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
scott.kooistra2.mil@mail.mil

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

Not in my
hands !

Delipari et al JADA 2002

C-Factor

2
1

# 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
Manufacturers 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 ??

BOTTOM
TOP

= 80%
Schattenberg et al, Dent Mater. 2008

PROBLEM
Calculations of energy density based on manufacturers
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
Surefill SDR Flow
Filtek Bulk Fill
Venus Bulk Fill
X-tra base
X-tra Fil
Tetric EvoCeram Bulk Fill
QuiXfil

Kerr
Dentsply Caulk
3M ESPE
Heraeus Kulzer
VOCO
VOCO
Ivoclar Vivadent
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)

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)

www.surefilsdrflow.com

LOW STRESS WHY?

Volumetric Shrinkage
SDR Flow
= 3.5%
Flowables
= 3-6%
Restoratives = 1-3%

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

* Polymer Shrinkage Tensometer

Clinicians Report Mar 2010; Vol 3, Issue 3

Polymerization Modulation

www.surefilsdrflow.com

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

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.surefilsdrflow.com

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
Shrinkage Stress
Shrinkage Rate

Micromechanical
Properties

-Surefill SDR Flow

-EsthetX
-EsthetX Flow
-Filtek Supreme Plus Flow
-Filtek Silorane

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

Surefill SDR Flow

G-aenial Universal Flow
Z100

68% Wt / 45% vol

69% Wt / 50% vol
85% Wt / 71% vol

Manuf.
4.0 mm
1.5 mm
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

Class I and II Restorations

must be capped 2.0 mm
restorative composite

(4)

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

Class I and II Restorations

must be capped 2.0 mm
restorative composite

(4)

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 m
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 m
Tech Manual - Tetric EvoCeram Bulk Fill

2 novel monomers unique to Filtek Bulk Fill Posterior

- High molecular weight aromatic dimethacrylate

- Limits # of reactive groups in resin

- Moderates volumetric shrinkage and stiffness, reducing
stress

- 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

SonicFill

Sonic-Activated, Bulk Fill Composite

Handpiece Technology

Side View

Handpiece is activated, pressure is

applied
Small tube fills with air
Air escapes from small holes in tube
Imbalance is created

Top View

Handpiece works on any MULTIflex coupler

Similar sterilization and maintenance protocol to other
air-driven instruments

2012 Trademarks are property of their respective owners

SonicFill

Sonic-Activated, Bulk Fill Composite

The SonicFill Objective:

To change the Class II Composite
restoration from a tedious, time
consuming process to an EFFICIENT and
PRACTICAL procedure without
compromising QUALITY.

2012 Trademarks are property of their respective owners

www.sonicfill.com

Watch the video

www.sonicfill.com

Depth of
Cure = 5 mm

Vol. Shrinkage
= 1.6%

Flexural Strength
= 187 MPa

Full 5-mm depth of cure in 20 seconds *

Light output of 550 mW/cm2
Filler = 83.5% wt, 69% vol

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

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

80% = Fully cured

5.1mm

- Dental Advisor
- CR
- Reality

* Dental Advisor tested using: Bottom: Top hardness ratio. Data available upon request.

2012 Trademarks are property of their respective owners

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

10 m

X-tra base

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
doesnt 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]

SDR flow +
capping
layer

Sonic Fill
Bulk fill
entire prep

Flowable
1-mm
Liner
flowable

liner

CONTROL
layered
hybrid

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

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

4 (20%)

3 (15%)

10 (50%)

1 (5%)

2 (10%)

GrandioSO
4 (20%)
Heavy Flow +
GrandioSo

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)%)

Filtek Flow +
Filtek

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.

Bulk-fill resin-based composites: an in vitro assessment of

their mechanical performance. Ilie et al Oper Dent. 2013
38-5,000-000, electronic .
Product
Tetric EvoCeram Bulk Fill
Venus Bulk Fill
SureFil SDR flow
X-tra Base (injectable)
X-tra Fil (paste)
SonicFill
Filtek Bulk Fill

Filler Wt% / Vol%

80 / 61
65 / 38
68 / 44
75 /
86 / 70
83.5 /
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

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
Nanohybrid layered

= 0%
= 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
Venus Bulk Fill
Surefil SDR Flow
X-tra base
Filtek Bulk Fill Flow
Coletene Dual-cure Bulk-Fill

Category
Flowable
Flowable
Flowable
Flowable
Flowable - Dual Cure

Tetric Evo Ceram Bulk Fill

X-tra fill
Sonic Fill
Xenius

Paste
Paste
Paste - Sonic HP
Paste glass fibers

Grandio Flow
Grandio

Hybrid - flowable
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 ?