs in 4-mm increments could be recommended.7-10, 13-17, 33 Others have
cautioned that some study protocols may overestimate DOC compared to depth of cure
determined by hardness profiles12 and have raised concerns that bulk-fill RBC may not be
adequately polymerized to a depth of 4-mm. 11, 12, 14, 18, 21, 34, 35 Clinicians need also
consider how accurately can they determine the thickness of RBC that they are placing
when it is well recognized that differences of 0.5 mm are undetectable clinically using
periodontal probes.36, 37
The present study evaluated the effect of different thicknesses on the Knoop
microhardness (KHN) values of bulk-fill RBCs. The null hypothesis was that there would
be no significant difference between the Knoop microhardness values at the bottom of the
three thicknesses of resin when four different bulk-fill RBCs were exposed for 20
seconds with a high power broad spectrum LED curing light.

2. METHODS & MATERIALS:

Four commercial posterior resin-based composite materials were evaluated: Tetric

EvoCeram Bulk Fill shade IVA (Ivoclar Vivadent, Amherst, NY), SureFil SDR Flow
shade A2 (Dentsply, York, PA), SonicFill shade A2 (Kerr, Orange, CA), and x-trafil
universal shade (Voco, Cuxhaven, Germany). For SonicFill, the manufacturer
recommends an increment thicknesses up to 5-mm, the other are intended to be used in at
most 4-mm increments and all RBCs except SureFil SDR Flow were high viscosity bulk
fill RBCs.38-41

2.1. Power and irradiance

The irradiance, radiant exposure and spectral emission from the LCU were
accurately measured using a 6-inch integrating sphere (Labsphere, North Sutton, NH,
USA) connected to a fiber-optic spectrometer (USB 4000, Ocean Optics, Dunedin, Fla,
USA). This fiber-optic system was calibrated before the experiment using the internal
reference lamp contained within the sphere. In addition to measuring the total spectral
radiant power from the LCU, the output was also measured through a 4-mm diameter
aperture placed over the entrance to the integrating sphere. This aperture matched the 4-
mm diameter of the specimens, and thus the spectral radiant power received by the
specimens and not the total output emitted from the LCU. Spectrasuite v2.0.162 software
(Ocean Optics) was used to collect and analyse the data. To determine the radiant
exposure received by the specimen, the mean radiant exposure delivered was calculated
by integrating the area under the real-time power versus time graph.

2.2. Knoop microhardness (KHN) measurements

The RBCs were expressed into metal rings that were 2, 4, or 6 mm thick (Figure 1a)
with a 4-mm internal diameter on plate heater to 30C. The top surface was covered with
a Mylar strip and the uncured RBC was allowed to stabilize by resting on the
temperature-controlled plate for 2 minutes in the dark before light curing. Based on a
pilot study, this was sufficient time to achieve a stable temperature at 30C.
RBC specimens were each irradiated for 20 s according to the digital timer of the LCU.
The microhardness was then measured as soon as physically possible (less than 10
minutes) at 9 points close to the top center of the specimen top and at 9 points at the
center at the bottom surfaces of each specimen. To achieve similar indentation lengths
and thus depths into the RBCs and thus minimize measurement errors, when the KHN
was above 12, a 50 g load was used on the indenter and when the KHN was below 12, a
10 g load was used. The load time was 8 seconds in both cases. Five specimens were
made for each condition. For each RBC, a Mixed Model ANOVA model was used
compare the KHN values achieved at the top and at the bottom of the 2, 4 and 6-mm
thick RBC specimens.
3. RESULTS

Based on the data obtained through the 4-mm aperture on the integrating sphere,
the radiant power, irradiance and radiant exposure delivered to the 4-mm diameter RBC
specimens was 151 mW, 1,202 mW/cm2, and 24.1 J/cm2 respectively. The total spectral
radiant power from the LCU into the integrating sphere and the radiant power that the 4
mm diameter specimens received during the 20 second exposure time is shown in Figures
2 a and b. As expected, within each RBC, there was no significant difference in the
microhardness values at the top of the 2, 4 and 6-mm thick specimens.

