Bulk Fill Materials
CAPT S. Kooistra, DC, USN
DDS Indiana University School of Dentistry
MS University of Michigan School of Dentistry
Councilor Academy of Operative Dentistry
Councilor American Board of Operative Dentistry
Editorial Review Board – Operative Dentistry Journal
CAPT Scott Kooistra, DC, USN
Chairman, Operative Dentistry - NPDS
BUMED Specialty Leader for Operative Dentistry
Comm: 301-319-4687 DSN: 285-4687
BULK FILL Materials
Definition
Light-cured composite materials that can
be placed and cured in bulk increments
of 4 – 5 mm thickness
BULK FILL Materials
Advantages of “New Class” of materials • Saves Time
• Easier
• Better adaptation to tooth
– Reduce chance for air entrapment
– Better conformity to cavity walls
– Better marginal integrity
• Less shrinkage stress
• Greater Depth of cure
– 4-5 mm
Why do we need bulk fill?
National Institute for Dental and
Craniofacial Research
“… Studies have shown that dental resin composites have an average replacement time of 5.7 years due to secondary decay and fracture of the restoration.”
MODES of FAILURE #1 - secondary caries #2 - fracture
Other reasons . . . . - Marginal breakdown - Wear - Discoloration - Pulpal death - Tooth fracture
Volumetric Shrinkage
1-3 % conventional composites
Marginal leakage, recurrent caries, sensitivity
Why do we need bulk fill?
Why incremental filling?
- Limited depth of cure
- Reduce shrinkage stress
Delipari et al JADA 2002
Not in my hands !
1
2
3
4
2
1
3
C-Factor
# bonded surfaces /
# unbonded surfaces
Fundamental Concept
Composites must be adequately polymerized to function
properly in the mouth
Bluephase LED manual - Ivoclar
Undesirable Consequences of
Inadequate Polymerization
- Inadequate physical properties - Reduced bond strengths - Increased breakdown at margins with use - Decreased biocompatibility - Potentially increased DNA damage due to leachates - Increased bacterial colonization of resin
J Can Dent Assoc 2010;76:a23
How do you measure polymerization ??
In the lab . . . . “Evaluate for monomer-to-polymer conversion using a
Fourier transform infrared spectrophotometer (FTIR) with an
attenuated total reflectance (ATR) detector . . . . Measure the
top, irradiated surface and also bottom of sample . . .”
F. Rueggeberg – SonicFill Scientific Portfolio
▫ Laboratory Studies
▫ Manufacturer’s Guidelines
0 mm tip-to-surface distance
ISO 4049 Depth of Cure - Scrape Back Method
10mm X 10mm mold
Light cure from top x 20 sec
Scrape soft material from bottom
Divide thickness by 2
Polymerization decreases from light
90% of max polymerization
How do you measure polymerization ??
Schattenberg et al, Dent Mater. 2008
BOTTOM
TOP = 80%
PROBLEM
Calculations of energy density based on manufacturer’s
recommendations ASSUME intimate contact with composite
material is possible (< 1.0 mm)
This MAY be possible for some anterior teeth
“Clinically Relevant Distance” can be much greater:
▫ 7+ mm in Class II box
▫ molar / premolar cusp tips on deep Class I
▫ Class Vs second molars
J Can Dent Assoc 2010;76:a23
Select BULK fill materials
• SonicFill Kerr
• Surefill SDR Flow Dentsply Caulk
• Filtek Bulk Fill 3M ESPE
• Venus Bulk Fill Heraeus Kulzer
• X-tra base VOCO
• X-tra Fil VOCO
• Tetric EvoCeram Bulk Fill Ivoclar Vivadent
• QuiXfil Denstply Caulk
BULK FILL Materials
They are NOT all the same!
