Bond Strength of a Flowable Bulk-fill Resin Composite

in Class II MOD Cavities

Rose Yakushijin Kumagai3 / Leonardo Colombo Zeidanb / Jose Augusto Rodrigues0 /
Andre Figueiredo Reisd / Jean-Frangois Roulete

Purpose: To evaluate the microtensile bond strength (pTBS) of a bulk-fill low-stress resin-based composite to
dentin from gingival walls of Class II MOD cavities.
Materials and Methods: Class II MOD cavities were prepared in 44 human molars with the distal and mesial
proximal boxes 4 and 6 mm deep, respectively. Eight experimental groups (n = 11) were obtained by a factorial
design including 1. “ com posite” in two levels: a bulk-fill low-stress composite (SureFil SDR Flow, Dentsply Caulk)
and a conventional composite (Filtek Z350 XT, 3M ESPE); 2. “filling technique” in two levels: bulk-fill (Bf) and
incremental (In); and 3. “ depth” in two levels: 4 mm and 6 mm in order to create different polymerization condi­
tions. Twenty-four hours after placement of restorations, teeth were sectioned into beams with a cross-sectional
bonded area of approximately 1 mm2. Bonded beams obtained from the gingival walls of the proximal boxes
were tested in tension at a crosshead speed of 1 m m /m in. Data were submitted to a 3-way ANOVA followed by a
post-hoc Tukey’s te st (p < 0.05).
Results: ANOVA failed to identify significant differences for the triple and double interaction between factors.
However, significant differences were observed for the factors “ com posite” and “filling technique” (p < 0 .0 5 ).
SDR presented significantly higher pTBS values for bulk and incremental filling techniques (p < 0.05), and the
incremental filling technique presented significantly higher pTBS values for both composites (p < 0.05).
Conclusion: It can be concluded that the bulk-fill flowable composite SDR may improve the bond strength to the
gingival walls of Class II MOD cavities.
Keywords: tensile strength, bulk-fill composite, filling technique.

J Adhes Dent 2015; 17: 427-432. Submitted for publication: 26.02.15; accepted for publication: 11.08.15
doi: 10.3290/j.jad.a35012

uring photopolymerization, monomers form a poly­ shrinkage stress and obtain optim al outcomes, com­
D mer network and resin-based composites become
solid and sh rin k.30’34 Shrinkage m an ifests its e lf as
posites need to be placed in increments of 2 mm.17’32
The incremental layering technique promotes a smaller
stress at the bonded cavity walls, which may develop ratio of the areas of bonded to unbonded composite
interfacial defects, enamel fractures, cuspal movements, resin layer, achieving a lower C-factor during polymer­
and microcracks.9’21'30 In order to reduce polymerization ization of each layer.8’17’21 In addition, an increment
thickness < 2 mm provides sufficient light penetration for
polymerization, resulting in enhanced physical and me­
a MSc Student, Dental Research and Graduate Studies Division, Department of
Restorative Dentistry, Guarulhos University, Guarulhos, SP, Brazil. Performed chanical properties, with improved marginal adaptation.
the experiments in partial fulfillment of requirements for a MSc degree. A high degree of conversion of the composite resin also
» Assisant Professor, Dental Research and Graduate Studies Division, Depart­ contributes to decreased cytotoxicity.21’23
ment of Restorative Dentistry, Guarulhos University, Guarulhos, SP, Brazil. However, the incremental technique has disadvantages,
Performed part of the experiments.
including the increased risk of incorporating voids or con­
c Adjunct Professor, Dental Research and Graduate Studies Division, Depart­ tamination between composite layers, resulting in possible
ment o f Restorative Dentistry, Guarulhos University, Guarulhos, SP, Brazil.
Performed the experiments, proofread the manuscript, performed statistical bond failures between increments. In addition, the clinician
evaluation and contributed substantially to discussion. can find placement difficult because of limited access in
d Adjunct Professor, Dental Research and Graduate Studies Division, Depart­ conservative preparations. The increased time required to
ment of Restorative Dentistry, Guarulhos University, Guarulhos, SP, Brazil. place and polymerize each layer is longer than in the bulk­
Hypothesis, performed the experiments, proofread the manuscript.
filling technique.1’7’17'26’30 Clinicians still desire easier and
e Professor, Department of Restorative Dental Sciences, College of Dentistry,
quicker composite restorations with less shrinkage.15
University of Florida, Gainesville, FL, USA. Hypothesis, experimental design,
proofread the manuscript, and contributed substantially to discussion. New materials with modified chemical compositions to
reduce polymerization shrinkage stress, marketed for bulk
Correspondence: Jose Augusto Rodrigues, CEPPE, Universidade Guarulhos application in direct resin composite restorations, have
- UnG, Prapa Tereza Cristina, 229 Guarulhos, SP, CEP 07023-070 Brazil.
Tel/Fax: +55-11-2464-1758. e-mail: [email protected] been recently introduced.33’36 These bulk-fill composites

