Republic of Iraq

Ministry of Higher Education

And scientific Research
University of Baghdad
College of Dentistry

Bulk Fill Composite

A project
Submitted to Collage of Dentistry, University of Baghdad. Department of
Conservative in fulfillment for the requirement to award the degree
B.D.S

Done by
Lina Salman Abed
5th Grade

Supervisor
Dr. Aliaa Mohsen Jabbar
B.D.S, M.SC. Conservative
Baghdad Iraq
2018 1439
 List of Contents
Title Subjects Page
No. No.
List of contents I
List of tables VI
List of figures VII
Introduction 1
2.1 Classification of dental composites 1
2.1.1 According to filler types and particle size 1
2.1.1.1 Macrofilled filler 2
2.1.1.2 Microfilled filler 2
2.1.1.3 Hybrid filler 2
2.1.1.4 Nanofilled filler 2
2.1.1.5 Bulk filler 2
2.1.2 According to Handling Characteristics 3
2.1.2.1 Universal: 3
2.1.2.2 Flowable; 3
2.1.2.4 Packable: 3
3.1 Classification of bulk-fill RBCs 3
3.1.1 Bulk-fill RBC 4
3.1.2 Bulk-fill base RBC 4
3.1.3 Sonic-activated bulk-fill RBC 4
3.1.4 Dual cure bulk-fill RBC 5
3.2 Mechanical properties of bulkfill RBC 6
3.2.1 Depth of cure 6
3.2.2 Polymerization shrinkage 8
3.2.3 Marginal gap formation 9
3.2.4 Physical and aesthetic properties 10
3.2.5 Clinical performance 11
3.3 The potential advantages of bulk-filling are: 12
3.4 The potential disadvantages of bulk-filling are: 12
3.5 Commercially available bulk fill materials 13
3.6. M™ ESPE™ Filtek™ Bulk Fill Posterior Restorative 13
material
3.6.1.1 Product Description 13
3.6.1.2 Composition 13
3.6.2 Tetric EvoCeram® Bulk Fill composite 14
3.6.1.3 Indications for Use 14
3.6.2.1 Composition of Tetric EvoCeram ® Bulk Fill composite 15
3.6.2.2 Filler technology of Tetric EvoCeram ® Bulk Fill 15
composite
3.6.3 Sonic Fill ™ composite 16
3.6.4 x-tra fil 17
3.6.4.1 Indications 17
3.6.4.2 Advantages 17
3.6.5 SDR®flow+ Bulk Fill Flowable Material 18
3.6.5.1 Desirable features of SDR 19
3.6.6 Filtek™ Bulk Fill Flowable composite 20
3.6.6.1 Indications 20
3.6.7 Venus® Bulk Fill 21
3.6.8 Tetric EvoFlow ® Bulk Fill 22
3.6.9.1 Indications 22
3.6.9.2 Advantages 23
3.6.9 x-tra base 23
3.6.11 Coltène Fill-Up 24
3.6.10 BEAUTIFIL-Bulk Flowable by Shofu 24
3.6.10.1 Preventive Effects of Giomer Materials 24
3.6.11.1 Features: 25
3.6.11.2 Indication: 25
3.6.12 Parkell Hyper IL™ 26
1.4 Previous studies on bulk fill materials 27
References 30
 List of Tables
Table Table Title Page
No. No.
Table (1) classification of bulkfill resin based composites 4
Table (2) Composition of Tetric EvoCeram® Bulk Fill composite 15
(Ivoclar Vivadent, 2013).
Table (3) physical properties of Venus® Bulk Fill (61) 21
 List of Figures