• Increment thickness - 4mm, 5mm
• Single increment use vs. “capping layer”
• Sculptable (paste-like) or flowable (syringe)
Feb 2013 Tech Manual - Tetric EvoCeram Bulk Fill
BULK FILL Materials Questions / Concerns
• Depth of cure [degree of conversion]
• Adaptation – microleakage
• Strength
• Mechanical properties
• Wear
• Contraction force and rate
• Handling
• Durability – clinical performance over time
SureFil SDR Flow – Dentsply - 2009
SDR™ = Stress Reducing Resin technology
SELF-LEVELING flowable base
2.0 mm “capping layer” of esthetic composite
Low Stress – 1.5 Mpa contraction force at margin
Bulk Fill – place in 4.0 mm increment
Filler: 68% weight / 45% volume Barium & Strontium aluminofluorosilicate glasses Resin: Urethane Dimethacrylate (UDMA)
www.surefilsdrflow.com
STATED INDICATIONS Base Class I & II restorations Class II box liner Pit & Fissure Sealant Conservative Class I restorations Filling of defects and undercuts in crown, inlay and onlay preparations (Core Buildup)
Volumetric Shrinkage SDR Flow = 3.5% Flowables = 3-6% Restoratives = 1-3%
LOW STRESS – WHY?
Clinician’s Report Mar 2010; Vol 3, Issue 3
* Polymer Shrinkage Tensometer
Contraction Stress * SDR Flow = 1.5 Mpa Flowables = 3-5 Mpa Restoratives = 2-3 Mpa
Stress RATE SDR Flow = 4 MPa/min Flowables = 5-13 MPa/min Restoratives = 3-10 MPa/min
www.surefilsdrflow.com
Polymerization Modulation
With SDR™ Technology, a “Polymerization Modulator” was
chemically embedded in the polymerizable resin backbone of
the SDR™ resin monomer. Based on scientific evidence
gathered to date, the “Polymerization Modulator” in SDR™
resin reduces stress build-up upon polymerization without a
reduction in the polymerization rate or conversion. Through
the use of the Polymerization Modulator, the SDR™ resin
forms a more relaxed network and provides significantly lower
polymerization stress than any other conventional resin.
www.surefilsdrflow.com
www.surefilsdrflow.com
Shrinks, but with less stress . . .
www.surefilsdrflow.com
“Adapts perfectly to matrix band and internal aspects of the preparation, even sharp angles” SDR Flow Demo Video
www.dentaladvisor.com
www.dentaladvisor.com
Research
Investigations on a methacrylate-based flowable composite
based on the SDR technology
Ilie and Hickel. Dental Materials 27(2011)348-355
-Surefill SDR Flow
-EsthetX
-EsthetX Flow
-Filtek Supreme Plus Flow
-Filtek Silorane
Shrinkage Stress
Shrinkage Rate
Micromechanical
Properties
RESULTS:
Shrinkage stress and stress rate were significantly lower for the SDR Flow compared to flowables and conventionals.
Stress: SDR Flow (1.1 Mpa) EsthetX Flow (5.3 Mpa)
Silorane (3.6 Mpa) Filtek Supreme Flow (6.5 Mpa)
Micromechanical properties of SDR Flow (and other flowables) were significantly lower than the conventional composite materials
SIGNIFICANCE:
The effect on the interfacial stress build-up difficult to predict.
Research
Bulk filling of high C-factor posterior cavities: Effect on
adhesion to cavity-bottom dentin.
Van Ende et al. Dental Materials 29(2013)269-277
Microtensile Bond Strength to bottom of cavity
preparations of different C-factor configurations
Manuf.