Vol 17, No 5, 2015 427

 Kumagai et al

Fig 1 Schem atic represen­

ta tio n of cavity preparation,
resin-based com posite (RBC)
restoration, and area of the gin­
gival wall in the proximal box of
the Class II cavity used for the
pTBS evaluation.

are designed to be placed in layers measuring 4 or 5 mm MATERIALS AND METHODS

in thickness and to be cured in one single step.543,28 y\s a
further advantage, they can be applied more quickly, thus The study protocol was approved by the Guarulhos
saving chair time.23'35 University Research Ethics Committee (# 641.271).
The first bulk-fill composite was SureFil SDR Flow The present study was designed to evaluate the bond
(SDR), and as a low-viscosity material, it has shown strength to cervical dentin of a bulk-fill flowable compos­
shrinkage stresses lower than conventional flowables, ite in a large tooth cavity (Fig 1) where the contraction
nano- and microhybrid as well as silorane-based compos­ stress associated with polymerization of resin composite
ites.4-6'14'28 In addition to decreased shrinkage stress, may be high. Forty-four molars received a Class II MOD
adequate polymerization has been reported in 4 mm in­ cavity preparation with 4 or 6 mm of depth in the distal
crements,15-18 in contrast to conventional composites, and mesial proximal boxes, respectively. Eight experi­
that are recommended to be applied in increments of mental groups with 11 samples each were obtained by
2 mm.19 However, few studies have evaluated this bulk- a factorial design. The factors under study were (Table
fill low-viscosity composite performance so far.30-31 A 1): “composite” in two levels, bulk-fill flowable (SDR) and
few years ago, concerns about the mechanical stability in conventional nanohybrid composite (Z350); “filling tech­
stress-bearing areas of restorations made with conven­ nique” in two levels, bulk-filling and incremental filling;
tional composites placed in bulk, absence of long-term and “cavity depth" in two levels, 4 mm or 6 mm.
clinical studies, and the lack of suitable bulk-filling ma­
terials discouraged most clinicians from implementing Cavity Preparation
these techniques.5-7 Non-carious third molars extracted for therapeutic rea­
Adhesion tests with clinically relevant cavities are im­ sons were stored in thymol solution and debrided of
portant, because the light intensity that reaches the cav­ residual plaque and calculus. The roots were removed
ity bottom can be reduced in comparison to restorations with double-faced diamond disks (#7020, KG Sorensen;
made on flat dentin surfaces.29 A decrease in the degree Barueri, SP, Brazil), then the pulp chambers were cleaned
of conversion as well as an increase in increment thick­ and filled with Clearfil SE Bond (Kuraray; Osaka, Japan)
ness have both been shown to negatively affect bond adhesive system and Filtek Z350 XT (3M ESPE; St Paul,
strength of composites restorations to dentin.24'29-35 In MN, USA) following manufacturers’ recommendations.
addition, the effects of bulk filling of high C-factor poster­ Standardized Class II MOD cavities were prepared us­
ior cavities on adhesion to cavity-bottom dentin may have ing a diamond bur (#3101G, KG Sorensen) in a high­
a great impact on the adhesion of composite systems.32 speed handpiece with air-water spray. The cavity dimen­
The aim of this study was to evaluate the microtensile sions were: 4 mm width bucco-lingually, 3 mm depth in
bond strength (pTBS) of a bulk-fill flowable composite to the oclusal box, and 4 mm depth in the distal and 6 mm
the gingival walls of standardized Class II MOD cavities, as depth in the mesial proximal box (Fig 1). After preparation,
compared to a conventional nanohybrid composite placed the cavities were evaluated using a stereomicroscope at
incrementally or in bulk. The null hypotheses to be tested 40X magnification (PanTec, Panambra Ind. e Tecnica; Sao
were: (1) there is no difference in the bond strength pro­ Paulo, Brazil) to check for any defects. Teeth that pre­
duced by a conventional and a bulk-fill composite; (2) there sented cavities with pulp exposure or enamel margins in
is no difference in the filling technique, incremental or bulk; the cervical walls were excluded and replaced by another
and (3) the cavity depth, 4 or 6 mm, does not influence tooth. Teeth were randomly assigned to the eight experi­
pTBS. mental groups and restored.

