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Effect of Mechanical Loading on the Cusp Deflection of Premolars Restored10.5005/jp-journals-10024-1491

with Direct and Indirect Techniques
Original researCh

The Effect of Mechanical Loading on the Cusp Deflection

of Premolars Restored with Direct and Indirect Techniques
1
Sandra Costa Zamboni, 2Lafayette Nogueira, 3Marco Antonio Bottino
4
Lourenço Correr Sobrinho, 5Luiz Felipe Valandro

ABSTRACT Cusp Deflection of Premolars Restored with Direct and Indirect

Techniques. J Contemp Dent Pract 2014;15(1):75-81.
Aim: This study assessed the effect of fatigue load cycling
on human premolars restored with MOD restorations (direct Source of support: Nil
and indirect approaches) on cuspal deflection, compared to
Conflict of interest: None declared
intact teeth (unprepared) and unrestored teeth with an inlay
preparation.
INTRODUCTION
Materials and methods: MOD inlay preparations were per-
formed on sixty premolars with their roots embedded in acrylic Recently, the concepts for restoring posterior teeth that
resin. These teeth were divided into six groups (n = 10): (1) intact
have intracoronal cavities changed for two main reasons:
teeth; (2) unrestored and prepared teeth; (3) teeth restored with
direct composite resin; (4) teeth restored with an indirect com- adhesive technology and better materials in the production
posite resin; (5) teeth restored with injected ceramic inlays (IPS of metal-free fixed partial dentures made with feldspathic
Empress 2 (Ivoclar); (6) teeth restored with CAD/CAM inlays ceramics or direct composites. These conditions led to
made of feldspathic ceramic (Vita Mark II). All of the indirect
minimal intervention approaches, which also contribute to
restorations were adhesively cemented. Strain-gauges were
bonded to the buccal and lingual surfaces of the specimens. a reduction in the risk of cuspal fracture of posterior teeth
Compressive axial loading of 100N was applied on the occlusal restored with inlay restorations.1-5
face of the specimens to measure the cuspal deflection Denehy and Torney6 first proposed the use of adhesive
(microstrain) under compressive loading. These measurements
were obtained before and after mechanical cycling (1 Hz, 37°C,
materials to reinforce weakened teeth and support under-
100,000x). mined enamel. Other studies have shown that the weakening
effect of cavity preparation can be alleviated with adhesive
Results: Comparing the results obtained before and after fati-
guing, the cuspal deflection increased only in the CAD/CAM materials.7-9 Intact teeth rarely break under masticatory
approach. The prepared tooth group had the highest cuspal stresses; however, teeth with extensive restorations can
deflection, before and after mechanical cycling. frequently suffer cuspal fracture.10,11 Cavity preparations
Conclusion: The evaluated restoring approaches decrease the have been routinely associated with the decreased fracture
cuspal deflection, consequently appear to improve the cuspal strength of restored teeth.12 Tooth deformation is indicative
reinforcement.
of a combination of stresses in the tooth, in the restoration or
Keywords: Inlay restorations, Porcelain, CAD/CAM, Composite across the tooth-restoration interface.13 Bell et al10 defined
resin, Cusp deflection, Mechanical loading.
the mechanism of breaking teeth: ‘Fragile cusps, caused
How to cite this article: Zamboni SC, Nogueira L, Bottino MA, by cavity preparation, injury or caries, break due to fatigue
Sobrinho LC, Valandro LF. Effect of Mechanical Loading on the and propagation of cracks during cuspal deflection from
masticatory load’. Cusp deflection is the result of intera-
1
PhD Graduate Student, 2Adjunct Professor, 3,4Professor ctions between the polymerization shrinkage stress of the
5
Associate Professor composite and the compliance of the cavity wall, a common
1
PhD Graduate Program, Prosthodontic unit, Science and biomechanical phenomenon observed in teeth restored with
Technology Institute, Sao Paulo State University, SP, Brazil composites.14 The cusps suffer deflection when submitted to
2,3
Department of Dental Materials and Prosthodontics, Sao a masticatory load, as the isthmus of the preparation weakens
Paulo State University, SP, Brazil the tooth.15
4
Department of Dental Materials, Piracicaba Dental School, Composite resins are widely used for direct restorations
University of Campinas, SP, Brazil
in posterior teeth, even though they still show functional
5
MSD/PhD Graduate Program, Prosthodontic Unit, Federal limitations due to polymerization contraction.16-18 During the
University of Santa Maria, RS, Brazil
early 1980s, the technique of indirect composite resin resto-
Corresponding Author: Luiz Felipe Valandro, Head of MSciD/ rations was introduced to improve the physical properties of
PhD Graduate Program, Prosthodontic Unit, Federal University
of Santa Maria, RS, Brazil, e-mail: lfvalandro@[Link] this material and reduce the effect of polymerization shrink-
age. Lopes et al19 demonstrated that indirect restorations
The Journal of Contemporary Dental Practice, January-February 2014;15(1):75-81 75
Sandra Costa Zamboni et al