Surefill SDR Flow 68% Wt / 45% vol 4.0 mm
G-aenial Universal Flow 69% Wt / 50% vol 1.5 mm
Z100 85% Wt / 71% vol 2.5 mm
METHODS:
Cavity preparations with different C-facors
3.5mm X 3.5mm X 4mm deep Bulk filled
3.5mm X 3.5mm X 2.5mm deep Bulk filled
Incremental
3.5mm X 3.5mm X flat dentin surface Bulk filled
RESULTS:
Surefill SDR Flow
No significant difference in bond strenth regardless of C-factor or filling technique (bulk vs. incremental)
Z100 & G-aenial Universal Flow
No significant difference with SDR when layered, but significantly lower than SDR (clinically unacceptable) when bulk filled [4 mm deep, 2.5 mm deep]
solutions.3m.com
solutions.3m.com
Filtek Bulk Fill - Flowable
Filler Loading = 64.5% wt (68)
= 42.5% vol (45)
Depth of Cure = 4 mm (4)
Class I and II Restorations
must be “capped” 2.0 mm
restorative composite
INDICATIONS
- Pit & Fissure Sealant
- PRR – non-stress bearing
- Undercut blockout
- Repair small enamel defects
- Repair small defects in composites
- Repair resin temporaries
- Base under Class I / Class II
- Liner under direct restoratives (Class II box)
- Class III and V restorations
- Core build-up where at least half the
coronal tooth structure remains to provide
support
Filtek Bulk Fill - Flowable
Filler Loading = 64.5% wt (68)
= 42.5% vol (45)
Depth of Cure = 4 mm (4)
Class I and II Restorations
must be “capped” 2.0 mm
restorative composite
Filler Load = 75% wt
Depth of Cure = 4 mm
Volumetric shrinkage = 2.54 %
2 shades - universal, A2
10 sec cure (≥ 1,000 mW / cm2)
Liner / base Class I and II
Golf
courses
are scary
places
Filler Load = 61% vol
Depth of Cure = 4 mm
Volumetric shrinkage = 1.7 %
1 Universal shade
10 sec cure (≥ 1,000 mW / cm2)
20 sec cure (≤ 800 mW / cm2)
Load-bearing Class I and II,
Core build-up
Tech Manual - Tetric EvoCeram Bulk Fill
Tech Manual - Tetric EvoCeram Bulk Fill
Filler Loading = 86% wt
Depth of Cure = 4 mm
Volumetric shrinkage = 1.7 %
1 Universal shade
10 sec cure
Load-bearing Class I and II, Core build-up
10 μm
Tech Manual - Tetric EvoCeram Bulk Fill
Filler Load = 86% wt, 66% vol
Depth of Cure = 4 mm
Volumetric shrinkage = 1.7 %
1 Universal shade
10 sec cure (≥ 800 mW / cm2)
20 sec cure (≤ 800 mW / cm2)
Load-bearing Class I and II,
Core build-up
10 μm
Tech Manual - Tetric EvoCeram Bulk Fill
- High molecular weight aromatic dimethacrylate
- Limits # of reactive groups in resin
- Moderates volumetric shrinkage and stiffness, reducing
stress
2 novel monomers unique to Filtek Bulk Fill Posterior
- Addition-fragmentation monomers [AFM]
- Cleaves during polymerization = stress relief
- Can still then react with the developing polymer
- Stress relief possible while maintaining physical properties
Filler Loading = 76.5% wt
= 58.4% vol
Depth of Cure = 5 mm
Volumetric Shrinkage =
5 shades – A1, A2, A3, B1, C2
Class I (4mm) – 20 sec cure (1,000-2,000 mW / cm2)
Class II (5 mm) – 30 sec (10 occl, 10 buccal, 10 lingual)
All direct restorations
Indirect inlays, onlays, veneers
Core build-ups
Questions?
www.sonicfill.com
Questions?
www.sonicfill.com
Questions?
www.sonicfill.com
Feb 2013 Tech Manual - Tetric EvoCeram Bulk Fill
©2012 Trademarks are property of their respective owners
SonicFill™ Sonic-Activated, Bulk Fill Composite
Side View
Top View
• Handpiece is activated, pressure is
applied
• Small tube fills with air
• Air escapes from small holes in tube
• Imbalance is created
• Handpiece works on any MULTIflex coupler
• Similar sterilization and maintenance protocol to other
air-driven instruments
Handpiece Technology
©2012 Trademarks are property of their respective owners
SonicFill™ Sonic-Activated, Bulk Fill Composite
To change the Class II Composite
restoration from a tedious, time
consuming process to an EFFICIENT and
PRACTICAL procedure without
compromising QUALITY.