Table 1 shows that SureFil SDR Flow was the softest resin with KHN values
ranging from 5.7 to 8.0 at the bottom of the specimens. SureFil SDR Flow was the only
resin that showed no significant difference between the KHN values at 2 and 4-mm and
the microhardness for SureFil SDR was only marginally significantly different between
the 2 and 6-mm thickness groups (Mixed Model ANOVA p<0.05), but the bottom at 6-
mm was only 59% of the hardness measured at the top. X-trafil and SonicFill were the
hardest materials at the top and at the bottom surfaces for the 2 and 4-mm thick
specimens (Table 1). However SonicFill was very soft (3.4 KHN) at the bottom of the 6-
mm thick specimens compared to a KHN of 24.9 at the bottom of the 4-mm thick
specimens. When compared to the mean KHN at the top (100%), the microhardness
values at the bottom of the specimens fell below the 80% level at 4-mm for Tetric
Evoceram Bulk Fill and SonicFill. The bottom:top hardness ratios were at least 80% at
the bottom of the 4-mm thick specimens for SureFil SDR Flow and X-trafil (Table 1).
4. DISCUSSION

This research evaluated the ability of a high powered broad spectrum LED curing
light to polymerize four brands of RBCs that were 2, 4 or 6-mm thick using Knoop
microhardness measurement techniques. As expected, there were no significant
differences in the Knoop microhardness measurements made at the top of the RBCs,
however there were significant differences in the KHN at the bottom between the
different thicknesses of the RBCs (Table 1). Thus the research hypothesis was rejected.

In contrast to previous studies that have often randomly chosen the timing and the
location of the microhardness indentation,8 the Knoop microhardness was measured as
soon as practical after light exposure and at the center of the specimen. The most
commonly used photosensitizer in RBCs is camphorquinone (CQ). Alternative
photoinitiators that are not as chromogenic as CQ are used by some RBC manufacturers
and are found in Tetric Evoceram Bulk Fill used in this study.41 These alternative
photoinitiators, such as monoacylphosphine oxide (TPO) and derivatives of dibenzoyl
germanium, 41-43 have peak absorbance values below 420 nm.41, 44-46 As these
photoinitiators will not be efficiently activated by monowave LED-based LCUs that
deliver light mostly in the 445 nm to 480 nm spectral range, a broader spectral emission
LED unit (Bluephase 20i) was used in this study (Figures 2 a and b). The light output
from this LCU remained stable over the 20 s exposure time and had two peaks in the
spectral emission, one at 413 nm and the other at 459 nm.

Although these alternative photoinitiators are more reactive than CQ, fewer of the
lower wavelength photons will reach the bottom of the RBC due to the effects of filler
particle size and increased Rayleigh scattering.44, 47-50 A previous observation found that
the depth of cure of filled CQ-based materials can be significantly greater than that of
TPO-based materials.51 This is supported by the finding that the Ivocerin containing
Tetric Evoceram Bulk Fill showed large significant differences in the KHN values
between 2 and 4-mm (Table 1).

The results obtained in this study could have been influenced by several different
factors. First, the mold used was made out of metal (Figure 1). This blocked transmission
of all light outside of the central 4-mm of the light guide tip. However, a metal mold is
specified in the ISO standard 4049 and has also been recommended by different authors
so as not to overestimate depth of cure.20, 52, 53 This metal mold created testing conditions
closer to clinical conditions where a metallic matrix is placed around the boxes in Class 2
preparations. Using laboratory grade equipment, this study measured the radiant exposure
received by the RBC rather than the total energy delivered by the LCU to the entire metal
mold. The radiant exposure (24.1 J/cm2) from the turbo tip on the Bluephase 20i should
have been more than enough to photocure the RBCs,25, 41 however exposure times longer
than 20 s may be required to cure these RBCs at the bottom of the 4-mm thick specimens.
Finally, in accordance with ISO 4049, the samples were measured as soon as practical
after light exposure because post-curing will increase the KHN values 31, 54 and mask how
well the RBC is cured when the patient leaves the dental office and starts to chew.