restored 97% of the initial tooth rigidity, establishing dura- (Dencrilay®, Dencril, Caieiras, Brazil) up to 3 mm from the
bility, esthetics and the ability of the restorative material to cervical line, in an apical direction and with the assistance
keep the cusps joined.20 of a surveyor (Figs 1A and B).
Indirect restorations have better physical properties than
direct composite restorations because they are fabricated MOD Cavity Preparation
under relatively ideal laboratory conditions.21 Teeth restored Standardized MOD cavity preparations (Fig. 2) were
with bonded ceramic inlays show biological compatibility, performed in groups 2, 3, 4, 5 and 6, using fresh conical
adequate compressive strength, similar thermal conductivity trunk diamond burs with rounded angles (KG Sorensen
to dental tissues, marginal integrity and color stability.22 3131, Barueri Brazil) at high speed under air/water spray
However, all-ceramic restorations can fail due to the cooling in a handpiece that was fixed to an adapted optic
propagation of cracks through the matrix, aiding in the microscope. Thus, the MOD preparations were as parallel
failure of the restoration.23 Previous studies have shown as possible to the long axis of the tooth. Cavity depth was
that adhesive cementation increases the fracture resistance standardized at 2 mm for the occlusal box and 4 mm for the
of these materials.24 proximal box. The cavosurface angle was straightened and
Therefore, the purpose of this current study was to all the specimens had rounded internal angles. The pulpal
evaluate the effect of fatigue load cycling on human and gingival walls were perpendicular to the long axis of
premolars restored with MOD restorations (direct and the tooth and the buccal, axial, lingual and proximal boxes
indirect approaches) on cuspal deflection, compared to walls had an angulation of 12°.25,26
intact teeth (unprepared) and unrestored teeth with an
inlay preparation. The hypotheses were that the restoring Inlay Restorations
approaches would promote similar cuspal deflection to sound
The specimens from groups 3, 4, 5 and 6 were restored as
teeth (cuspal reinforcement outcome) and that the prepared
follows:
teeth would depict the highest values of cuspal deflection.
Table 1: Testing groups according to the restoring technique and
control groups
MATERIALS AND METHODS Groups (n = 10) Material Restoring approach
1* Sound teeth -----
Sixty intact human maxillary premolars of similar size and
2** Cavity preparation None
shape were selected, according to the inclusion criteria of only (no restoration)
a lack of cracks in the tooth. The teeth were extracted for 3 Composite resin Direct
orthodontic reasons and with the informed consent of the 4 Composite resin Indirect
patients (protocol n° 088/2005-PH/CEP). The teeth were 5 Pressable glass-
ceramic (lithium
homogeneously divided into 6 groups (Table 1), according
disilicate)
to their vestibular-lingual dimensions. 6 CAD/CAM porcelain
The roots of each specimen were embedded in a (feldspathic)
metallic cylinder filled with chemically cured acrylic resin *gold-standard group; ** Negative control group

A B
Figs 1A and B: (A) Teeth being mounted in a cylindrical base; (B) Teeth embedded in acrylic resin
(each color indicates an experimental group)

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Effect of Mechanical Loading on the Cusp Deflection of Premolars Restored with Direct and Indirect Techniques