The SonicFill Objective:
www.sonicfill.com
www.sonicfill.com Watch the video
Full 5-mm depth of cure in 20 seconds *
Light output of 550 mW/cm2
Filler = 83.5% wt, 69% vol
Depth of
Cure = 5 mm
Vol. Shrinkage
= 1.6%
Flexural Strength
= 187 MPa
PERFECTION
www.sonicfill.com
www.sonicfill.com
“All bulk fill composites in this study have a degree of
cure well above 80% of their top, irradiated surface
value when evaluated at a depth of 6mm. Thus, it is
reasonable to assume that restorations employing
SonicFill as a bulk fill material have the potential to
produce clinically successful restorations.” Dr. Fred Rueggeberg, Georgia Health Sciences University
©2012 Trademarks are property of their respective owners
SonicFill™ Sonic-Activated, Bulk Fill Composite
Polymerization ration (bottom/top)
Medical College of Georgia – Dr. Fred Rueggeberg
©2012 Trademarks are property of their respective owners
SonicFill™ Sonic-Activated, Bulk Fill Composite
Cure Depth
550 mW/cm2 for 20 Seconds
97%*
= 80% or more
5.1mm
* Dental Advisor tested using: Bottom: Top hardness ratio. Data available upon request.
80% = Fully cured
- Dental Advisor
- CR
- Reality
ISO 4049 Depth of Cure - Scrape Back Method
10mm X 10mm mold
Light cure from top x 20 sec
Scrape soft material from bottom
Divide thickness by 2
Polymerization decreases from light
90% of max polymerization
SonicFill SureFil SDR Flow X-tra base
10 μm
Clinical Case SonicFill #28-29
Filtek P-60 3M SonicFill
http://www.afms.af.mil/decs/
http://www.afms.af.mil/decs/
http://www.afms.af.mil/decs/
Recommendations – SonicFill
• Promising product, but limited studies
• Utilized to enhance internal adaptation and
have less voids
• Recommend 2-3 mm increments
• It may cure adequately to 6+ mm, but that
doesn’t solve the volumetric shrinkage issue
Research Microleakage in Class II composite restorations below the
CEJ: In vitro evaluation of different restorative techniques.
Poggio et al Med Oral Patol Oral Cir Bucal. 2013 Sep
1;18(5):e793-8.
Evaluate microleakage Class II box – below CEJ
Filtek Flowable (1mm) + Filtek Supreme incremental
GrandioSO Heavy Flow (1mm) + GrandioSo incremental
Surefill SDR Flow (4mm) + Esthet-X HD
SonicFill (4+ mm) bulk
Grandio Layered incremental [CONTROL]
CONTROL
– layered
hybrid
Flowable
Liner
Sonic Fill
Bulk fill
entire prep
SDR flow +
capping
layer
1-mm
flowable
liner
Dye Penetration Scores 0 = no dye penetration 1 = slight penetration short of the DEJ 2 = dye penetration < 2/3 to axial wall 3 = dye penetration > 2/3 to the axial wall 4 = dye penetration to the axial wall
3 2 1
4
3 2 1
4
NO
leakage
Within
enamel
< 2/3 to
axial wall
> 2/3 to
axial wall
To and up
axial wall
Score 0 Score 1 Score 2 Score 3 Score 4
Filtek Flow +
Filtek
4 (20%) 3 (15%) 10 (50%) 1 (5%) 2 (10%)
GrandioSO
Heavy Flow +
GrandioSo
4 (20%) 9 (45%) 4 (20%) 1 (5%) 2 (10%)
Surefill SDR
Flow +
EsthetX HD
3 (15%) 10 (50%) 4 (20%) 2 (10%) 1 (5%)
SonicFill 12 (60%) 5 (25%) 2 (10%) 1 (5%) 0 (0%)
Grandio
Layered
CONTROL
11 (55%) 7 (35%) 1 (5%) 1 (5%) 0 (0)%)
Research
Bulk-fill resin-based composites: an in vitro assessment of
their mechanical performance. Ilie et al Oper Dent. 2013
38-5,000-000, electronic .
Assess the mechanical performance of the bulk-fill RBCs and compare to flowable and conventional RBCs.
Product Filler Wt% / Vol%
Tetric EvoCeram Bulk Fill 80 / 61
Venus Bulk Fill 65 / 38
SureFil SDR flow 68 / 44
X-tra Base (injectable) 75 /
X-tra Fil (paste) 86 / 70
SonicFill 83.5 /
Filtek Bulk Fill 64.5 / 42.5
Bulk-fill resin-based composites: an in vitro assessment of
their mechanical performance. Ilie et al Oper Dent. 2013
38-5,000-000, electronic .