According to the manufacturers, many of their new bulk-fill materials can be

adequately cured in 4 to 5-mm increments without having to modify the light curing
protocol.38-41 How the manufacturers determine these recommendations is often unclear
and for bulk-fill materials, the ISO 4049 method may well overestimate depth of cure
compared to the determination by Vickers hardness estimations of the degree of
conversion.12 The SureFil SDR Flow resin was the only material that showed no
significant difference in the KHN at 2 and 4-mm and minimal difference at 6-mm depth.
As shown in Table 1, this RBC is very soft and, in accordance with the manufacturers
instructions, should be overlaid with a harder RBC.

When compared to the mean KHN at the top (100%), the bottom:top ratios were
at least 80% at the bottom of the 4-mm thick specimens of SureFil SDR Flow and x-
trafil, but were only 70% at the bottom of the 4 mm thick specimens of Tetric Evoceram
Bulk Fill and SonicFill. This is despite the 5-mm depth of cure claim for SonicFill.38
Similar bottom:top hardness ratios that were less than 80% for 4-mm of Tetric Evoceram
Bulk Fill have been reported by several other researchers17, 18 and for SonicFill,16
although a another study reported that SonicFill and Tetric EvoCeram Bulk Fill had the
greatest depth of cure compared to X-tra base and Venus Bulk Fill.9 Thus, although
some studies have reported that bulk-filling RBCs can be adequately cured to a depth of
at least 4-mm 7-10, 13-17 the present study supports several other studies that have suggested
that bulk filling and curing can produce undercured RBCs.11, 12, 14, 18, 21, 34, 35 To minimize
the occurrence of often contradictory results, the findings of the present study suggest
that some standardization is desperately required when making claims about the
adequacy of curing bulk fill RBCs. For example, some authors use metal molds,9, 11, 12, 17,
18
, some did not specify the mold material,7, 10 some used semi-transparent molds,13, 16, 20
despite its limitations many report Vickers hardness7-16, some report Knoop17-22 while
others use Martens hardness,26 some use low loads, 7, 12, 18 others use high loads (1kg and
above),11, 17 some test immediately, 12 others after at least 24 hours,7-11, 13-17 and most do
not report the radiant exposure received by the RBC specimens.8, 11-15, 17, 18, 34, 35 This is of
concern because the DOC is strongly influenced by the radiant exposure16 and unless it is
know what light the RBC received, the study is not reproducible.

Consequently, at best it is recommended that clinicians should be aware that the

depth of cure among bulk-fill RBCs may vary dramatically21 and that small and
potentially clinically immeasurable differences in RBC thickness may have a large effect
on the adequacy of polymerization. In addition, because SureFil SDR Flow was a soft
RBC, in accordance with manufacturer's instructions, this RBC should be overlaid with a
conventional resin. The clinician should be aware of these limitations and develop their
clinical skills to recognize clinically differences between a 3.5 and a 4.5 mm thickness of
RBC.
5. CONCLUSIONS:

Within the limitations of this study that measured the RBC almost immediately

after light exposure, it was concluded:

1. SureFil SDR Flow was the softest bulk filling RBC tested.

2. For SureFil SDR Flow, x-trafil and SonicFill, there was no significant difference

between the KHN values at the top and at the bottom of the 2-mm thick specimens.

3. At the bottom of the 4-mm thick specimens, the KHN values for x-trafil, Tetric

EvoCeram Bulk Fill and SonicFill at 4-mm were all significantly less than at 2-mm.

4. The bottom:top hardness ratio of the 4-mm thick specimens for SureFil SDR and

x-trafil was above 80%.

Conflicts of interest The authors declare that they have no conflicts of interest.

Compliance with Ethical Standards:

Funding: This was an unfunded study.

Ethical approval: This article does not contain any studies with human participants or

animals performed by any of the authors.

Tables:

Table 1: Mean Standard Deviation (S.D.) Knoop microhardness (KHN) at the top and

bottom of the 2, 4 and 6-mm thick specimens together with the Bottom:Top hardness

ratios compared to the mean microhardness at the top surface. Bold lines indicate which

cells deliver a Bottom:Top hardness ratio of at least 80%.

Figures:

Figure 1. The 2, 4 and 6-mm deep metal rings with a 4-mm internal diameter hole that

was filled with RBC.