Group 3 visible-light curing unit (XL3000-3M ESPE, with a light

intensity of 620 mW/cm2) for 20 seconds on each face.
MOD cavities were restored with a direct approach using a
3-step etch and rinse adhesive system (Scotchbond Multi- Group 5
Purpose System, 3M ESPE) and composite resin (Z350,
3M ESPE), according to the manufacturer’s instructions. Hot-pressed, all-ceramic restorations were made with a
The entire cavity was etched with 35% phosphoric acid lithium disilicate material (IPS Empress, Ivoclar-Vivadent,
and dried, avoiding dehydration. The primer and adhesive Schaan, Liechtenstein), using the injection molding technique.
agent were applied and light cured for 10 seconds. The All of the instructions recommended by the manufacturer
composite resin was placed using the incremental insertion were followed. Before inlay cementation, the inner surfaces
technique. Each increment was light-cured for 40 seconds of the restorations were etched with 5% hydrofluoric acid
using a visible-light curing unit (XL 3000-3M ESPE, with (IPS Ceramic Etching, Ivoclar Vivadent) for 20 seconds,
an intensity of 620 mW/cm2). rinsed with water, dried, and Salinized (RelyX Ceramic
The crowns with MOD cavities from groups 4, 5 and 6 Primer-3M ESPE). The cementation procedures (dentin
(indirect approach) were impressed. A one-stage impression treatment) were the same as for those described in Group 4.
was taken of each prepared tooth using a double-viscosity
Group 6
polyvinylsiloxane impression material (Aquasil Ultra LV,
Dentsply), and an individual impression tray. Master dies Inlay restorations were fabricated from Vita Mark II ceramic
were then produced (Stone type IV, Durone, Dentsply). One blocks (Vita, Bad Sackingen, Germany) using the standard
technician produced the indirect restorations. technique of the Cerec software. The inner surfaces of the
restorations were then etched with 5% hydrofluoric acid
Group 4 (IPS Ceramic Etching, Ivoclar Vivadent), rinsed with water,
dried and silanized (RelyX Ceramic Primer- 3M ESPE).
MOD inlay preparations were made and restored with the
The same cementation procedures described in group 4
Sinfony System. This indirect composite material was
was followed.
subjected to a first and second polymerization cycle as
All of the specimens were stored in distilled water at
determined by the manufacturer. For inlay cementation, a
37° C for 24 hours.
3-step etch and rinse adhesive system (Scotchbond Multi-
Purpose Plus system, 3M ESPE) was used and combined
Static Compressive Load and
with a dual-cure resin cement (Relyx ARC, 3M ESPE).
Deflection Measurements
The entire cavity was etched with 35% phosphoric acid and
dried, avoiding dehydration. Then, the Activator®, Primer® Single precalibrated strain gauges (model 060 BG-Excel
and Catalyst® products were applied on enamel/dentin, as Sensory) were bonded with superglue (Super Bonder Gel,
recommended by manufacturer. A resin luting agent (RelyX Loctite, Sao Paulo, Brazil) to the buccal and lingual cusps
ARC, 3M ESPE) was manipulated and applied to the internal of each specimen, 0.5 mm above of the cementoenamel
surface of the inlay, the cement excess was carefully removed junction. Two gauges were bonded to each tooth, one on the
from the margins and the resin cement was cured with a buccal and one on the lingual surface of the crown, in order
to independently measure the deflection of each cusp. The
gauges were bonded at a level that corresponded with the
intended pulpal floor of the MOD cavity. This was reported
to be the location of the highest strains, leading to cuspal
deflection. A metallic cylinder, with an 8 mm diameter, was
applied to the internal surfaces of the crown, with a load of
100N in a universal testing machine (EMIC, model DL-
1000, Sao Jose dos Pinhais, Brazil) at a speed of 1 mm/
min. The cuspal deflection before mechanical cycling was
registered in micron deformation (µst) (Fig. 3).

Mechanical Cycling Testing

After the initial measurements (before cycling), the
specimens were submitted to 100,000 mechanical cycles
Fig. 2: Preparation of a specimen with a load of 50 N and a frequency of 1 Hz. During

The Journal of Contemporary Dental Practice, January-February 2014;15(1):75-81 77