METHODS:
Macromechanical properties tested
Flexural strength
3-point bending test
Flexural modulus
Micromechanical properties tested
Indentation modulus
Vickers hardness
Creep
Bulk-fill resin-based composites: an in vitro assessment of
their mechanical performance. Ilie et al Oper Dent. 2013
38-5,000-000, electronic .
RESULTS:
Compared to nanohybrid/microhybrid RBCs, the bulk fill materials show significantly lower mechanical properties
Lower modulus of elasticity will result in higher deformability under masticatory stresses and could lead to catastrophic failure in load-bearing areas
Capping layer mandatory due to low indentation modulus and hardness for SDR Flow, Venus Bulk Fill and Filtek Bulk Fill
Bulk-fill resin-based composites: an in vitro assessment of
their mechanical performance. Ilie et al Oper Dent. 2013
38-5,000-000, electronic .
Research A randomized controlled three year evaluation of “bulk-filled”
posterior resin restorations based on stress decreasing
resin technology. Van Dijken JWV & Pallesen U. Dental
Materials 2014 (30):e245-e251.
METHODS:
3-year follow up 76 Class II and 28 Class I paired restorations
SDR flow (base up to 4 mm)
+ CeramX mono (2 mm capping layer)
VS.
CeramX mono (2 mm layering technique)
__________________________________________
CeramX mono = Nanohybrid 57% volume fillers
RESULTS:
Annual Failure Rates:
SDR + nanohybrid = 0%
Nanohybrid layered = 1.3% (1 tooth fx, 1 comp fx)
NO SECONDARY CARIES OBSERVED
* Materials with a high rate of catastrophic failures can be detected already in 2-3 year follow ups
Research Physico-mechanical characteristics of commercially
available bulk-fill composites. Leprince JG et al. Journal of
Dentistry 2014 (42):993-1000.
Product Category
Venus Bulk Fill Flowable
Surefil SDR Flow Flowable
X-tra base Flowable
Filtek Bulk Fill Flow Flowable
Coletene Dual-cure Bulk-Fill Flowable - Dual Cure
Tetric Evo Ceram Bulk Fill Paste
X-tra fill Paste
Sonic Fill Paste - Sonic HP
Xenius Paste – glass fibers
Grandio Flow Hybrid - flowable
Grandio Hybrid - paste
METHODS:
2mm X 2mm X 25mm samples
Macromechanical properties tested
Flexural strength
Elastic modulus
Micromechanical properties tested
Vickers microhardness
Vickers microhardness [24 hours ethanol immersion]
Polymer Network Density = VHN/dry VHN
Degree of conversion
Filler Content – Wt %
Flexural Strength
Dentin = 12-20
Elastic Modulus
Degree of Conversion
RESULTS:
Filler mass fraction [60.7 Filtek BF – 85.3 Grandio]
Flexural Strength [76 MPa Venus BF – 140.3 SonicF]
AND
Elastic Modulus [3.3 Gpa Venus BF – 15.3 Grandio]
were directly related to filler content . . . . .
CONCLUSIONS:
Filler content important parameter for mechanical properties
Compromised mechanical properties (relative to hybrid)
Use for restorations under high occlusal load ??
Long-term stability (ethanol softening) is questionable and should be prevented from direct contact with oral cavity
SUMMARY - Bulk Fill Materials
• NOT ALL THE SAME !
• The physical properties (flowables) inferior in
every way to a highly-filled restorative composite
• Legitimate 4.0 – 5.0 mm cure ????
• Microleakage no better than current RBCs
SUMMARY - Bulk Fill Materials
• Seem to result in enhanced internal adaptation
and less voids than incremental RBC placement
• Marginal adaptation no better than current RBCs
RECOMMENDATIONS
• We should be using the BEST materials we have
access to ↑ filler = better properties
• IF you do NOT have problems with adaptation or
voids, may not be necessary
• Highly filled materials (pastes) may be good first
increment in deeper Class I and Class IIs
– Enhanced curability
– Thicker increment? (i.e. 3 mm)
• Highly filled materials good core material
Questions ?