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CLINICAL ARTICLE

Bulk Fill Composites: An Anatomic Sculpting Technique


RONALDO HIRATA, DDS, MS, PhD*, WILLIAM KABBACH, DDS, MS, PhD,
OSWALDO SCOPIN DE ANDRADE, DDS, MS, PhD, ESTEVAM A BONFANTE, DDS, MS, PhD,
MARCELO GIANNINI, DDS, MS, PhD, PAULO GUILHERME COELHO, DDS, MS, PhD**

ABSTRACT
Composite resins have been routinely used for posterior cavities due to a phasedown on amalgam as a restorative
option. However, clinical problems related to polymerization shrinkage demands careful and specific techniques for
placement of the composite layers. New low shrinkage composites are now marketed for bulk filling of cavities
without the need of a traditional layering. With this new concept, the restoration can be built in one or two layers,
depending on the classification of the bulk fill material. This article discusses and presents two alternative techniques
using the low shrinkage composites, suggesting a called amalgam-like sculpting technique, one using a flowable bulk fill
and other a regular bulk fill material. Clinical cases illustrate these two alternatives compared with the layered
technique.

CLINICAL SIGNIFICANCE
New techniques using low shrinkage composites for bulk filling can provide a simpler technical approach for the
clinician in sculpting and generating highly esthetic posterior composites.
(J Esthet Restor Dent 27:335343, 2015)

INTRODUCTION
Esthetic restorative materials have been routinely used
due to highly increasing patients demand. Most
commonly used for improved esthetics in operative
dentistry are ceramics of the particle-lled glass family
and composite resins. Although the latter represent a
clinically validated class of material, several concerns
remain regarding its polymerization shrinkage which
has been an active research topic.15 It has been
suggested that polymerization shrinkage may lead to
contraction of the total composite volume, elicited by
the cross-linking of the monomeric chains, and
eventually generate marginal leakage, post-operative
sensitivity, and dental cracks.6,7

The dental industry is devoting eorts in innovation of


composite resin-based materials due to a legal restrain
treaty on mercury-based products recently announced
by the United Nations Environment Programme of the
Committee, which established a deadline, in 2020, to
nish the commercialization of mercury-based products
in 170 nations.8 Besides the global phasedown on
amalgam, an important amount of such eorts has been
applied in the last decades in research toward the
development of minimum or nonshrinking restorative
composites.3
In the last few years, low shrinkage composites have
been presented, with a concept of bulk lling in a
owable consistency for use as a cavity base/liner, and

*Assistant Professor, Department of Biomaterials and Biomimetics, New York University, New York, NY, USA

Professor of Post Graduation on Restorative Dentistry, Department of Restorative Dentistry, CETAO, Sao Paulo, SP, Brazil

Director of Post Graduation on Restorative Dentistry, Department of Restorative Dentistry, SENAC, Sao Paulo, SP, Brazil

Assistant Professor, Department of Prosthodontics, Bauru School of Dentistry, University of So Paulo, Bauru, So Paulo, Brazil

Associate Professor, Department of Restorative Dentistry, Piracicaba Dental School, State University of Campinas, Piracicaba, So Paulo, Brazil
**Associate Professor, Department of Biomaterials and Biomimetics, New York University, New York, NY, USA

2015 Wiley Periodicals, Inc.

DOI 10.1111/jerd.12159

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SCULPTING TECHNIQUE FOR BULK FILL COMPOSITES Hirata et al

also in a regular consistency to be conventionally used


in the entire restoration.
This manuscript describes material and clinical
properties of regular and bulk ll composites
combined with the presentation of three clinical cases
with three dierent approaches where the nal
restoration was accomplished with maximum
esthetics by using either a regular resin composite, a
bulk ll owable composite as a base, or a regular
consistency bulk ll composite. The key learning
points are to report how to use composites yielding
minimum polymerization contraction stresses
and to describe a novel one-step and two-step
amalgam-like sculpture technique for bulk ll
composites.