Figure Figure title Page

No. No.
(1) Handpiece of Sonic – activated bulk – fill RBC 5
(2) Application of a bulk – fill RBC in 4 mm layers with an 6
optional conventional flowable RBC liner.
(3) 3M™ ESPE™ Filtek™ Bulk Fill Posterior Restorative 14
material
(4) Sonic fill composite 16
(5) x-tra fil by voco 18
(6). Show the shades of SDR flow+bulk fill composite 20
(7) filtek-bulk-fill-flowable 21
(8) x-tra base by voco. 23
(9) Step by step coltene fill-up application. 25
(10) parkell hyperfil 26
1.1 Introduction
Composite resin is the material with the broadest application in restorative
dentistry due to its optic and physic properties being very similar to the natural dental
tissue, in order to re-establish dental function, form and aesthetic [1,2]. The material
presents as its principal characteristic adhesion to the dental structure, avoiding
further damage to the dental tissue, however, it presents as disadvantages a strong
polymerization contraction stress, with risk of causing marginal gap and staining,
microinfiltration, post-procedure sensibility, secondary caries and cusp fracture,
characterising a bad prognostic. With that in mind, the technology industry developed
bulk-fill low-polymerization contraction resins, which permit the insertion of larger
quantities of resins and a shorter photopolymerization time. There is an expressive
growth on the number of studies regarding this issue in the last five years. [3-6]
bulk fill composite
bulk fill composite are a new class of material with scientific evidence for
claims of low polymerization shrinkage and 4 mm depths of cure. the appearance
,handling,and mechanical properties of bulk fill composite vary between flowable
and high viscosity materials. [3-6]
2.1 Classification of dental composites
2.1.1 According to filler types and particle size
Resin filler can be made of glasses or ceramics. Glass fillers are usually made of
crystalline silica, silicone dioxide, lithium/barium-aluminium glass, and borosilicate
glass containing zinc/strontium/lithium. Ceramic fillers are made of zirconia-silica, or
zirconium oxide. (3)
Fillers can be further subdivided based on their particle size and shapes such as:

2.1.1.1Macrofilled filler
 Macrofilled fillers have a particle size ranging from 5 - 10µm. They have good
mechanical strength but poor wear resistance. Final restoration is difficult to polish
adequately leaving rough surfaces, and therefore this type of resin is plaque retentive.
(3)
2.1.1.2 Microfilled filler
Microfilled fillers are made of colloidal silica with a particle size of 0.4 µm.
Resin with this type of filler is easier to polish compared to macrofilled. However, its
mechanical properties are compromised as filler load is lower than in conventional
(only 40-45% by weight). Therefore, it is contraindicated for load-bearing situations,
and has poor wear resistance.(3)
2.1.1.3 Hybrid filler
Hybrid filler contains particles of various sizes with filler load of 75-85% by
weight. It was designed to get the benefits of both macrofilled and microfilled fillers.
Resins with hybrid filler have reduced thermal expansion and higher mechanical
strength. However, it has higher polymerisation shrinkage due to a larger volume of
dilutent monomer which controls viscosity of resin. (3)
2.1.1.4 Nanofilled filler
Nanofilled composite has a filler particle size of 20-70nm. Nanoparticles form
nanocluster units and act as a single unit. They have high mechanical strength similar
to hybrid material, high wear resistance, and are easily polished. However, nanofilled
resins are difficult to adapt to the cavity margins due to high volume of filler. (3)
2.1.1.5 Bulk filler
Bulk filler is composed of non-agglomerated silica and zirconia particles. It has
nanohybrid particles and filler load of 77% by weight. Designed to decrease clinical
steps with possibility of light curing through 4-5mm incremental depth, and reduce
stress within remaining tooth tissue. Unfortunately, it is not as strong in compression
and has decreased wear resistance compared to conventional material (4).
2.1.2 According to Handling Characteristics
 This classification divides resin composite into three broad categories based on
their handling characteristics:
2.1.2.1 Universal:
advocated for general use, oldest subtype of resin composite
2.1.2.2 Flowable;
fluid consistency used for very small restorations
2.1.2.4 Packable:
stiffer, more viscous material used solely for posterior parts of the mouth
Manufacturers manipulate the handling characteristics by altering the
constituents of the material. Generally, the stiffer materials (packable) exhibit a
higher filler content whilst fluid materials (flowable) exhibit lower filler loading. (5)

