Ó

Operative Dentistry, 2014, 39-6, 000-000

Polymerization Shrinkage and Depth

of Cure of Bulk-Fill Resin
Composites and Highly Filled
Flowable Resin
J-H Jang  S-H Park  I-N Hwang

Clinical Relevance
As an alternative to conventional resin composites for direct posterior restorations, the use
of new strategic composites that speed up the restorative procedure should be guided by
careful attention to case selection and operative procedure.

SUMMARY composites and light cured for 20 seconds,

The aim of this study was to evaluate the followed by 24 hours of water storage. The
polymerization behavior and depth of cure surface hardness was measured on the top and
(DOC) of recently introduced resin composites the bottom using a Vickers microhardness
for posterior use: highly filled flowable com- (HV) indenter. The linear polymerization
posite and composites for bulk fill. A highly shrinkage of the composite specimens after
filled flowable (G-aenial Universal Flo [GUF]), photo-initiation decreased in the following
two bulk-fill flowables (Surefil SDR Flow order: TF and GUF . VBF . SDR . FS and
[SDR] and Venus Bulk fill [VBF]), and a bulk- TBF (p,0.05). The polymerization shrinkage
fill nonflowable composite (Tetric N-Ceram stress of the six composite groups decreased in
Bulk fill [TBF]) were compared with two con- the following order: GUF . TF and VBF . SDR
ventional composites (Tetric Flow [TF], Filtek . FS and TBF (p,0.05). The mean bottom
Supreme Ultra [FS]). Linear polymerization surface HV of SDR and VBF exceeded 80% of
shrinkage and polymerization shrinkage the top surface HV (HV-80%). However, the
stress were each measured with custom-made bottom of GUF and TBF failed to reach HV-
devices. To evaluate DOC, the composite spec- 80%. A highly filled flowable (GUF) revealed
imen was prepared using a mold with a hole of limitations in polymerization shrinkage and
4 mm depth and 4 mm internal diameter. The DOC. Bulk-fill flowables (SDR and VBF) were
hole was bulk filled with each of the six properly cured in 4-mm bulk, but they shrank
more than the conventional nonflowable com-
*Corresponding author: 333, Yongbong-Dong, Buk-Gu, posite. A bulk-fill nonflowable (TBF) showed
Gwang-ju, 500-757, Republic of Korea; e-mail: hinso@
chonnam.ac.kr
comparable shrinkage to the conventional
nonflowable composite, but it was not suffi-
DOI: 10.2341/13-307-L
ciently cured in the 4-mm bulk.
2 Operative Dentistry