428 The Journal of Adhesive Dentistry

 Kumagai et al

Table 1 Experimental groups obtained by a factorial design

Group n Composite type Product name Filling technique Box depth

G1 ii Bulk-fill flowable SDR Bulk-fill 4 mm

G2 i i Bulk-fill flowable SDR Bulk-fill 6 mm

G3 ii Conventional Z350 Bulk-fill 4 mm

G4 i i Conventional Z350 Bulk-fill 6 mm

G5 ii Bulk-fill flowable SDR Incremental 4 mm

G6 i i Bulk-fill flowable SDR Incremental 6 mm

G7 ii Conventional Z350 Incremental 4 mm

G8 i i Conventional Z350 Incremental 6 mm

SDR: SureFil SDR Flow; Z350: Filtek Z350 XT.

Restorative Procedure in order to obtain at least 3 beams with a cross-sec­

A metal matrix band was placed around the tooth using tional bonded area of approximately 1 mm2 at the gin­
a Tofflemire retainer. All cavities were restored with gival wall (IsoMet 1000; Buehler; Lake Bluff, IL, USA).
the same two-step etch-and-rinse adhesive system (XP Beams were tested in tension in a Universal Testing Ma­
Bond, Dentsply DeTrey; Konstanz, Germany) applied chine (EZ Test, Shimadzu; Kyoto, Japan) at a crosshead
according to the manufacturer’s instructions. All cavity speed of 1 mm/min until fracture. The cross-sectional
preparations were etched with 36% phosphoric acid area of each specimen was measured using a digital
(DeTrey Conditioner 36) for 15 s, washed for 15 s, caliper (Mitutoyo; Tokyo, Japan), and the microtensile
and gently dried with absorption paper. The adhesive bond strength was expressed in MPa.
XP Bond (Dentsply DeTrey) was dispensed onto a dis­ Failure mode was recorded using a light microscope
posable brush and applied to the cavity for 20 s. The at 50X magnification (PanTec, Panambra Ind e Tecnica).
solvent was evaporated for at least 5 s and photo- Failure mode at the fractured interface was classified into
activated for 10 s using an LED device (Radii Plus, SDI; 1 of 3 types: CD (cohesive failure in dentin), AD (adhesive
Bayswater, Victoria, Australia) with an average power failure between hybrid layer and dentin), and CC (cohesive
output of 1850 mW/cm2, periodically monitored with failure in composite resin). Instead of classifying failures
a curing-light meter (CureRite, Dentsply Caulk; Milford, as mixed, the area percentage of each type of failure in
DE, USA). each specimen was recorded.16
The cavities were filled with the tested composites:
the bulk-fill flowable composite SDR (SureFil SDR Flow, Statistical Analysis
shade U, Dentsply Caulk) or the conventional composite The Shapiro-Wilk test was applied to test for normality
Z350 (Filtek Z350 XT, shade A3E, 3M ESPE) according to (p = 0.263). Since data showed normal distribution, a
the groups. With the bulk-fill technique, composites were three-way ANOVA considering the factors “composite” ,
inserted in a 3-mm layer in the 4-mm box, in a 5-mm layer “filling technique” , and “depth” followed by a post-hoc