Sandra Costa Zamboni et al

Vital teeth with conservative restorations are less susce-

ptible to fracture than prepared teeth, as confirmed in the
literature.7,19,27-29 When comparing the deflection values of
sound teeth with those of restored teeth, the restored teeth
exhibited a capacity of cuspal reinforcement with lowered
resistance to breaking. The adhesive approaches of indirect
and direct restorations promote the bond between hard dental
tissues and restorative materials,19,30 cuspal reinforcement
and reducing deflection.
Choosing the best technique and material according
to functional demands and determining the amount of
remaining tooth structure for optimum strength against
fracture are key factors for success.11 The results from the
Fig. 3: Static compressive load applications on teeth current study support the hypotheses proposed, since the
restored teeth had similar cuspal deflection to sound teeth,
cycling, the specimens were kept immersed in water at 37 ± and lower cuspal deflection than those teeth that were only
1°C, regulated by a thermostat. After the fatigue testing, prepared and not restored.
the magnitude of cuspal deflection was evaluated again, as The results of the current study indicated that a direct
described previously. composite resin restoration was able to improve the
resistance to fracture when compared with intact teeth.
Experimental Design and Statistic Analysis Dental composite materials are widely used with many
This study presented two factors (restorative approach in 6 techniques and compositions to increase the resistance
levels, and mechanical cycling in 2 levels). Thus, the data of the composite resin. The resin system of 3M, Filtek
in microstrain was submitted to 2-way ANOVA and Tukey’s Z350, shows good results, possibly due to the composition
test (5%). (manufacture’s information), consisting of three major
components: TEGDMA, UDMA and BIS-EMA, where the
RESULTS
Table 2: Two-way ANOVA of the data of microstrain
Two-way ANOVA (Table 2) shows that mechanical cycling Source df SS MS F P
(p = 0.0334) had statistically significance on cuspal deflection Mechanical 1 19.04 19.036 4.64 0.0334
results. Also the tooth condition (p < 0.0001) significantly cycling
affected the deflection (the prepared and unrestored tooth Restoring 5 533.62 106.724 26.02 0.0000
group had the highest cuspal deflection). condition
Table 3 presents the means and standard deviations of the Interaction 5 32.69 6.539 1.59 0.1679
tested conditions and the Tukey posthoc test results (alpha = Error 108 443.03 4.102
0.05). All of the restored groups had significantly lower Total 119 1028.38
cuspal deflection when compared to the nonrestored prepared
Table 3: Mean values and SD of cuspal deflection (µst) before
group, not only before, but also after mechanical cycling. and after mechanical loading for each restorative material and
When comparing the different restoring conditions and the control groups
negative/positive control groups after mechanical cycling, Tooth condition Mechanical loading
the prepared and unrestored teeth had the highest cuspal Before** After**
deflection, while the sound teeth and the ‘restored groups’ Sound teeth* 577.0 ± 2.7 Ba 577.5 ± 2.6 Ba
were statistically similar. Only the restoration made of CAD/ Prepared teeth* 583.4 ± 2.8 Aa 584.4 ± 0.8 Aa
CAM porcelain (group 5) had a significantly increased Direct composite resin* 579.2 ± 3.9 Ba 579.2 ± 0.9 Ba
cuspal deflection after fatiguing. Indirect composite 578.1 ± 1.4 Ba 578.2 ± 1.1 Ba
resin*
DISCUSSION Pressable glass- 578.7 ± 1.6 Ba 578.7 ± 0.8 Ba
ceramic*
This current investigation observed that the cuspal deflection
in restored premolars with inlay cavities is similar to sound CAD/CAM porcelain* 577.5 ± 1.9 Ba 580.5 ± 1 Bb

teeth. The adhesive properties of the restorative approaches *Means from the same row followed by the same lower-case letters
are not significantly different at p < 0.05 according to Tukey HSD
appear be the main reason for reinforcement of the prepared test; **Values from the same column followed by the same capital
premolars. letter do not differ according to the Tukey HSD test (p < 0.05)

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Effect of Mechanical Loading on the Cusp Deflection of Premolars Restored with Direct and Indirect Techniques