INTRODUCTION properties; thus, they are indicated not only as a

cavity liner but also for larger posterior restora-
Because composite has shown a level of success as a
restorative material, there have been continuous tions.17 The latest version of flowable composites for
efforts to improve its physical and mechanical simplifying the restorative procedure is the bulk-
properties and the operating techniques used to filling posterior flowable. Surefil SDR Flow (SDR;
apply it.1-3 Even so, complications related to poly- Dentsply Caulk, Milford, DE, USA) and Venus Bulk
merization shrinkage stress and curing depth still fill (VBF; Heraeus Kulzer GmbH, Hanau, Germany)
cause significant reluctance to use them. Not only are intended to be placed and bulk-cured in one
will this polymerization shrinkage stress be trapped increment up to 4 mm. The matrix composition of
within the material itself, but it also will exert forces these two bulk-fill flowables is based on modified
on the adhesive interfaces of the dentin.4,5 Conse- urethane dimethacrylate (UDMA). The manufactur-
quently, this shrinkage stress could lead to abundant er of SDR says that it differs from conventional
clinical problems such as microleakage, marginal composites by incorporating stress-decreasing resin
gap formation, recurrent caries, pulpal irritation, technology, which comprises a high molecular
and maybe even tooth loss.2 The decrease in the weight polymerization modulator in the matrix
degree of conversion is also a nuisance, compromis- structure. This unique molecular structure contrib-
ing the physical properties and increasing elution of utes to the delay of the gel point, which represents
the monomer. It might lead to postoperative sensi- an increase of viscosity through network formation,
tivity and result in premature failure of the and it allows for a greater pregelation-phase time.18
composite restoration.6,7 In terms of the depth of cure (DOC), these new-
generation flowable composites showed satisfactory
Various clinical strategies have been suggested to results in 4-mm increments after 20 seconds of
reduce the restorative complications in direct poste- photo-polymerization, which is recommended by the
rior composite restoration; these include an incre- manufacturer.19
mental layering technique, the use of a flowable
lining layer, and the modulation of the photo- Along with the bulk-fill flowables, the bulk-fill
initiation mechanism.1,8,9 Among them, incremental nonflowable composite, Tetric N-Ceram Bulk-fill
layering is the standard of care for placement of (TBF; Ivoclar Vivadent, Schaan, Liechtenstein),
resin composites in cavity preparations exceeding 2 was recently launched with the claim that it would
mm, by virtue of the sufficient exposure of the entire substitute for not only the conventional nonflowable
increment to the curing light, as well as the composite but also for the bulk-fill flowables that are
reduction of the volume of the contracting materi- required for the final 2 mm when using the
al.10,11 Despite those strategies having been shown incremental layering technique. According to the
to be effective in improving the longevity of restora- manufacturer‘s information, this new composite will
tions,11-13 clinicians still desire easier and quicker achieve full-depth bulk fill up to 4 mm without a
composite restorations with less shrinkage. Signifi- superficial capping layer, unlike the bulk-fill flow-
cant advances have been made in composite formu- ables. The manufacturer states that TBF contains a
lations that target less shrinkage and are more user shrinkage stress reliever to minimize polymerization
friendly; these include 1) highly filled flowable, 2) shrinkage; this is a modified unique filler partially
bulk-fill flowable, and 3) bulk-fill nonflowable com- functionalized with silanes.
posites. Up to now, an incremental layering technique has
Flowable composite was introduced in the 1990s, been the standard procedure in direct posterior
and it was promoted because it is injectable, which is composite restorations to reduce polymerization
regarded as a desirable handling property and shrinkage stress and achieve adequate DOC.11,20
allows simplification of the placement procedure.14- Yet, recent advances in composite technology for
16
Typically, flowable composite has a lower filler direct posterior restoration have been targeted as
content and higher volume of resin matrix when alternatives to the incremental layering technique.
compared with nonflowable composite, so the first- Hence, the overall evaluation of the mechanical
generation flowable composite was applied as a properties and polymerization shrinkage of various
cavity liner or Class V restoration due to the low strategic composites including highly filled flow-
elastic modulus. However, the recent generations of ables, bulk-fill flowables, and bulk-fill nonflowable
flowable composite (G-aenial Universal Flo [GUF], composites is mandatory.
GC Co, Milford, DE, USA) have higher filler content This study evaluated and compared the recently
and are claimed to have improved mechanical developed resin composites that are targeted as an
Jang, Park & Hwang: Bulk-Fill RBCs and Highly Filled Flowable Resin 3