in the 6-mm box, and a 2-mm-thick layer in the occlusal Tukey’s test at a pre-set a of 5% were applied using
box (Fig 1). Composites were photo-activated for 20 s statistical software (IBM SPSS version 20.0.0, IBM;
(LED, Radii Plus, SDI), and because Surefil SDR flow Armonk, NY, USA). Pre-test failures were not included in
needs conventional composite coverage, a 1-mm final the statistical analysis.22
occlusal layer of the conventional composite (Filtek Z350
XT) was applied and polymerized for 20 s for all groups
(Fig 1). In the incremental technique groups, both 4-mm RESULTS
and 6-mm boxes were filled in increments of less than
2-mm thickness. The 4-mm box received 2 increments, The mean pTBS values are presented in Table 3. Three-
the 6-mm box 3 increments, and the occlusal box one in­ way ANOVA revealed significant differences for the
crement, followed by 1 mm thickness of the conventional factor “composite” (p < 0 .0 5 ) and for the factor “filling
composite for all groups. The teeth were stored for 24 h technique” (p < 0.05). However, no significant difference
in 100% relative humidity at 37°C. was detected for the factor "depth” (p = 0.684). In ad­
dition, 3-way ANOVA failed to identify significant differ­
Microtensile Bond Strength ences for the double interactions (p > 0.05) and for the
The proximal boxes of specimens were serially sec­ triple interaction “composite x filling technique x depth”
tioned in the buccal/lingual and mesial/distal directions (p = 0.914).

Vol 17, No 5, 2015 429

Kumagai et a I

Table 2 Materials and their components, manufacturers, and batch numbers used in this study

Material (manufacturer), Components

batch number

XP Bond (Dentsply DeTrey; Kon­ Carboxylic acid modified dimethacrylate (TCB resin), PENTA, UDMA, TEG-DMA, HEMA, butylated ben-
stanz, Germany) zenediol (stabilizer), ethyl-4- dimethylaminobenzoate, camphorquinone, functionalized amorphous
1311000750 silica, t-butanol
Filtek Z 350 XT, shade AE3 (3M Bis-GMA, UDMA, TEG-DMA, bis-EMA, silica filler, zirconia filler, zirconia/silica cluster fille r
ESPE; St Paul, MN, USA)
9 0 2 4 9 7 /9 8 4 5 2 1

SureFill SDR, shade U (Dentsply Barium-alumino-fluoro-borosilicate glass, strontium alumino-fluoro-silicate glass, m odified urethane
DeTrey; Konstanz, Germany) dimethacrylate resin, EBPADMA, triethyleneglycol dimethacrylate, camphorquinone, butylated hy­
785648F droxyl toluene, UV stabilizer, titanium oxide, iron oxide pigments
DeTrey Conditioner 36 (Dentsply 36% phosphoric acid, silica
DeTrey; Konstanz, Germany)
7523

Abbreviations: bis-GMA: bisphenol-glycidyl methacrylate; HEMA: 2-hydroxyethyl methacrylate; DMA: dimethacrylate; GPDM: glycerol phosphate dimethacrylate; UDMA:
Urethane dimethacrylate; PENTA: phosphonated penta-acrylate ester; EBPADMA, ethoxylated bisphenol-A dimethacrylate; TEG-DMA, triethylene glycol dimethacrylate.