Figure 2. Power (mW) delivered over the 20 second exposure time (Fig. 2a) and spectral

radiant power from the LCU (Fig. 2b) measured both with and without a 4-mm diameter

aperture at the entrance to the integrating sphere:

Note the stable radiant power output over the 20 s and the presence of emission peaks at

413 nm and 459 nm.

References
1. Heintze SD, Rousson V. Clinical effectiveness of direct class II restorations - a
meta-analysis. J Adhes Dent. 14, 2012, 407-431.
2. Price RB, Ferracane JL, Shortall AC. Light-Curing Units: A Review of What We
Need to Know. J Dent Res. 94, 2015, 1179-1186.
3. Durner J, Obermaier J, Draenert M, Ilie N. Correlation of the degree of
conversion with the amount of elutable substances in nano-hybrid dental composites.
Dent Mater. 28, 2012, 1146-1153.
4. Oberholzer TG, Makofane ME, du Preez IC, George R. Modern high powered led
curing lights and their effect on pulp chamber temperature of bulk and incrementally
cured composite resin. Eur J Prosthodont Restor Dent. 20, 2012, 50-55.
5. Shortall A, El-Mahy W, Stewardson D, Addison O, Palin W. Initial fracture
resistance and curing temperature rise of ten contemporary resin-based composites with
increasing radiant exposure. J Dent. 41, 2013, 455-463.
6. Gomes M, DeVito-Moraes A, Francci C, Moraes R, Pereira T, Froes-Salgado N,
et al. Temperature increase at the light guide tip of 15 contemporary LED units and
thermal variation at the pulpal floor of cavities: an infrared thermographic analysis. Oper
Dent. 38, 2013, 324-333.
7. Czasch P, Ilie N. In vitro comparison of mechanical properties and degree of cure
of bulk fill composites. Clin Oral Investig. 17, 2013, 227-235.
8. Finan L, Palin WM, Moskwa N, McGinley EL, Fleming GJ. The influence of
irradiation potential on the degree of conversion and mechanical properties of two bulk-
fill flowable RBC base materials. Dent Mater. 29, 2013, 906-912.
9. Alrahlah A, Silikas N, Watts DC. Post-cure depth of cure of bulk fill dental resin-
composites. Dent Mater. 30, 2014, 149-154.
10. Ilie N, Kessler A, Durner J. Influence of various irradiation processes on the
mechanical properties and polymerisation kinetics of bulk-fill resin based composites. J
Dent. 41, 2013, 695-702.
11. Zorzin J, Maier E, Harre S, Fey T, Belli R, Lohbauer U, et al. Bulk-fill resin
composites: polymerization properties and extended light curing. Dent Mater. 31, 2015,
293-301.
12. Flury S, Hayoz S, Peutzfeldt A, Husler J, Lussi A. Depth of cure of resin
composites: is the ISO 4049 method suitable for bulk fill materials? Dent Mater. 28,
2012, 521-528.
13. Kim EH, Jung KH, Son SA, Hur B, Kwon YH, Park JK. Effect of resin thickness
on the microhardness and optical properties of bulk-fill resin composites. Restor Dent
Endod. 40, 2015, 128-135.
14. Jang JH, Park SH, Hwang IN. Polymerization shrinkage and depth of cure of
bulk-fill resin composites and highly filled flowable resin. Oper Dent. 40, 2015, 172-180.
15. Francis AV, Braxton AD, Ahmad W, Tantbirojn D, Simon JF, Versluis A. Cuspal
Flexure and Extent of Cure of a Bulk-fill Flowable Base Composite. Oper Dent. 40,
2015, 515-523.
16. Ilie N, Stark K. Curing behaviour of high-viscosity bulk-fill composites. J Dent.
42, 2014, 977-985.
17. El-Damanhoury H, Platt J. Polymerization shrinkage stress kinetics and related
properties of bulk-fill resin composites. Oper Dent. 39, 2014, 374-382.
18. Tarle Z, Attin T, Marovic D, Andermatt L, Ristic M, Taubock TT. Influence of