alternative to composite restoration with the incre- Depth of Cure by Vickers Microhardness
mental layering technique, regarding their polymer- An opaque poly-acrylic mold (Dentsply Caulk), 4 mm
ization behavior and DOC. The following null long with an internal diameter of 4 mm, was used to
hypotheses were evaluated: 1) There would be no prepare the composite specimens. The mold was
differences in polymerization shrinkage behavior placed on a glass slide covered with a Mylar strip,
(including shrinkage strain/stress) between bulk-fill then the composite was filled in bulk for each
composites and conventional composites; and 2) material. The upper surface of the mold was filled
there would be no differences in DOC between tested with composite and was covered with a Mylar strip,
resin composites. followed by a glass slide. Then, the specimen was
polymerized for 20 seconds, keeping the tip of the
METHODS AND MATERIALS light-curing unit in contact with the 1.2-mm-thick
Six brands of resin composite materials were glass slide to ensure a constant distance from the
analyzed. The chemical composition and manufac- specimen. After polymerization, each specimen was
turers’ information about the materials are listed in removed from the mold. The specimens were stored
Table 1. in distilled water for 24 hours at room temperature.
Subsequently, the top and bottom surface hardness
Linear Polymerization Shrinkage of each 4-mm high specimen were measured using
Measurement the Vickers microhardness instrument (HMV-2,
Shimadzu, Kyoto, Japan). The measuring indenter,
The linear polymerization shrinkage of the compos-
the Vickers pyramid, was pressed to the composite
ite specimens was measured using a custom-made
specimen using a load of 4.903 N for five seconds.
linometer (R&B Inc, Daejeon, Korea). A fixed
The surface Vickers hardness (HV) was measured at
amount of composite was pressed between a glass
three points of each specimen to minimize measure-
slide and aluminum disk to produce specimens 1.5
ment errors within a specimen. The DOC, usually
mm in thickness and 4.5 mm in diameter. The tip of
acknowledged as the thickness of the composite that
the linear variable differentiated transducer (LVDT)
is adequately polymerized or rather as the depth
sensor (R&B Inc) was placed on the center of the where HV equals the surface value multiplied by an
glass slide with constant pressure and was set to the arbitrary ratio, usually 0.8 (HV-80%), was calculat-
zero point. The light-curing unit was positioned on ed.21,22 Therefore, each specimen HV of the lower
the custom-made light-curing unit station to ensure surface was compared with the upper surface value
a constant 2-mm distance from the glass slide. An and was noted when it dropped below HV-80%.
LED light-curing unit (Bluephase, Ivoclar Vivadent)
was used at a light intensity of 700 mW/cm2. The
Statistical Analysis
specimen was then polymerized for 40 seconds.
During the light curing, the displacement distance The results of the present study were analyzed by
of the disk was measured every 0.5 seconds for 120 using SAS 9.2 (SAS Inc, Cary, NC, USA). A one-way
seconds; the displacement was caused by the linear analysis of variance was applied to examine the
shrinkage of the composite material. significance of the differences in polymerization
shrinkage strain occurring in 120 seconds and stress
Polymerization Shrinkage Stress in 180 seconds. Pearson correlation analysis was
Measurement used to compare the correlation between polymeri-
zation shrinkage strain and stress. The differences
The polymerization shrinkage stress of the compos- in microhardness between the top and bottom
ite specimens was measured using a custom-made surfaces within each material were compared using
device (R&B Inc). To do so, 0.3g of the composite was paired t-tests. Scheffé and Bonferroni comparison
carried to the acrylic disk of the measuring device. tests were used to isolate statistical significance at
The steel rod of the device was positioned 1 mm the 95% confidence level.
above the acrylic disk to ensure a constant thickness
of the specimen. The specimen was then polymerized RESULTS
for 40 seconds. As it was light cured toward the light
source, the polymerization shrinkage stress of the Linear Polymerization Shrinkage
composite specimen was measured by a load cell Measurement
connected to the metal rod and computer. The data The patterns of linear polymerization shrinkage of
were recorded every 0.5 seconds for 180 seconds. the six composite materials after photo-initiation are
4 Operative Dentistry

Table 1: Materials, Manufacturers, and Chemical Composition of Matrix and Filler

Product (Code) Type Manufacturer, Batch No. Matrix System
Tetric N-Flow (TF) Flowable Ivoclar Vivadent, Schaan, Liechtenstein Bis-GMA, UDMA, TEGDMA
N03326
SDR (SDR) Bulk-fill flowable Dentsply Caulk, Milford, DE, USA Modified UDMA, EBPDMA, TEGDMA
100831
Venus Bulk Fill (VBF) Bulk-fill flowable Heraeus Kulzer GmbH, Hanau, UDMA, EBPDMA, TEGDMA
Germany 010100
G-aenial Universal Flo (GUF) High-viscosity flowable GC Co., Milford, DE, USA 1108032 UDMA, Bis-MEPP, TEGDMA
Filtek Supreme Ultra (FS) Nano-composite 3M ESPE, St Paul, MN, USA N367463 Bis-PMA, DUDMA, Bis-GMA, TEGDMA
(nonflowable)
Tetric N-Ceram Bulk Fill (TBF) High-viscosity bulk-fill Ivoclar Vivadent, Schaan, Liechtenstein Bis-GMA, DMA
composite (nonflowable) R52452
Abbreviations: Bis-GMA, bisphenol-A diglycidyl ether dimethacrylate; Bis-MEPP, 2,2-Bis (4-methacryloxypolyethoxyphenyl) propane; DUDMA, diurethane
dimethacrylate; EBPDMA, ethoxylated bisphenol-A dimethacrylate; TEGDMA, triethylene glycol dimethacrylate; UDMA, urethane dimethacrylate.
a
Prepolymer includes monomer, glass filler and ytterbium fluoride.
Note: Material information as supplied by manufacturer.