Table 3 Mean bond strength values in MPa for the different composite resins applied with different filling tech­
niques in 4- and 6-mm-deep cavities

Composite Depth Filling technique

Bulk filling (no. of beams/pre-test failures) Incremental (no. of beams/pre-test failures)

Bulk-fill flowable SDR 4 mm 5 0 .8 ± 2 2 .7 Ab (3 3 /3 ) 56 .3 ± 1 1 .6 Aa (3 3 /6 )
6 mm 4 9 .8 ± 9 .8 Ab (3 3 /9 ) 6 3 .9 ± 8 .6 Aa (3 3 /4 )
Conventional Z350 4 mm 3 2 .5 + 1 2 .9 Bb (3 3 /1 1 ) 4 0 .3 ± 1 4 .7 Ba (3 3 /7 )
6 mm 2 7 .2 ± 1 1 .5 Bb (3 3 /2 2 ) 4 3 .6 ± 2 0 .1 Ba (3 3 /9 )
Means followed by different superscript letters (upper case: column; lower case: row) are significantly different according to Tukey's test at the 95% confidence level.

No significant difference was observed between the 4- presented significantly higher bond strength values than
and 6-mm-deep proximal boxes, independent of the com­ the bulk-filling technique, for both the conventional and
posite and filling technique used (p > 0.05). The bulk-fill the bulk-fill composites.
flowable composite SDR presented higher bond strength The use of a bulk-fill flowable composite in deep, wide
values than did the conventional composite Z350 for dental cavities is faster and easier than traditional in­
both bulk and incremental filling techniques (p < 0 .0 5 ). cremental restoration, it also saves tim e and improves
In addition, independent of the composite resin used, material handling and adaptation.3-5 Cavity depth did not
the incremental filling technique produced significantly influence bond strength values of either composite inde­
higher bond strength values than did the bulk-filling tech­ pendent of the filling technique, which led to acceptance
nique (p < 0.05). Descriptive data of failure mode analysis of the third null hypothesis. The bulk-fill flowable SDR
(Fig 2) showed a higher percentage of adhesive failures showed significantly higher bond strength values than
between composite and dentin for all groups. did the conventional composite Z350 in the Class II MOD
preparation with deep proximal boxes, even with the 5-mm
bulk-filling insertion technique. These results are in agree­
DISCUSSION ment with Flury et al,11 who observed that shear bond
strength remained constant for SDR with increasing layer
The incremental layering technique has been recognized thickness up to 6 mm, while the microhardness and shear
as standard procedure in direct posterior com posite bond strength of the conventional resin composite (Filtek
restorations to reduce polymerization shrinkage stress Supreme XTE) decreased with increasing layer thickness.
and achieve an adequate degree of monomer conver­ SDR hardness values corresponded with those obtained
s io n .21'31 However, the bulk-fill flow able com posite using three distinct increment thicknesses of a conven­
SDR showed higher bond strength values than the tional composite resin.11
conventional composite Z350. Thus, the firs t null hy­ The rate of the polymerization reaction has also been
pothesis was rejected. The second null hypothesis was shown to modulate stress, since a slower cure would al­
also rejected, because the incremental filling technique low viscous flow a nd /or chain relaxation, accommodating

430 The Journal of Adhesive Dentistry

 Kumagai et al

, .
6 mm Filtek Z350 XT
Incremental
6 mm Filtek Z350 XT "
Bulk
6 mm SDR Incremental
-
6 mm SDR Bulk
4 mm Filtek Z350 XT
Incremental
4 mm Filtek Z350 XT
Bulk

6 mm SDR Incremental

6 mm SDR Bulk

)% 20% 40% 60% 80% 10 3%

Fig 2 Failure mode distribution ■ Adhesive ■ Cohesive in composite ■ Cohesive in dent n

in the experimental groups (%).