LOW SHRINKAGE COMPOSITES:


BULK FILL CONCEPT
Common problems associated with the shrinkage
generated by the polymerization process and
cross-linking of the monomers are inltration of the
restoration margins, secondary caries, enamel cracks,
and post-operative sensitivity.6
The continuous search for a low shrinkage resin
composite included new materials like ormocers and
siloranes. Their resulting shrinkage stress and volume
analysis showed promising results compared with

regular methacrylate composites.2 However, the need


for a specic adhesive system for this kind of material,
as the limitation of repair with Bisphenol glycidyl
metacrylate (BIS-GMA) materials, has limited their
widespread indication. In addition, the diculty in
achieving optimal depth of polymerization of the
siloranes was another drawback.9 Also, in the past,10
chemically cured composites launched for use as a base
(e.g., Bisll 2B; BISCO, Schaumburg, IL, USA) claimed
a bulk lling with a less stress shrinkage polymerization
process.
A more recent generation of resin composites with
photoinitiators, such as urethane-based patented
monomer, allowed for indication of bulk lling of
layers up to 4 mm thickness.11 This composite was
named Smart Dentin Replacement (SDR) owable
composite (Dentsply, York, PA, USA). Nevertheless, an
overlying layer of regular composite for anatomy
completion was still necessary. Its benets regarding
reduced shrinkage stress are still controverse.
Microcomputed tomography (microCT)
reconstructions of class I cavity preparations restored
with bulk ll composites (SDR ow; Dentsply) showed
less gaps, after polymerization, on the cavity oor
interface compared with a regular resin composite
(Vitalescence/Ultradent, Salt Lake City, UT, USA)
(Figures 1 and 2).
A modication of the concept of owable bulk lling
composites has been proposed by the industry, allowing

FIGURE 1. Microcomputed tomography (microCT) 3D reconstructions of a regular composite, bonded with its proprietary
adhesive system in a class I preparation, used as bulk filling. Shrinkage (around 4.0%) is depicted at the occlusal surface as well as on
the cavity walls which resulted in gaps. A, 3D rendering of composite restoration with shrinkage after curing (Green). B, 2D slice of
composite restoration showing shrinkage on occlusal surface and bottom of cavity.

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FIGURE 2. Microcomputed
tomography (microCT) threedimensional (3D) reconstruction of a
bulk fill low shrinkage flowable
composite used as a bulk filling along
with its proprietary adhesive system
in a class I preparation. Note the
absence of gaps and the shrinkage
(around 2.5%) concentrated on the
occlusal surface. A, 3D rendering of
composite restoration with shrinkage
after curing (Green). B, 2D slice of
composite restoration showing
shrinkage only on occlusal surface.
TABLE 1 Low shrinkage bulk fill composites and their manufacturers in tandem with their indications
Composite

Manufacturer

Consistency

Indication

Surefill SDR flowable

Dentsply (York, PA, USA)

flowable

Base of restorations untill 4 mm.

Tetric Evo-ceram Bulk fill

Ivoclar Vivadent (Schaan, Liechtenstein)

regular

Full Restoration untill 4 mm.

Venus Bulk fill

Kulzer (Hanau, Germany)

regular

Full Restoration untill 4 mm.

Filtek Bulk fill

3M (St. Paul, MN, USA)

flowable

Base of restorations untill 4 mm.

X-tra base flowable bulk fill

VOCO (Cuxhaven, Germany)

flowable

Base of restorations untill 4 mm.

EQUIA Fil

GC (Alsip, IL, USA)

the complete restoration of cavities with no need of an


overlying nal layer to complete anatomy. Thus, a
4 mm12 (or 5 mm depending on manufacturers
directions) can be directly placed without an
incremental layering technique due to presence of
stress reliever monomers and specic
photoinitiators.1113 Tetric Evo-ceram bulk ll (Ivoclar
Vivadent, Schaan, Liechtenstein), Venus Bulk Fill
(Kulzer, Hanau, Germany), and Sonic-ll (Kerr,
Orange, CA, USA) are some commercial
examples.
Some manufacturers also suggested both options: a
owable bulk ll composite applied as a base or a
regular bulk ll composite for all the reconstruction
(Beautiful bulk ll; Shofu, San Marcos, CA, USA). In
Table 1, we present a selection of resin composites
and their manufacturers in tandem with their
indications.

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Self adherent bulk fill composite

TECHNIQUES FOR IMPROVED SHRINKAGE


STRESS DISTRIBUTION: LAYERING, BULK
FILL, AND THE TWO-STEP AMALGAM-LIKE
TECHNIQUE
The Layering Technique
A layering technique is highly desirable in order to
decrease the issues generated by resin composite
polymerization shrinkage.14 The insertion of a layer of
composite is supported by the rationale of C-factor
reduction, which is dened by the number of bonded
walls divided by the number of free surfaces.15 By using
an incremental layering technique, the resin composite
is bonded to a reduced number of cavity walls that
decreases the C-factor thus reducing its shrinkage
levels. However, the clinical steps become highly
sensitive to operator handling, and the nal functional
and esthetic result may also be compromised.