presented in Figure 1. The amount of polymerization age stress for each test group are summarized in
shrinkage of the composite specimens after photo- Table 2.
initiation decreased in the following order: Groups
TF and GUF . VBF . SDR . FS and TBF (p,0.05). Depth of Cure by Vickers Microhardness
In all groups, the shrinkage graph curve was steep in The statistical analysis of HV on the top and the
the first 20 seconds, which coincides with the bottom surfaces and the bottom-to-top ratio for each
polymerization time, followed by a gradual increase. test group are presented in Table 3. All of the
composites except VBF showed significantly lower
Polymerization Shrinkage Stress HV values for the bottom compared with the top
Measurement surface (p,0.05). Among the bulk-fill composites,
The patterns of shrinkage stress of the six composite the bottom surface HV of SDR and VBF, which were
materials after photo-initiation are shown in Figure the bulk-fill flowables, exceeded HV-80%. However,
TBF and GUF, which were bulk-fill nonflowable and
2. The polymerization shrinkage stress of six
highly filled flowable, respectively, failed to reach
composite groups decreased in the following order:
HV-80%.
Groups GUF . TF and VBF . SDR . FS and TBF
(p,0.05).
DISCUSSION
Pearson correlation analysis showed that with
In the current study, the polymerization shrinkage
respect to the shrinkage strain, shrinkage stress
behavior and mechanical properties of recently
correlated significantly (r=0.890). The mean amount
introduced resin composites including highly filled
of linear shrinkage and the polymerization shrink- flowables, bulk-fill flowables, and bulk-fill nonflow-

Figure 1. Comparison of the linear polymerization shrinkage, Figure 2. Comparison of the polymerization shrinkage stress,
average curves (n=8). average curves (n=8).
Jang, Park & Hwang: Bulk-Fill RBCs and Highly Filled Flowable Resin 5

Table 1: Extended.
Filler System Filler Load (wt%/vol%) Flexural Modulus (GPa)
Barium glass, ytterbium fluoride, and silica 63.8/43 5.3

Barium aluminofluoride borosilicate glass 68/44 5.0

Barium aluminofluoride borosilicate glass, ytterbium fluoride, and silica 65/38 3.6

Silica, strontium glass 69/50 7.95

Zirconia/silica 78.5/63.3 11

Barium alumino silicate glass, prepolymer fillera 80 (including 17% prepolymers)/60 4.5

able composite were investigated and compared with lm (Table 2), although its shrinkage was greater
conventional resin composites. than that of the two nonflowable composites. This
The flowable composites SDR and VBF, which are might be attributed to the modified polymer chains
intended to bulk-fill, showed lower polymerization of the bulk-fill flowables, which are very flexible in
shrinkage than the conventional flowable composite. the pregelation phase.24 This highly stress-relieving
The nonflowable composites, TBF and FS, presented internal monomer might delay the gel point, which
no significant differences in polymerization shrink- could allow more time to compensate for the
age (Figures 1 and 2). Thus, the first null hypothesis shrinkage; consequently, polymerization shrinkage
was partially rejected. would be reduced.18,19

The two nonflowable composites (TBF and FS) Polymerization shrinkage induces shrinkage
showed significantly lower linear polymerization stress during the curing of the resin composites. In
shrinkage compared with the flowable composites our study, a strong correlation was observed between
(Figure 1). In general, the flowable composite had a the shrinkage strain and stress (Table 2). The
lower inorganic filler content and higher volume of magnitude of the polymerization shrinkage stress
has been found to be dependent on volumetric
resin matrix as compared with the nonflowable
polymerization shrinkage and polymer elastic mod-
composite, and it usually exhibited a greater amount
ulus,9,25 whereas polymerization shrinkage is relat-
of polymerization shrinkage.23 The flowable compos-
ed to the degree of conversion and initial reactive
ites intended for bulk filling (SDR and VBF) showed
group concentration.4,26 Generally, increasing the
lower linear shrinkage than the conventional flow-
filler load in the resin matrix results in reduction of
able composite (TF) (Figure 1). SDR exhibited the
overall shrinkage of the composite due to the
least linear polymerization shrinkage in the tested
reduced availability of the monomer for the curing
flowables for 120 seconds, with an average of 25.36
reaction. But it also may result in a high elastic