part of the shrinkage and reducing stress.6 SDR presents been used, the light would probably not have been able to
a chromophore-mediated free-radical polymerization for a reach the bottom surface and bond strength would likely
slower curing process. The extended pre-gel phase allows be severely compromised. The theory that placing direct
unconstrained shrinkage while maintaining a low modulus restorations in multiple layers for conventional compos­
of elasticity, thus resulting in decreased polymerization ites is beneficial was confirmed in the present study.
stress within the developing composite matrix.27 It is cur­ The lower bond strength values observed in groups
rently accepted that composites with a high modulus of restored with the conventional composite Z350 applied
elasticity produce higher shrinkage stresses than do com­ in one bulk-fill increment are a result of the interaction of
posites with a low modulus of elasticity.9 There is also a factors, such as limited light penetration throughout the
current opinion that composite bulk placement is detri­ composite resin as function of depth, restricted by 20 s of
mental to the com posite/tooth interface.1 It seems that light curing and the configuration of the cavity walls. This
SDR counterbalances these two factors. The findings of might have affected the degree of conversion and thus ad­
the present investigation revealed that despite being bulk hesion. However, a lower degree of conversion is likely to
placed, the bond strength values obtained for SDR, either generate less contraction stress around the cavity walls.
bulk or incrementally placed, were significantly higher than The conventional composite Z350 presented significantly
those obtained for the conventional composite. lower bond strength values and a high number of pre-test
SDR is a very translucent composite, and standard light failures when the bulk placement technique was used.
energy densities used to cure conventional composites Thus, for Z350 conventional composite, the bulk-filling
are able to propagate throughout this material, promoting technique, which is not recommended by the manufac­
ideal polymerization in thicker increments.10'27 These prop­ turer, should not be encouraged.
erties were probably improved in the incremental-insertion Nevertheless, if the light is only partially able to reach
groups.10 SDR groups presented significantly higher bond the bottom surface, the conversion of monomers is incom­
strength values when the incremental technique was used plete while the polymerization shrinkage is building up in
in comparison with the bulk-filling technique. Jang et al15 the restoration. Notwithstanding, the low bond strength
showed a favorable degree of conversion at the bottom results observed for Z350 in the present study may be
surface of 4-mm-thick SDR samples, reaching 80% of the due to the combination of a lower degree of conversion
mean top surface hardness. Benetti et al3 observed that and less strain in the bonding area. This may explain lower
the depth of cure is generally improved for the bulk-fill bond strength for the bulk-filling technique than for multiple
material when compared with conventional resin compos­ increments. Several studies have found SDR to achieve an
ites. It has also been demonstrated that with increasing acceptable degree of conversion,2’3'11'15 and the mechan­
increment thickness, microhardness and bond strength ism of shrinkage stress reduction is related to chemically
decrease for the conventional composite, but generally modified polymer chains, which are very flexible in the pre­
remains constant for the bulk-fill resin com posites.11 gelation phase.26 The lower flexural modulus combined
Conventional composites are not intended for place­ with the slower contraction rate allowed the material to par­
ment in one bulk increment in deep cavities. The conven­ tially counteract the effect of polymerization contraction.14
tional composite used here was an enamel shade (AE3) of Optical coherence tomography studies showed that
Z350 XT - which is more translucent - to improve the light SDR performed better than the conventional composites,
propagation throughout conventional control groups. This with 20% less volumetric polymerization contraction than a
increased the chance of light to reach the bottom surface conventional composite in a micro computed-tomography
of 6- and 4-mm-deep fillings. If a body or dentin shade had analysis in Class I cavities.12'20 Jang et al15 observed that

