10.21608/adjc.2023.232806.

1390 Advanced Dental Journal

Volume 5 (2023) | Issue 4| Pages 752-760

Original Article

Comparative Evaluation of Preheating versus

Sonic Activation of Bulk-Fill Resin Composite
Ahmed Mohamed Hoseny Mahmoud Fayed1, Ahmed Fawzy Aboelezz2, Ahmed Tarek Farouk1
1 Operative Dentistry Department, Misr International University, Cairo, Egypt.
2 Operative Dentistry Department, Suez Canal University, Ismailia, Egypt.

Email: [email protected]

Submitted: 29-08-2023
Accepted: 13-09-2023

Abstract
Aim: This study aimed to investigate the effect different physical energies, either heat or sonic activation, on the
surface microhardness of two different bulk-fill resin composites. Materials and Methods: Sixty disc shaped resin
composite specimens with standardized diameter of 6mm and overall thickness of 4 mm were used in this study. The
prepared specimens were divided into two equal groups (N=30), according to type of bulk fill resin composite (R);
Group 1: X-tra fil (Voco) (R1) and Group 2: SonicFill 3 (Kerr) (R2). Each group was further subdivided into three
equal subgroups according to the method of energy (E) delivered to the bulk fill resin composite material before light
initiated polymerization (n=10); either without any energy delivered to the material (Eo), preheating at 54℃ using
resin composite heating device (Calset, AdDent Inc, Danbury, CT, USA) (E1) or sonic activation (SonicFill™ hand
piece, Kerr, USA) (E2). Specimens were cured from the top using light curing unit for 40 seconds. Finally, the VHN
(S) was evaluated at the top (S1) and the bottom (S2) surfaces of each specimen. Results: Three-way ANOVA
revealed statistically significant differences in two main effects; the types of resin composites (P<0.0001), and tested
depth of restoration (P<0.0001). On the other hand, methods of physical activation showed no statistical significant
differences (P = 0.631). Conclusions: Bulk fill resin composite formulation is a major determinant of its Vicker’s
hardness number. Both sonication and pre-heating had the same effect on VHN of nano-hybrid, SonicFill 3 bulk fill
resin composite.

Keywords: Bulk-fill resin composite, Resin composite preheating, Sonic activation, Microhardness.

broadened the applications, rendering them a

I. INTRODUCTION
universal direct restoration(1).
Although the introduction of light activated
The 60s of the last centuries witnessed the
introduction of resin-based tooth colored polymerization of resin composite is viewed as
restorations which is due to their mechanical a breakthrough, yet the depth of penetration
and esthetical superiority substituted acrylic of light in the material remain its crucial point
that led to the introduction of the incremental
resins as an esthetic dental restoration. Further
generations of resin composite (RC) showed packing technique. However, a risk of air
modifications in strength, wear resistance, bubbles entrapment and moisture
handling and esthetics. Such modifications contamination appeared in between sequential
increased their popularity and applications in increments(2,3). In the early 2000s, in a trial to
solve such problem, a so-called bulk-fill resin
various dental fields. Added to this
improvement, resin bonding technologies have composites were introduced in the market with
 Fayed et al.,