Table 2. Mean (Standard Deviation) Amount of Linear

Shrinkage and Polymerization Shrinkage Stress Table 3. Comparison of Vickers Surface Hardness (HV)
for Each Test Group (n=8) of Top and 4-mm Bottom, as well as Depth of
Cure (HV-80%), for Each Test Group (n=8)
Material Linear Shrinkage (lm) Shrinkage Stress (kgf)
Material Top 4-mm Bottom Bottom-to-Top
TF 35.75 (2.71)Aa 4.02 (0.37)A Ratio
SDR 25.36 (1.49)B 3.08 (0.16)B TF 35.36 (4.62)A 26.36 (6.90)B 0.74
VBF 32.14 (1.75)C 4.34 (0.35)A SDR 32.14 (1.42)A 30.28 (1.73)B 0.94
GUF 38.38 (1.28)A 5.59 (0.41)C VBF 30.55 (1.17)A 29.95 (1.16)A 0.98
FS 11.13 (1.15)D 2.48 (0.15)D GUF 48.54 (5.39)A 23.75 (1.51)B 0.49
TBF 11.57 (1.48)D 2.09 (0.20)D FS 87.30 (6.41)A 67.21 (4.96)B 0.77
Abbreviations: FS, Filtek Supreme Ultra; GUF, G-aenial Universal Flo; TBF,
Tetric N-Ceram Bulk Fill; TF, Tetric N-Flow; VBF, Venus Bulk Fill. TBF 49.05 (3.82)A 37.83 (5.73)B 0.77
a a
The measured linear shrinkage and the shrinkage stress were within 120 The samples were light polymerized for 20 seconds and stored for 24
and 180 seconds, respectively. Different small cap letters indicate hours at room temperature in distilled water. HV is detailed in mean and
statistically differences between the groups (p,0.05). The Pearson standard deviations. Different small cap letters indicate statistically
correlation coefficient between shrinkage strain 3 stress was 0.890 differences between the top and 4-mm-depth bottom HV (p,0.05). A ratio of
(r=0.890, p=0.000). bottom-to-top surface microhardness over 0.80 indicates adequate DOC.
6 Operative Dentistry

modulus of the material, which can lead to high The favorable DOC results of SDR and VBF might
shrinkage stress.14,27 The present results of the be attributed to the translucent matrix being highly
shrinkage stress test showed an inverse relationship conducible to light transmission and the incorpora-
between the filler load and flexural modulus (Table tion of a functional photoactive group in the
1). Concerning the polymerization shrinkage stress, methacrylate matrix.33 Previous studies19,34 report-
which relies on the volumetric shrinkage and elastic ed that bulk-fill flowables exhibited large filler size
modulus, the order of the stress value of our study with dominant polygonally shaped features com-
was similar to the order of the estimated shrinkage pared with conventional flowable resin composites,
strain value multiplied by each material’s flexural as seen with a scanning electron microscope. The
modulus. These results coincide with those of a filler load was slightly increased, but the filler-
previous study, which hypothesized that a relevant matrix interface was assumed to be decreased, due to
influence of the material’s stiffness on stress devel- the bigger size of the filler particle. Hence, it allows
opment was present.28 more curing light to transmit through the composite
and improve the DOC.
Of the flowable composites, SDR showed the least
polymerization shrinkage stress, although it has a TBF, a bulk-fill nonflowable composite, also
relatively high filler load and elastic modulus (Table contains a translucent filler and matrix that allow
1). The modified matrix containing the shrinkage the light to pass through the material. 29 In
modulator might incorporate it to control the addition, it includes Ivocerin (Ivoclar Vivadent),
polymerization kinetics. Among the tested bulk-fill which is described as a germanium-based photo-
materials, TBF, which is a bulk-fill nonflowable initiator. According to the manufacturer, Ivocerin
composite, showed the least polymerization shrink- has a higher photo-curing activity than camphor-
age stress. Several factors might have affected the quinone, due to its higher absorption in the region
results. First, this material contained a shrinkage between 400 and 450 nm.35,36 Furthermore, it can
stress reliever, which is a special filler functionalized be used without the addition of an amine as
with silane.29 The manufacturer stated that the coinitiator and forms at least two radicals able to
shrinkage stress reliever features a lower modulus of initiate the radical polymerization; thus, it is more
elasticity so that it acts like a microscopic spring, efficient than camphorquinone/amine systems with
attenuating the forces generated during shrinkage.29 only one radical having that capability.36,37 How-
Second, the material included prepolymerized fillers. ever, in our study, TBF presented no difference in
Resin composites typically show a relatively low the HV value of the bottom-to-top ratio compared
elastic modulus with the use of prepolymerized filler with the conventional nonflowable composite, FS
particles.30 (Table 3). A recent study7 was consistent with our
result; it investigated the DOC of several resin
Microhardness has been suggested as a way to composites including TBF using the ISO 4049
examine the DOC of photo-activated resin composite. method and 80%-HV depth method. The author
According to Bouschlicher,31 a value over 0.80 in reported that the TBF specimens showed a low
bottom-to-top surface microhardness indicates ade- DOC, calculated from the bottom-to-top surface
quate DOC. The HV values are highly dependent on microhardness; this might have resulted in the
the size, weight, and volume of the filler particles as hardness of TBF, which dropped drastically after
well as on the chemical composition of the composite the measurement of the superficial surface (0.1
when the test instrument produces larger indenta- mm).
tions than the size of the filler.32 Consequently, the
Although the bulk-fill flowables, SDR and VBF,
HV values in our study present the average micro-
are indicated for restoration in bulk up to a 4 mm
hardness of the fillers and matrix, and for this
thickness, the manufacturers commonly recom-
reason, the HV value should not be considered a
mend that these materials be covered with a 2-
mechanical property and should be compared only
mm-thick capping layer by using conventional
within the same material.
nonflowable composites.24,37 This step is mandatory
In our study, the bottom surface HV values of SDR not only for reinforcing the surface hardness but
and VBF, which are bulk-fill flowables, exceeded also for preventing subsequent water sorption of the
HV-80%. The HV values of the bottom-to-top ratio of composite material. Recent research indicated that
TBF, a bulk-fill nonflowable, and GUF, a highly the composites intended for bulk fill, including SDR
filled flowable, were less than 0.80 (Table 3). Thus, and VBF, are more susceptible to water deteriora-
the second null hypothesis was partially rejected. tion in comparison with conventional composites,
Jang, Park & Hwang: Bulk-Fill RBCs and Highly Filled Flowable Resin 7