Vol 17, No 5, 2015 431

Kumagai et al

SDR showed lower linear polymerization shrinkage and 14. llie N, Hickel R. Investigation on a methacrylate-based flowable com­
lower shrinkage stress than did a conventional flowable posite based on the SDRTM technology. Dent Mater 2011;27:348-355.
15. Jang JH, Park SH, Hwang IN. Polymerization shrinkage and depth of
composite. In addition, under fatigue testing, sim ilar mar­ cure of bulk-fill resin composites and highly filled flowable resin. Oper
ginal integrity was observed in MOD cavities restored with Dent 2015;40:172-180.
a 4-mm bulk increment of SDR and incremental layering of 16. Kasaz AC, Pena CE, de Alexandre RS, Viotti RG, Santana VB, Arrais CA,
a conventional composite.25-35 A long-term clinical study Giannini M, Reis AF. Effects of a peripheral enamel margin on the long­
term bond strength and nanoleakage of composite/dentin interfaces
demonstrated that the 4-mm bulk-filling technique with produced by self-adhesive and conventional resin cements. J Adhes
the flowable resin composite SDR showed good clinical Dent 2012;14:251-263.
performance, comparable at the 3-year follow-up with the 17. Lazarchik DA, Hammond BD, Sikes CL, Looney SW, Rueggeberg FA.
Hardness comparison of bulk-filled/transtooth and incremental-filled/oc-
2-mm resin composite incremental layering technique.30 clusally irradiated composite resins. J Prosthet Dent 2007;98:129-140.
Especially due to regional variability in the dentin sub­ 18. Moorthy A, Hogg CH, Dowling AH, Grufferty BF, Benetti AR, Fleming
strate, the microtensile bond strength te st can some­ GJ. Cuspal deflection and microleakage in premolar teeth restored
with bulk-fill flowable resin-based composite base materials. J Dent
tim es result in high standard deviation values. However, 2012:40500-505.
it is still the most commonly used te st for measuring the 19. Nayif MM, Nakajima M, Foxton RM, Tagami J. Bond strength and ulti­
performance of materials applied on human teeth in a mate tensile strength of resin composite filled into dentine cavity; effect
of bulk and incremental filling technique. J Dent 2008;36:228-234.
clinically relevant setup.22 Our results support previous
20. Nazari A, Sadr A, Shimada Y, Tagami J, Sumi Y. 3D assessment of void
findings that the flowable bulk-fill SDR seems to be ac­ and gap formation in flowable resin composites using optical coherence
ceptable for bulk application in increments thicker than tomography. J Adhes Dent 2013;15:237-243.
4 mm. However, further laboratory and long-term clinical 21. Park J, Chang J, Ferracane J, Lee IB. How should composite be layered
investigations with bulk-fill composites remain necessary. to reduce shrinkage stress: Incremental or bulk filling? Dent Mater
2008;24:1501-1505.
22. Pashley DH, Carvalho RM, Sano H, Nakajima M, Yoshiyama M, Shono
Y, Fernandes CA, Tay F. The microtensile bond test: a review. J Adhes
CONCLUSION Dent 1999;1:299-309.
23. Poskus LT, Placido E, Cardoso PE. Influence of placement techniques
on Vickers and Knoop hardness of class II composite resin restor­
Compared to a conventional nanohybrid composite, the ations. Dent Mater 2004;20:726-732.
bulk-fill flowable com posite SDR improves the bond 24. Price RB, Doyle G, Murphy D. Effects of composite thickness on the
strength at gingival walls of large Class II cavities. shear bond strength to dentin. J Can Dent Assoc 2000; 66:35-39.
25. Roggendorf MJ, Kramer N, Appelt A, Naumann M, Frankenberger R.
Marginal quality of flowable 4-mm base vs. conventionally layered resin
composite. J Dent 2011;39:643-647.
REFERENCES 26. Sarrett DC. Clinical challenges and the relevance of materials testing
for posterior composite restorations. Dent Mater 2005;21:9-20.
1. Abbas G, Fleming GJ, Harrington E. Shortall AC, Burke FJ. Cuspal move­
ment and microleakage in premolar teeth restored with a packable com­ 27. Scientific Compendium Surefil® SDR® flow 2011. http://www.surefils-