3.1 Classification of bulk-fill RBCs

Bulk-fill RBC restorative materials can be categorized into high-viscosity or low-
viscosity, light or dual cured.
Table 1 discusses some of these available materials, their maximum incremental
depth and whether or not they require a conventional RBC capping layer.
All of the bulk-fill restorative materials can be capped with conventional RBC to
improve their aesthetics or physical characteristics of the restoration; for some of the
materials this is advised as essential in providing the restoration.

Table (1) classification of bulkfill resin based composites

3.1.1 Bulk-fill RBC
Bulk-fill RBCs are designed to be placed in deeper increments (3 mm+) than
conventional RBCs (2 mm maximum). Bulk-fill RBC materials can be used more
efficiently to restore large cavities with RBC such as that following completion of
root canal treatment.
3.1.2 Bulk-fill base RBC
The low viscosity, light-cured flowable materials have been termed bulk-fill bases
as they always require a conventional layer of RBC to cap the restoration due to
reduced wear resistance and hardness properties (6).
Bulk-fill base RBC can be used along with a conventional RBC to efficiently restore
large cavities.
3.1.3 Sonic-activated bulk-fill RBC
Kerr have produced Sonic Fill 2, a high viscosity bulk-fill resin RBC which
becomes low viscosity with the use of sonic vibration (allowing the material to flow
into the cavity).
 Figure (1): handpiece of Sonic-activated bulk-fill RBC
The manufacturers claim that material contains a highly filled composite resin,
combined with modifiers that are activated by sonic energy produced by a specially
designated handpiece to reduce the viscosity of the material during placement. It can
therefore be applied into the cavity as a flowable RBC before returning to a more
viscous state that can be carved or moulded.
High viscosity bulk-fill restorative material can be used to efficiently restore
large access cavities with RBC following completion of root canal treatment. The
flowable properties resulting from sonic vibrations may lead to close adaption of the
material to the cavity walls, however, care must be taken to prevent the creation of
ledges and overhangs. This can easily be smoothed and polished after occlusal
adjustment.( 13)

3.1.4 Dual cure bulk-fill RBC

Two dual cure bulk-fill RBCs have also come onto the market. These aim to
combine both chemical and light-cure technology to enable the surface of restorations
to be light-cured for polishing, while the full depth of the restoration will be
chemically-cured over time.
The surface of Fill-up (Coltene) can be light-cured, polished and finished. Fill-up
can be used with Parabond (Coltene) or One Coat (7) Universal with One Coat
Activator (Coltene). Meanwhile the full depth of the restoration will be chemically
cured within three minutes and can be suitable for bulk-filling cavities of any depth
(10 mm+) in a single increment.(8)
Figure. (2a) Application of a bulk-fill RBC in 4 mm layers with an optional conventional flowable
RBC liner that is, 3M ESPE - Filtek Bulk-Fill Posterior Restorative; Ivoclar Vivadent- Tetric
EvoCeram Bulk-Fill; Voco - xtra fil. b) Application of a bulk-fill base RBC in 4 mm layers with a
marginal ridge and occlusal capping layer of conventional RBC. Note that a 1 mm seal is shown at
the base of the cavity with the bulk-fill base RBC that is, Dentsply - SDR; 3M ESPE - Filtek Bulk-
Fill Flowable; Heraeus Kulzer - Venus Bulk-Fill; Ivoclar Vivadent - Tetric EvoFlow Bulk-Fill;
Voco - xtra base. c) Application of a sonic activated bulk-fill RBC in 5 mm layers that is, Kerr -
SonicFill 2. d) Application of a dual cure bulk-fill RBC in a single increment layer that is, Coltene -
Fill Up; Parkell – HyperFil. As these RBCs typically have inferior aesthetics a capping layer of
conventional RBC can be incorporated to improve these attributes. e) Application of conventional
RBC in 2 mm increments that is, Kerr - Herculite XR