irradiation time on subsurface degree of conversion and microhardness of high-viscosity
bulk-fill resin composites. Clin Oral Investig. 19, 2015, 831-840.
19. Price RB, Whalen JM, Price TB, Felix CM, Fahey J. The effect of specimen
temperature on the polymerization of a resin-composite. Dent Mater. 27, 2011, 983-989.
20. Erickson RL, Barkmeier WW. Curing characteristics of a composite. Part 2: The
effect of curing configuration on depth and distribution of cure. Dent Mater. 30, 2014,
e134-145.
21. Pedalino I, Hartup GR, Vandewalle KS. Depth of cure of bulk-fill flowable
composite resins. Gen Dent. 63, 2015, e28-34.
22. Ferracane JL. Correlation between hardness and degree of conversion during the
setting reaction of unfilled dental restorative resins. Dent Mater. 1, 1985, 11-14.
23. Erickson RL, Barkmeier WW, Halvorson RH. Curing characteristics of a
composite - Part 1: Cure depth relationship to conversion, hardness and radiant exposure.
Dent Mater. 30, 2014, e125-133.
24. Li J, Li H, Fok AS, Watts DC. Multiple correlations of material parameters of
light-cured dental composites. Dent Mater. 25, 2009, 829-836.
25. Anusavice KJ, Phillips RW, Shen C, Rawls HR. Phillips' science of dental
materials. 12th ed. St. Louis, Mo.: Elsevier/Saunders; 2013.
26. Shahdad SA, McCabe JF, Bull S, Rusby S, Wassell RW. Hardness measured with
traditional Vickers and Martens hardness methods. Dent Mater. 23, 2007, 1079-1085.
27. Leprince JG, Palin WM, Vanacker J, Sabbagh J, Devaux J, Leloup G. Physico-
mechanical characteristics of commercially available bulk-fill composites. J Dent. 42,
2014, 993-1000.
28. Fischer J, Roeske S, Stawarczyk B, Hammerle CH. Investigations in the
correlation between Martens hardness and flexural strength of composite resin restorative
materials. Dent Mater J. 29, 2010, 188-192.
29. Watts DC, Amer O, Combe EC. Characteristics of visible-light-activated
composite systems. Br Dent J. 156, 1984, 209-215.
30. Vandewalle KS, Ferracane JL, Hilton TJ, Erickson RL, Sakaguchi RL. Effect of
energy density on properties and marginal integrity of posterior resin composite
restorations. Dent Mater. 20, 2004, 96-106.
31. Johnston WM, Leung RL, Fan PL. A mathematical model for post-irradiation
hardening of photoactivated composite resins. Dent Mater. 1, 1985, 191-194.
32. Ilie N, Bucuta S, Draenert M. Bulk-fill resin-based composites: an in vitro
assessment of their mechanical performance. Oper Dent. 38, 2013, 618-625.
33. van Dijken JW, Pallesen U. A randomized controlled three year evaluation of
"bulk-filled" posterior resin restorations based on stress decreasing resin technology.
Dent Mater. 30, 2014, e245-251.
34. Abbas G, Fleming GJ, Harrington E, Shortall AC, Burke FJ. Cuspal movement
and microleakage in premolar teeth restored with a packable composite cured in bulk or
in increments. J Dent. 31, 2003, 437-444.
35. Tiba A, Zeller GG, Estrich CG, Hong A. A Laboratory Evaluation of Bulk-Fill
Versus Traditional Multi-Increment-Fill Resin-Based Composites. J Am Dent Assoc. 144,
2013, 1182-1183.
36. Neto JB, Filho GR, Tramontina VA, Sallum EA, Nociti FH, Jr., Sallum AW.
Millimeter marks and probe tip diameter standardisation from commercially available
periodontal probes. A comparative study. J Int Acad Periodontol. 3, 2001, 57-60.
37. Buduneli E, Aksoy O, Kose T, Atilla G. Accuracy and reproducibility of two
manual periodontal probes. An in vitro study. J Clin Periodontol. 31, 2004, 815-819.