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FIGURE 3. The schematic shows a bucco-lingual section of a


class I cavity of 4 5 mm. Two millimeters thickness portions
of composite are inserted and should be in contact with no
more than two cavity walls to reduce the C-factor. In this way,
a cavity with a total volume of 20 mm3 (4 mm 5 mm 5 mm)
would need five to six increments to be completely filled.
Exceeding the number of layers may increase the
incorporation of voids which may act as stress raisers at
interfaces.

Therefore, the lling technique for posterior teeth


should guarantee a correct accomodation of composite,
especially to cavity margins, proper reconstruction of
anatomy, and reduction of the inherent shrinkage stress
generated by the polymerization contraction.16
An important advantage of the incremental layering
technique is the possibility to reproduce the aspects of a
natural tooth, such as its dierent opacities, shades, and
translucencies of enamel/dentin,17 which can be
individualized during buildup in attempt to match with
natural structures.18
A technique proposed by Hirata19 is described in
Figure 3.
After removing a compromised restoration and
remaining decayed tissue, a prolaxis should follow
within the cavity with a consepsis scrub (Ultradent, Salt
Lake City, UT, USA). In the posterior area, two-step
self-etching adhesive systems are preferable, with the
option of selective enamel etching if desired.20
Previous application of a traditional owable composite
is recommended to provide a more favorable cavity

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FIGURE 4. Conventional incremental layering technique:


Initial aspect of a resin composite restorations with
infiltration.

conformation for the regular material. It should be


performed at the angles of the cavity, and in irregular
areas of the pulpal oor.21
After curing the owable layer, adaptation of a
dentin/opaque layer is proceeded, always with a
A3/A3.5 color. In posterior teeth, shade matching is not
necessary, once the most important aspect of in this
region is the thickness and levels of
opacity/translucency. The key for matching the perfect
shade in posterior teeth is to combine dentin layering in
its proper thickness, as well as the enamel or
translucent layer (Figures 46).
An ideal thickness of dentin should provide 2.5 mm of
space for the chromatic and achromatic enamels. A
reference that can be used to ensure that such space
has been provided is a burnisher, such as the 26/30
Burnisher (Cosmedent, Chicago, IL, USA), which
should t within the composite built dentin layer,
leaving 2.5 mm occlusally for the enamel. After curing
the layer rst in direction to the palatal/lingual walls,
and then in direction to buccal walls, layering of the
restoration can be continued.
A second layer of chromatic enamel is selected
(chromatic enamel meaning an enamel composite with
a specic VITA shade). The selected shade has to be
one or two shades less than the one used for dentin; A2
enamel is currently the most used for the chromatic

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SCULPTING TECHNIQUE FOR BULK FILL COMPOSITES Hirata et al

FIGURE 5. Cavity after removal of a compromised


restoration and secondary caries. A self-etching adhesive was
used (Scotchbond Universal; 3M Espe, St. Paul, MN, USA).

FIGURE 6. Layering of dentin with a A3.5 dentin resin


composite (Empress Direct A3,5 dentin; Ivoclar Vivadent,
Schaan, Liechtenstein).

above, once these composites were developed for


simplication of steps, avoiding several layers of varied
shades. A technique modication is suggested in
attempt to simplify steps based on the concept that
incremental layering may not always be necessary.
If all the restoration is performed in one shot, then a
similar sculpturing process used for amalgam may be
used.

FIGURE 7. Chromatic enamel layer of a A3 enamel


composite (Empress Direct A3,5 enamel; Ivoclar Vivadent,
Schaan, Liechtenstein).

Within this context, two possibilities will be described


and clinical cases illustrated: (1) one using a owable
bulk ll composite and (2) the second one using a bulk
ll regular composite.

enamel layer. As a reference, after this layer, a space of


1.2 mm should be available in order to get a perfect
thickness of the achromatic enamel (achromatic enamel
meaning an enamel composite that do not use a VITA
shade, usually they provide references like P/Pearl,
T/Trans, E/enamel) (Figure 7).

Bulk Fill Flowable and Regular Composite:


Two-Step Amalgam-Like Sculpting Technique
After application and photocuring of the dental
adhesive, a layer of owable composite with a thickness
limit of 4 mm is applied in the cavity, and the curing
time will be 20 seconds.22

The last layer must be individually applied for each


cusp so one may control the contouring of the nal
anatomy (Figure 8).

Low shrinkage bulk ll composites can be used for the


lling of posterior cavities, with a correct indication of
cavities untill 4 to 5 mm thickness (depending on
manufacturer). With these materials, a cavity can be
lled with less layers. Two consistencies are available
for the bulk ll composites: owable (used as a base)
and regular consistency (used to ll and restore in one
shot).