3.2 Mechanical properties of bulkfill RBC

3.2.1Depth of cure
It is widely accepted that conventional RBC restorations should be placed and
cured in 2 mm increments to allow adequate conversion of the unpolymerized RBC
resin.(9) The real depth of cure achieved for a given material can vary with the shade
and translucency; darker shades with greater opacity actually have a shallower depth
of cure compared to lighter more translucent resins.
The majority of bulk-fill materials on the market are purely light-cured, although
some are dual-cure. Manufacturers have attempted to increase the depth of cure by a
variety of methods including:
• Reducing the filler content (10)
• Increasing filler particle size (10)
• The use of additional photo-initiators. (11,12)
Reducing the filler content and increasing the filler size within RBC reduces the
amount of scatter at the resin-filler interface and increases the amount of absorbed
light that can activate the photo-initiator.
 Tetric EvoCeram Bulk-fill increases the depth of cure by using several
different photo-initiators. (11,12) The manufacturers claim that it is the addition of a
highly reactive photo-initiator, named Ivocerin that allows it to be polymerized in
larger increments, when compared to standard photo-initiators such as,
camphorquinone or lucririn. (11,12)
Despite these changes, however, the majority of these light-cured bulk-fill
materials are still limited to being used in increments of 4–5 mm. It is important to
note that some of the manufacturers light-curing claims are based on high intensity
LED light-curing units. Some companies recommend a minimum light-curing light
intensity which may be higher than many existing units.
Another factor to consider is the drop in intensity when the distance from the
light tip is increased.
One study found that increasing the distance from the light-cure tip to the RBC
restoration surface, decreased light intensity by 10% for every 1 mm. While it
has been found that when curing through 2 mm of RBC the intensity can be reduced
to 6% of its initial intensity. (13)

It is for this reason that the authors advise caution when attempting to cure
increments of 4 mm or more. An assessment of the direct access, distance of the light
tip from the base of the cavity and the intensity of the light-curing unit should be
considered when deciding suitable curing times for each individual case (14).
In addition, the effectiveness of light-cure units within general practice has often
been found to be inadequate with up to 50% of units not reaching minimum
irradiation levels (300 mW/cm2). (15) Therefore, it is recommended that light-curing
units are regularly maintained and assessed for their power output.(16)
There is mixed evidence regarding the manufacturers light-cure times. Some
studies have suggested that recommended light-cure times for bulk-fill materials
cannot be advocated, with longer curing times being required (17).
 One in vitro study identified that some of the available bulk-fill base RBCs had
significantly lower depths of cure than those claimed by the manufacturer (18).
However, most recent studies support the manufacturer’s claims, that with
optimal curing conditions the RBC can achieve an adequate hardness at the increased
depths. (19-21). If the increment depth is too large uncured resin may remain at the
base, which may result in post-operative sensitivity, marginal leakage, caries and
mechanical failure of the restoration. The advent of dual-cured RBC materials is an
exciting innovation, as it negates concerns over depth of cure, whilst retaining the
desirable properties of RBC restorations.
3.2.2 Polymerization shrinkage
Incremental placement of purely light-cured RBC is recommended to reduce
the effect of polymerisation shrinkage that occurs on curing (22).
When the unpolymerised RBC resin touches more than one wall of the cavity
preparation it increases the c-factor (23).
This shrinkage stress can lead to failure of the restoration at the weakest
interface which is between the tooth and restorative material (23) .
This in turn can result in a number of potential problems including secondary
caries, marginal staining, tooth fracture, and post-operative sensitivity. The
manufacturers of bulk-fill materials claim lower polymerization stresses than
conventional RBCs when placed in greater increment thickness.
Overall, the bulk-fill materials have been shown to have similar volumetric
shrinkage to conventional RBC controls, which may suggest there is no overall
benefit to using these materials (18).
However, when looking at the shrinkage stress specifically, in vitro studies have
shown bulk-fill materials exhibit less shrinkage stress than conventional RBCs (21).
This suggests that while the bulk-fill materials shrink, this is not necessarily to
the detriment of the marginal integrity. Manufacturers have altered the shrinkage
stress effect in a number of ways including inclusion of shrinkage stress relievers
which have a lower elastic modulus (24).
 SDR has included a polymerization modulator which interacts with the
camphorquinone photo initiator to result in a slower elasticity modulus development
(25).