majority of TEGDMA has been replaced with a blend of fatigue of these materials is a function of the competition
UDMA and BIS-EMA, contributing to the resistance of a between intrinsic parameters related to the mechanisms of
tooth breaking that has been restored with this material and structural degradation and extrinsic factors related to the
an associated adhesive.7,28 discontinuation of the crack propagation. Thus, this would
The filler contains a combination of a nonagglomerated/ be one of the factors that could justify the success of teeth
nonaggregated, 20 nm nanosilica filler and loosely bound restored with IPS Empress 2, which presents a greater
agglomerated zirconium/silica nanoclusters, consisting of number of crystals of a homogeneous format that limits crack
agglomerates of zirconium/silica particles. It is proposed by propagation through the process of energy absorption.37 The
the current authors that this material increases the resistance resistance of the material is related the type of load, which
of cusp deflection by joining the two cusps.27,31 Similar would explain the biggest capacity of this material to resist
results for composite resin in class II MOD preparations were tension. Most likely, the presence of crystals of lithium
found by many authors when they compared direct composite disilicate was responsible for the results found in the current
resins with other indirect restoring materials.8,12,28,32 study, presenting similar values to intact teeth before and
Jensen et al28 and Cötert et al8 compared direct composite after mechanical loading.
with indirect ceramic restorations and concluded that both Several authors8,12,32,34 concluded that ceramics have
restorations re-established resistance to breaking that was a resistance to fracture similar to other types of restorative
similar to intact teeth. When these authors compared the materials when used in MOD inlay restorations by using
materials in compression, ceramics presented better results. comparative tests between direct composites, indirect
Dalpino et al12 concluded that composite resin restorations composites and ceramics using diverse methodologies.
increased the resistance to breaking without significant Some methods of restoration preparation have been
differences between the groups of indirect materials (resin developed to increase the main deficiencies of fragility, low
and ceramics). Similar results were achieved by Burman et tenacity and low tensile strength.38 Machined ceramics have
al32 Even though these studies assessed fracture resistance, been indicated as excellent restorative materials. The results
their findings corroborate with the results displayed from of the specimens restored with the CAD/CAM system in the
this current study. current study exhibited no significant difference from the
The principal limitation for the use of direct composite other restorative materials and the groups of sound teeth,
resin is the volume of the material that is used, with an effect before and after mechanical loading. However, only the
on polymerization shrinkage and the resulting cracks in the Cerec group increased when comparing the values before
remaining dental structure, causing postoperative pain and and after mechanical cycling, different from the other groups,
recurrent caries. Lee et al14 indicated that the use of the which had similar cuspal deflection before and after cycling.
incremental restoring technique33 or an indirect inlay could The feldspar restorations obtained by the CAD/CAM
reduce cuspal deformation. approach may be more susceptible to crack propagation
Brunton et al34 stated that indirect composite resin under load stress.39-41 It is proposed that these differences
restorations presented greater flexibility and low rigidity, are due to machining (grinding using diamond bur) during
allowing the tooth to deflect when under occlusal forces, in the CAD/CAM process, which can provide machined
relation to indirect ceramic restorations. Cötert et al8 did not grooves of different depths, leading to crack propagation.39-41
find significant differences in resistance to breaking between Additionally, the restorative blank is formed from feldspathic
direct adhesive restoring materials, composite inlays, porcelain, without the reinforcement of natural crystals,
ceramic inlays and posterior composites. Additionally, which would normally hinder the propagation of cracks,
the statistical data of resistance to fracture of the indirect thus enabling greater cuspal deflection.39-41
composite resin was similar to intact teeth.32 These findings Hannig et al33 indicated that premolars restored with the
agree with the findings from the current study, where the CAD/CAM system presented a number of severe fractures,
group that received indirect resin composite restorations which was significantly greater then the results obtained
presented deflection values that were similar with intact with the control group of premolars.
teeth. Overall, this present investigation found that the studied
In ceramic materials, the mechanism of crack propagation, restoring strategies to restore inlay cavities in premolars
leading to fatigue, is sufficiently distinct.35 The resistance to reestablished the cuspal deflection to values that were
crack propagation results from two mechanisms: intrinsic, similar to sound teeth. Thus these strategies appear to be
which occurs in the crack and is related to the growth and good strategies for these restorations, even though other
propagation of a crack; and extrinsic, which is related to the factors may influence their performance. Further studies
retardation of the crack propagation.36 The behavior under using long-term fatigue aging (fatigue life prediction) should
The Journal of Contemporary Dental Practice, January-February 2014;15(1):75-81 79
Sandra Costa Zamboni et al

be performed to better predict the clinical performance of 14. Lee MR, Cho BH, Son HH, Um CM, Lee IB. Influence of cavity
these restoring approaches. dimension and restoration methods on the cusps deflection
of premolars in composite restorations. Dental Mater 2007;
23(3):288-295.
CONCLUSION 15. Larson TD, Douglas WH, Geistfeld RE. Effect of prepared
cavities on the strength of teeth. Oper Dent 1981;6(1):2-5.
1. The restorative approaches (direct and indirect restora- 16. Takahashi H, Finger WJ, Wegner K, Utterodt A, Komatsu M,
tions) used to restore the MOD inlay promote cuspal Wöstmann B, Balkenhol M. Factors influencing marginal cavity
reinforcement of premolars, since the cuspal deflections adaptation of nanofiller containing resin composite restorations.
of the restored groups was similar to the sound teeth and Dental Mater 2010;26(12):1166-1175.
17. Meira JB, Braga RR, Ballester RY, Tanaka CB, Versluis A.
lower than prepared teeth.
Understanding contradictory data in contraction stress tests.
2. The adhesion between inlay restorations and dental hard J Dent Res 2011;90(3):365-370.
tissues appears to be crucial for cuspal reinforcement. 18. Yamamoto T, Nishide A, Swain MV, Ferracane JL, Sakaguchi
RL, Momoi Y. Contraction stresses in dental composites adjacent
to and at the bonded interface as measured by crack analysis.
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