The Bulk Fill Technique


The technique used for bulk ll composites is simpler
than the traditional incremental layering described

2015 Wiley Periodicals, Inc.

DOI 10.1111/jerd.12159

Journal of Esthetic and Restorative Dentistry

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SCULPTING TECHNIQUE FOR BULK FILL COMPOSITES Hirata et al

FIGURE 8. Achromatic enamel


layer of a neutral transparent
composite (Empress Direct T20;
Ivoclar Vivadent, Schaan,
Liechtenstein). A, restoration after
the final layer. B, follow up of one
month.

FIGURE 9. The schematic shows a bucco-lingual section of a


class I cavity of 4 5 mm. A bulk fill composite layer is made
as a core, leading a thickness of 1.3 mm. For a regular
composite as a last layer.

FIGURE 10. Initial aspect of a first maxillary molar showing


a grayish area on the distal aspect of the occlusal surface,
suggesting the presence of caries.

space from the margin for the last layer of a regular


composite that will allow the nal sculpture of the
occlusal surface. A clinical sequence of this technique is
presented in Figures 10 through 14.

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FIGURE 11. After caries removal, a self-etching adhesive


(Clearfil SE Bond; Kuraray, Ibaraki, Japan) was applied into the
cavity.

Bulk Fill Regular Composite: One-Step


Amalgam-Like Sculpting Technique
This technique (Figure 15) refers to the use of a regular
consistency bulk ll composite that itself provides
enough consistency to allow sculpture and
reconstruction of the entire restoration in one
shot. This material can be accommodated in a
single layer up to 4 mm thickness. A clinical
sequence of this technique is described in Figures 16
through 20.

The technique here dened as two-step amalgam-like


sculpting technique (Figure 9) refers to the use of a
owable bulk ll composite to build the core in one
single layer of up to 4 mm thickness, leaving 1.2 mm of

Laboratorial data have already shown less volumetric


shrinkage of the bulk ll materials compared with
regular composites,1 and also less polymerization
stress.5 In a 3-year clinical investigation, bulk-lled

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FIGURE 12. A flowable bulk fill


composite (SRD flowable; Denstply,
York, PA, USA) was used to fill the
cavity leaving only 1.3 mm space for
the last layer. A, Positioning of tip
applicator. B, Application of
composite (Note the flowable
consistency inside cavity).

FIGURE 13. Enamel layer being reconstructed by an enamel


composite (Enamel HRI; Miscerium, Genova, Italy).

FIGURE 14. Aspect of the finished restoration.

FIGURE 15. The schematic shows a bucco-lingual section of


a class I cavity of 4 5 mm. All the restoration can be made
using a single layer of a bulk fill regular composite.

FIGURE 16. Initial case showing amalgam restorations that


will be replaced.

CONCLUSION
restorations showed comparable results to 2 mm resin
composite layering technique.23 These initial results
seem to be promising, yet more research are expected
to validate a long term result.

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DOI 10.1111/jerd.12159

A description of dierent techniques, including the


traditional incremental layering as well as the new
concepts of bulk lling used for posterior composites

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FIGURE 17. Selective etching of enamel prior self-adhesive


application.

FIGURE 18. After application of dental adhesive, a bulk fill


regular consistency composite layer is applied filling the cavity
all the way to the occlusal cavosurface (Tetric Evo Ceram Bulk
Fill; Ivoclar Vivadent, Schaan, Liechtenstein). The final sculpture
is made with the better definition of principal sulcus and
correct inclination of cuspids.

FIGURE 19. Stains (Kolor+plus; Kerr, Orange, CA, USA) can


be applied in the depth of the sulcus. A transparent surface
sealant (Optiguard; Kerr, Orange, CA, USA) is applied over the
stains just to protect from the abrasion.

FIGURE 20. Final clinical result.

restorations was presented. Both one- and two-step


amalgam-like sculpture techniques for use with new
low shrinkage bulk ll composites seem more
straightforward, relative to incremental layering, and yet
provide acceptable esthetics and reduced
polymerization shrinkage.

1.

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DISCLOSURE
The authors do not have any nancial interest in the
companies whose materials are included in this article.

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Reprint requests: Ronaldo Hirata, DDS, MS, PhD, Department of


Biomaterials and Biomimetics, New York University, 345 E 24th Street,
New York, NY 10010, USA; Tel.: 212-998-9214; Fax: 212-995-4244; email:
rh1694@nyu.edu

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