a methacrylate-based matrix. The first marketed was proposed in literature, with a claim to
material, SDR (Dentsply Sirona, Konstanz, improve physical and mechanical properties of
Germany), was a flowable resin composite the final resin composite restorations(10,11).
based on a stress-decreasing resin technology to Based on the former considerations, the aim
be used in 4-mm layers as open or closed dentin of the present study was to investigate the effect
replacement beneath conventional resin of different physical energies, either heat or
composite(4). To allow for efficient photo- sonic activation, on the surface microhardness
initiated polymerization, literature proposed of two different bulk-fill resin composites. The
either reduction of filler content, increasing null hypothesis was that neither resin composite
filler translucency, using fillers and matrix with formulation, physical activation energies nor
close refractive indices, in addition to the use of tested surface (top/bottom) would affect
a more sensitive initiators to boost the microhardness (VHN) of the tested bulk-fill
polymerization reaction. These materials are resin composites.
categorized according to their rheological
properties, either as dentin substitute materials II. MATERIALS AND METHODS
that require a 2-mm posterior hybrid composite a) Sample Size Calculation
coat or as high-viscosity resin composites that Sample size calculation was done by
do not require an occlusal resin composite power analysis used Vicker Hardness Number
coat(5). Degree of conversion (DC) is the (VHN) as a primary outcome. The effect size f
number of double carbon links (C=C) present in = (0.6157877) was calculated based upon the
the monomers, which are converted into single results of Abed et al. 2015(2) and assuming that
links (C-C) to form the polymer chains during the standard deviation within each group =
the polymerization process. There is no doubt 16.49, using alpha level of 5% and beta level of
that the durability and performance of the final 95% i.e. power = 95%. The minimum estimated
resin composite restoration is related to its sample size was a total of 54 samples (10
degree of conversion, which play a major role samples per subgroup). Sample size calculation
in controlling surface and bulk properties of the was done using G*Power version 3.1.9.2.
material. That is why surface microhardness,
shade change and bulk properties evaluation are b) Study Design and Grouping
Sixty disc shaped resin composite
considered in literature to be indirect methods
specimens with standardized diameter of 6 mm
to evaluate and compare resin composite
and overall thickness of 4 mm were used in this
maturation based on direct correlation claimed
study. The prepared specimens were divided
in literature(6,7).
into two equal groups (N=30) according to type
Sonic-activated bulk-fill resin composites
of bulk fill resin composite (R) used; Group 1:
were introduced to the market as posterior bulk
X-tra fil (Voco, Germany) (R1) and Group 2:
restorations. They are modified with special
SonicFill 3 (Kerr, USA) (R2). These bulk-fill
modifiers rendering it sensitive and reactive to
resin composite materials, their manufacturers
sonic energy. As sonic energy is applied, the
and chemical composition are illustrated in
modifier causes the viscosity to drop (up to
Table (1). Each group was further subdivided
87%), increasing the flowability of the
into three equal subgroups (n=10) according to
composite. This process is reversed as soon as
the method of energy delivered (E) to the bulk
sonic energy is stopped allowing for carving
fill resin composite material before light
and contouring. Such process is claimed to have
initiated polymerization; either without any
a positive impact on adaptation, DC and
energy delivered to the material (Eo),
workability(8,9).
preheating at 54℃ using resin composite
Also in a trial to improve the adaptation and
heating device (Calset™, AdDent Inc,
DC, and reduce voids and air entrapment, of
Danbury, CT, USA) (E1) or sonic activation
highly filled resin composite a preheating step

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(SonicFill™ hand piece, Kerr) (E2). Specimens seconds. Finally, the VHN (S) was evaluated at
were cured from the top according to the the top (S1) and the bottom (S2) surfaces of each
manufacturer recommendation using light specimen.
curing unit (3M ESPE Elipar™ S10) for 40

Table (1): Bulk-fill resin composite materials, manufacturer and their chemical composition.
Material / Composition
Manufacturer Matrix Filler type and %
Micro-hybrid RC, X-tra fil Bis-GMA, UDMA, Barium boron alumino-silicate glass
Voco, Germany TEGDMA (0.04-3 µm), Filler loading 86% by wt
Nano-hybrid RC, SonicFill 3 Bis-EMA and Barium silicon dioxide glass
Kerr, USA TEGDMA (10-30 nm), Filler loading 81 % by wt

c) Packing and Curing of Resin Composite the holes of the mold as a single increment,
Specimens packed to avoid incorporation of voids inside
The devices and procedures of bulk fill the bulk of the material and then a glass slide
resin composite activation, either by heat or with a light finger pressure was placed over the
sonic energy, are described in Table (2) & (3) injected resin composite to obtain a flat
respectively. Moreover, they are illustrated by a specimens with uniform thickness. Finally,
schematic diagram in Figure (1). specimens were cured from the top according
A rectangular teflon split mold having 5 to the manufacturer recommendation using
holes with standardized diameter 6 mm and light curing unit (3M ESPE Elipar™ S10) for
depth of 4 mm were used. All specimens were 40 seconds. The screws of the mold were
prepared with the same manner in which the untightened to remove the constructed discs.
resin composite materials was injected inside

Table (2): The devices used for bulk fill resin composites activation.
Apparatus Manufacture Description
AdDent Inc, Allows heating of resin composites up to
CalsetTM
Danbury, CT, USA 98°F (37°C), 130°F(54°C) or 155°F(68°C)
SonicFillTM
Kerr, USA Allows sonically activated delivery
hand piece
EliparTM S10 Intensity: 1200mW/cm2
3M ESPE, USA
light curing unit Wavelength: 430-480 nm

Table (3): Procedures of bulk fill resin composites activation.