posite cured in bulk or in increments. J Dent 2003;31:437-444. drflow.com/sites/default/files/SureFil_TechnicaLManual.pdf
2. Alshali RZ, Silikas N, Satterthwaite JD. Degree of conversion of bulk-fill 28. Tiba A, Zeller GG, Estrich CG, Hong A. A laboratory evaluation of bulk-
fill versus traditional multi-increment-fill resin-based. J Am Dent Assoc
compared to conventional resin-composites at two time intervals. Dent
2013;144:1182-1183.
Mater 2013;29:e213-217.
29. Vandewalle KS, Roberts HW, Rueggeberg FA. Power distribution across
3. Benetti A, Havndrup-Pedersen C, Honore D, Pedersen M, Pallesen U.
Bulk-fill resin composites: polymerization contraction, depth of cure, the face of different light guides and its effect on composite surface
and gap formation. Oper Dent 2015;40:190-200. microhardness. J Esthet Restor Dent 2008;20:108-117.
30. van Dijken JW, Pallesen U. A randomized controlled three year evalu­
4. Burgess J, Cakir D. Comparative properties of low-shrinkage composite
ation of “ bulk-filled” posterior resin restorations based on stress de­
resins. Compend Contin Educ Dent 2010;31(special issue 2):10-15.
creasing resin technology. Dent Mater 2014;30:e245-251.
5. Czasch P, llie N. In vitro comparison of mechanical properties and degree
of cure of bulk fill composites. Clin Oral Investig 2013;17:227-235. 31. van Dijken JW, Pallesen U. Randomized 3-year clinical evaluation of Class
I and II posterior resin restorations placed with a bulk-fill resin composite
6. Davidson CL, de Gee AJ. Relaxation of polymerization contraction and a one-step self-etching adhesive. J Adhes Dent 2015;17:81-88.
stresses by flow in dental composites. J Dent Res 1984;63:146-148.
32. Van Ende A, De Munck J, Van Landuyt KL, Poitevin A, Peumans M, Van
7. El-Safty S, Silikas N, Watts DC. Creep deformation of restorative resin- Meerbeek B. Bulk-filling of high C-factor posterior cavities: effect on ad­
composites intended for bulk-fill placement. Dent Mater 2012;28:928-935. hesion to cavity-bottom dentin. Dent Mater 2013;29:269-277.
8. Feiizer AJ, De Gee AJ, Davidson CL. Setting stress in composite resin in 33. Van Ende A, Mine A, De Munck J, Poitevin A, Van Meerbeek B. Bonding of
relation to configuration of the restoration. J Dent Res 1987:66:1636- low-shrinking composites in high C-factor cavities. J Dent 2012;40:295-
1639. 303.
9. Ferracane JL. Developing a more complete understanding of stresses 34. Versluis A, Douglas WH, Cross M, Sakaguchi RL. Does an incremental
produced in dental com posites during polymerization. Dent Mater filling technique reduce polymerization shrinkage stresses? J Dent Res
2005;21:36-42. 1996;75:871-878.
10. Flury S, Hayoz S, Peutzfeldt A, Husler J, Lussi A. Depth of cure of resin 35. Xu X, Sandras DA, Burgess JO. Shear bond strength with increasing
composites: is the ISO 4049 method suitable for bulk fill materials? light-guide distance from dentin. J Esthet Restor Dent 2006;18:19-27.
Dent Mater 2012;28:521-528.
36. Zaruba M, Wegehaupt FJ, Attin T. Comparison between different flow
11. Flury S, Peutzfeldt A, Lussi A. Influence of increment thickness on application techniques: SDR vs flowable com posite. J Adhes Dent
microhardness and dentin bond strength of bulk fill resin composites. 2013;15:115-121.
Dent Mater 2014;30:1104-1112.
12. Hirata R, Clozza E, Giannini M, Farrokhmanesh E, Janal M, Tovar N,
Bonfante EA, Coelho PG. Shrinkage assessment of low shrinkage com­
posites using micro-computed tomography. J Biomed Mater Res B Appl
Biomater 2015;103:798-806. Clinical relevance: The bulk-fill flowable composite
13. llie N, Bucuta S, Draenert M. Bulk-fill resin based composites: An in vitro as­ may improve the bond strength in MOD cavities.
sessment of their mechanical performance. Oper Dent 2013;38:618-625.

432 The Journal of Adhesive Dentistry

Copyright of Journal of Adhesive Dentistry is the property of Quintessence Publishing
Company Inc. and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.