38. Sonic Fill: Directions for use. Orange, CA: Kerr Corporation; 2011.
39. Sure Fill SDR. DENTSPLY. 2014 [cited June 29, 2014]; Available from:
http://www.surefilsdrflow.com/sites/default/files/SureFil_DFU.pdf
40. X-traFil Instructions for Use. VOCO. 2014 [cited June 29, 2014]; Available
from: http://www.voco.com/en/products/_products/x_tra_fil/x-tra_fil_22spr_049.pdf
41. Tetric EvoCeram Bulk Fill, Scientific Documentation. Ivoclar Vivadent 2014
[cited 2014-10-15]; Available from: http://www.ivoclarvivadent.com/zoolu-
website/media/document/17021/Tetric+EvoCeram+Bulk+Fill
42. Burtscher P. Ivocerin in comparison to camphorquinone. Ivoclar Vivadent Report,
No. 19, July, 2013; 2013.
43. Moszner N, Fischer UK, Ganster B, Liska R, Rheinberger V. Benzoyl germanium
derivatives as novel visible light photoinitiators for dental materials. Dent Mater. 24,
2008, 901-907.
44. Price RB, Felix CA. Effect of delivering light in specific narrow bandwidths from
394 to 515nm on the micro-hardness of resin composites. Dent Mater. 25, 2009, 899-908.
45. Palin WM, Senyilmaz DP, Marquis PM, Shortall AC. Cure width potential for
MOD resin composite molar restorations. Dent Mater. 24, 2008, 1083-1094.
46. Randolph LD, Palin WM, Bebelman S, Devaux J, Gallez B, Leloup G, et al.
Ultra-fast light-curing resin composite with increased conversion and reduced monomer
elution. Dent Mater. 30, 2014, 594-604.
47. Arikawa H, Fujii K, Kanie T, Inoue K. Light transmittance characteristics of
light-cured composite resins. Dent Mater. 14, 1998, 405-411.
48. dos Santos GB, Alto RV, Filho HR, da Silva EM, Fellows CE. Light transmission
on dental resin composites. Dent Mater. 24, 2008, 571-576.
49. Jandt KD, Mills RW. A brief history of LED photopolymerization. Dent Mater.
29, 2013, 605-617.
50. Masotti AS, Onofrio AB, Conceicao EN, Spohr AM. UV-vis spectrophotometric
direct transmittance analysis of composite resins. Dent Mater. 23, 2007, 724-730.
51. Leprince JG, Hadis M, Shortall AC, Ferracane JL, Devaux J, Leloup G, et al.
Photoinitiator type and applicability of exposure reciprocity law in filled and unfilled
photoactive resins. Dent Mater. 27, 2011, 157-164.
52. ISO 4049: 2009 Dentistry- Polymer-based restorative materials. Geneva,
Switzerland: International Organization for Standardization; 2009.
53. Asmussen E, Peutzfeldt A. Polymer structure of a light-cured resin composite in
relation to distance from the surface. Eur J Oral Sci. 111, 2003, 277-279.
54. Abu-elenain DA, Lewis SH, Stansbury JW. Property evolution during vitrification
of dimethacrylate photopolymer networks. Dent Mater. 29, 2013, 1173-1181.
 Table 1: Mean Standard Deviation (S.D.) Knoop microhardness (KHN) at the top and

bottom of the 2, 4 and 6-mm thick specimens together with the Bottom:Top hardness

ratios compared to the mean microhardness at the top surface. Bold lines indicate which

cells deliver a Bottom:Top hardness ratio of at least 80%.

Tetric Bulk Tetric Bulk

SDR SDR x-trafil x-trafil SonicFill SonicFill
Fill Fill

% of Top % of Top % of Top % of Top

Thickness KHN KHN KHN KHN
KHN KHN KHN KHN

Top 9.71.3A 100 36.22.9E 100 24.22.3 100 35.72.4 G 100

2 mm 8.00.9 A,B 82 36.03.2 E 99 21.21.4 88 33.71.6 G 94

4 mm 7.70.5 B,C 80 31.82.8 88 16.92.1 70 24.92.5 70

6 mm 5.71.1 C 59 22.02.1 61 6.91.9 29 3.41.3 10

Superscript letters A,B.. show groups that had no significant difference (Mixed Model

ANOVA p<0.05) n= 9 indents per specimen surface x 5 specimens = 45 values per cell.