Group Sub-group Procedure
Eo R1 Eo Non activated resin composite compule. (Figure 1-a)
Resin composite compule pre-heated at 54 ℃ (CalsetTM, AdDent Inc, Danbury,CT,
E1 R1 E1
USA). (Figure 1-b)
R1
Resin composite was loaded in an empty compules that is designed to be mounted
(X-tra fil)
on SonicFill™ hand piece, after the cap of the compules were unscrewed carefully
E2 R1 E2
without distorting the compule (Figure 2-a), and injected with SonicFill™ hand
piece at power 3. (Figure 1-c)
Resin composite were loaded in empty regular compules [Figure 2-b] to facilitate
Eo R2 Eo
its injection. (Figure 1-d)
R2 Resin composite were loaded in empty regular compules to facilitate pre-heated at
E1 R2 E1
(SonicFill 3) 54 ℃ (Calset, AdDent Inc, Danbury, CT, USA). (Figure 1-e)
Resin composite compules were mounted on SonicFill™ hand piece and injected at
E2 R2E2
power 3 that was adjusted on the hand piece as an average power. (Figure 1-f)

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 Fayed et al.,

Figure (1): Schematic diagram illustrating activation of bulk fill resin composites.

Figure (2): Empty compules after the caps were removed carefully without compules distortion
[(a) SonicFill compule. (b) Regular compule].

d) Hardness Test effect of variables of the study, and post-hoc

Vickers hardness numbers were test was used to detect significance if
determined using a micro-hardness tester present between different subgroups. The
(Wilson® Hardness Tester, Model Tukon significance level was set a p≤0.05. IBM
1102, Buehler, Lake Bluff, IL, USA). The SPSS statistics for windows, was used for
test was carried out by using a load of 100g statistical analysis.
(HV 0.1), time = 10 seconds dwell time.
The Vickers’s hardness number (N/mm2) III. RESULTS
was recorded as an average of six readings,
three from each surface [Top (S1) and Three-way ANOVA was used to
Bottom (S2)] for each specimen. Percent test the three main effects namely, the type
drop in VHN at the tested surface were of resin composite, the mode of physical
calculated by equation [(VHN activation and the tested surfaces
Bottom/VHN Top) X 100](12). [Table (4)]. The first main effect (type
of resin composite) had two levels namely;
e) Statistical Analysis X-trafil (Voco, Germany) and SonicFill 3
Numerical data from the experiment (Kerr, USA). The second main effect
was collected, tabulated and checked for (modes of physical activation) had three
normality using test of normality (Shapiro– levels namely; no physical activation,
Wilk test). The data was found to be preheating or sonic activation. The third
normally distributed and a parametric test, main effect (tested surface of specimen) had
three way ANOVA, was used to detect the

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two levels namely, top and bottom of tested subgroups are presented in [Table (5)
specimen. Three-way ANOVA revealed & Figure (2)]. All the tested subgroup
statistical significant for two main effects; showed a statistical significant drop upon
the types of resin composites (P<0.0001) comparing the top versus bottom VHN, yet
and tested surface (P<0.0001). On the other it is very clear that all tested materials
hand modes of physical activation showed suffered from less than 20% drop in VHN,
no statistical significant effect (P = 0.631). that is to say the bottom surface achieved
There was no statistical significant over 80% of the maximum hardness of the
interaction between the three main effects top surface except for the R2Eo subgroup
(P = 0.499). The value for all subgroups in where the drop was 20.8%. The highest
group I showed a higher statistical recorded VHN value was 86.27±3.32
significant VHN than those of recorded for preheated X-tra fill, while the
corresponding subgroups in group II. lowest was for the preheated SonicFill 3
Mean values, standard deviations 66.05±1.68. Statistical significance was
and percent drop in VHN at the tested detected between all the subgroups yet no
surface were calculated by equation [(VHN significant difference was detected inside
Bottom/VHN Top) X 100] of VHN for the the subgroups.

Table (4): Three-way ANOVA for the three main effects of the study.
Source Sum of Squares df Mean Square F Sig.
R 4696.843 1 4696.8 426.99 0.00001
E 10.234 2 5.1 0.47 0.631
S 1956.722 1 1956.7 177.89 0.00001
R*E*S 15.526 2 7.8 0.7 0.499

Table (5): Means, standard deviation, significance and percent drop in VHN for the tested subgroups.
Top(S1) Bottom(S2) S2/S1
Mean SD Mean SD x 100
Eo R1 Eo 83.0533ab 3.02 73.0067cd 1.29 87.9%
E1 R1 E1 86.2667a 3.32 76.2333bc 3.47 88.37%
R1 E2 R1 E2 84.2333a 2.02 72.3400cd 3.1 85.88%
Eo R2 Eo 69.0983cd 1.53 54.7767e 5.9 79.2%
E1 R2 E1 66.0533d 1.68 55.1267e 3.67 83.5%
R2 E2 R2E2 67.6067d 4.72 56.3000e 2.95 83.68%
Different superscript show statistical significance p≤0.05

90
80
70
60
50
40
30
20
10
0
R1 Eo R1 E1 R1 E2 R2 Eo R2 E1 R2E2

Top (S1) Bottom (S2)

Figure (3): Microhardness (VHN) of all tested subgroups.