causing creeping deformation of the composites.38 Despite the limitations of this study, bulk-fill
SDR and VBF commonly incorporate UDMA in- flowables (SDR and VBF) were properly cured in 4-
stead of bisphenol A-glycidyl methacrylate (Bis- mm increments, but they showed more shrinkage
GMA), and the matrix contents are increased to than conventional nonflowable composite. The bulk-
control the consistency.18 A high-content UDMA fill nonflowable (TBF) showed comparable shrinkage
matrix exhibits low viscosity that contributes to the to that of conventional nonflowable composite, but it
void-free bulk-fill restoration. Yet it is also known was not sufficiently cured in 4-mm increments. The
as a high water-sorptive composite matrix com- highly filled flowable (GUF) revealed, due to its
pared with Bis-GMA or triethyleneglycol-dimetha- polymerization shrinkage and DOC, its limitation as
crylate (TEGDMA).39 The absorbed moisture may an alternative to conventional nonflowable compos-
expand the matrix and induce crazing and hygro- ite. Further study of real restorations and long-term
scopic expansion; it could elute the residual mono- clinical evaluation are required for final evaluation
mers, resulting in dimensional change of the of the suggested results.
composite restoration, and weaken the mechanical
properties.40,41 Furthermore, the results of the Acknowledgements
present study showed that the polymerization Sincere thanks to Professor Dr. Kyoung-Kyu Choi and Sang
shrinkage of bulk-fill flowables was higher than Hyuk Park, professor, Department of Conservative Dentistry,
that of the conventional nonflowable composite. Kyung-Hee University, for their valuable advice regarding
analysis of the results. The dental companies Dentsply, GC,
Considering these limitations, their use as the first Heraeus, 3M ESPE, and Ivoclar Vivadent are gratefully
increment in Class II restorations as a dentin and acknowledged for their generous donation of materials for
proximal enamel replacement might result in this study.
poorer physical properties than restoration with a
conventional composite. To minimize the configu- Conflict of Interest
ration factor and restorative water sorption, the The authors have no proprietary, financial, or other personal
interest of any nature or kind in any product, service, and/or
inner core of the cavity should be filled with a bulk- company that is presented in this article.
fill flowable first, and the placement of the conven-
tional nonflowable composite on the outer capping (Accepted 31 March 2014)
layer would result in better restorative integrity in
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