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IV. DISCUSSION inorganic fillers. Variation in

Nowadays, as an attempt to overcome the organic/inorganic ratios control the full
drawbacks of incremental packing behavior, characteristics and performance of
techniques, indicated for conventional resin the material(17,18).
composites, there is a growing switch to the Regarding the monomer content, both
use of bulk fill resin composite material due tested bulk fill resin composites contains
to simplified restoration procedures offered varying portions of short chain monomers.
by them and their ability to pack a full cavity Although its exact quantity is not informed by
with a single increment, saving operators’ the manufacturers, a previous study
time and simplifying the technique(13). highlighted the elution of such monomers
In a trial to boost the performance of bulk (mainly TEGDMA) from SonicFill compared
fill restorations, different types of energy to other bulk-fill resin composites(16,19),
delivery systems were introduced throughout indicating that the monomer content is not
the last years mainly, thermal and sonic low. Although TEGDMA and Bis-EMA
energy, in a single step. These trials targeted present in SonicFill 3 is similar to Bis-GMA
to eliminate the need for a cavity liner, in having functional terminal methacrylate
modifying the physical and mechanical groups, yet being linear chain, these
properties of resin composites and increasing monomers reduce viscosity. Initial reduced
the workability and adaptation of heavily viscosity of resin composites may play a role
filled materials(14). Preheating of resin in reducing their mechanical properties(3,20),
composites was recommended as a method to which could further explain our VHN
improve the properties and adaptation of the findings. Also for the organic matrix, the
final resin composite restorations. A presence of stiffer Bis-GMA(21), in X-tra fill,
temperature of 54°C was chosen in our study may have also played a positive role in
since temperatures in the range between 54°C improving the surface microhardness(9,22)
and 68°C was described as the most proper detected in our study. Furthermore, monomer
range to improve workability and reactivity and filler/matrix refractive index
performance of the material(9,10). mismatch may participate in variation of
In the current study only the formulation different resin composites maturation(23).
of the resin composite used together with the Surprisingly, Sonicfill 3 showed nearly
tested surface of resin composite either top or the same response regarding VHN when
bottom had an effect of the mean VHN. subjected to either sonic or thermal energy
Regarding the VHN of tested surface, the two which may be due to the potential of both
tested bulk fill resin composite showed a energies to enhance polymerization kinetics
significant drop in VHN however neither of with respect to charge distribution and
them dropped below 80% at their 4mm inherent molecular stability of
thickness, except subgroup R2Eo. Therefore, monomers (24,25)
. This is in agreement with the
4mm is considered a safe thickness for bulk finding of Yang et al. who concluded in their
fill resin composite used in the study, taking study on bulk fill resin composites that
in considerations sonication or pre- sonication and pre-heating are beneficial
heating(15), as a value of 80 % or more is an techniques to enhance the performance of
indicator of proper degree of conversion(16). bulk fill resin composites(8). On the other
Different bulk fill resin composites’ side, this contradicts with Demirel et al. who
formulation have been introduced in the found preheating considerably improve the
market by manufactures, such formulas performance of all tested resin composites,
contain a varying types and concentrations of except for that of SonicFill 2(26).
the two major ingredients of resin composite, The SonicFill 3 resin composite, on the
which are the organic monomers and the other hand, is a reformulation of its

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predecessor SonicFill and SonicFill 2. Based V. CONCLUSIONS

on manufacturer claim, compositional 1. Bulk fill resin composite formulation is a
modification targeted the material major determinant of its Vicker’s hardness
performance. However, to the best of our number.
knowledge, literature is so far lacking studies 2. Both sonication and pre-heating had the
evaluating in vitro and in vivo SonicFill 3 same effect on VHN of nano-hybrid,
performance. Yet, one may note that the SonicFill bulk fill resin composite.
composite resin line-up remained presenting
high filler content [81.3 wt %](24). Conflict of Interest
Sonication and pre-heating appeared to The authors declare no conflict of interest.
slightly improve microhardness of bulk fill
Funding
resin composites used in our study.
This research received no specific grant from
Microhardness is considered one of the
any funding agency in the public,
determiners of the degree of conversion,
commercial, or not-for-profit sectors.
consequently, there may be an influence of
sonic and thermal energy on the degree of Ethics
conversion of bulk fill materials(27). The study was approved by the ethical
Regarding the inorganic filler, the committee of the faculty of dentistry, Suez
variation in filler loading, type and size may Canal University, (Approval No 696/2023)
play a role as shown in our study, as the established according to ‘’WHO-2011’’
X-tra fill showed higher VHN that may standards.
be due to the claim in literature that as filler
size increase, mechanical properties
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