3.2.3 Marginal gap formation

When looking at marginal gap formation and adaptation, studies are not
conclusive. Some have shown no statistical difference between a number of bulk-fill
materials compared to conventional RBC, (26) whereas some literature suggests there
is an improvement of the marginal seal with bulk-fill materials compared with
conventional layering (27).
A further study has found that the higher viscosity bulk-fill RBCs result in
greater marginal gap formation (28).
One method to overcome this problem with high-viscosity materials is heating
them prior to placement and/or using a low viscosity RBC material to seal the base of
the cavity. Dual cure bulk-fill RBCs have also shown acceptable marginal adaption
post curing (29) .
Gap-free interfaces have been reported to be lower with increasing depths of
preparation as would be expected.35,39 However, when comparing the same
preparation depths with conventional RBC against bulk-fill materials no differences
were found (26,30).
This suggests that it is the cavity depth which is a more important factor than the
type of RBC material with regards to interface gap formation. Overall, the evidence is
reassuring for the marginal adaptation of these new materials.

3.2.4 Physical and aesthetic properties

In the development of conventional RBCs, manufacturers have continually
sought to increase the filler content of their products in order to improve the
materials’ mechanical properties. However, this is not the case in many bulk-fill
materials, which tend to have lower filler loading in order to increase the depth of
cure.
 A recent lab-based study comparing many of the materials within this article
including a dual cure material (Fill Up – Coltene), highlighted some concerns over
the mechanical properties of strength over conventional RBCs (31)
The authors of this study suggested that also some of the bulk-fill base RBCs
have poor long-term stability from softening and highlighted the need for ensuring
they are not exposed to the oral environment which may negate their advantages (31).
Kerr’s Sonicfill 2 system has a relatively high filler content (83.5% Wt.), which
has been shown to have the higher flexural and compressive strength values,
compared to Tetric EvoCeram bulk-fill (79-81% Wt.) and SDR (68% Wt.) which
have lower filler contents (32).
The latter requires a capping layer of conventional RBC due to these inferior
properties and is therefore a bulk-fill base rather than a material that can be used for
an entire restoration (32).
Bulk-fill base RBCs have been found to have comparably low fracture
toughness and abrasion resistance to conventional flowable RBCs (33).
Therefore, manufacturers advise that bulk-fill base RBCs are capped with a
conventional RBC. This reduces the potential advantage of increased speed of
placement compared to materials that do not need a capping layer and may be placed
in a single increment depending on the depth of the cavity.
Interestingly dual cured bulk-fill RBCs (that is, Fill – up) also have low filler
content (65% Wt.), (34) however, the manufacturers have advised this material can
be used without a final conventional RBC capping layer.
Given the lack of clinical trials the authors give caution to using this material as
per manufacture guidelines due to its comparably low filler content which may render
it prone to increased wear rates.
Within in vitro studies the bulk-fill RBCs show a wide range of physical
properties and do not perform equally, therefore, the clinician must carefully select
materials based on their experiences
3.2.5 Clinical performance
There is limited good quality in-vitro research regarding bulk-fill RBC
materials, while clinical in vivo research is scarce apart from a few trials and case
reports. Some clinical evidence is emerging that demonstrates bulk-fill base RBCs
are a suitable alternative to amalgam or conventional RBC, (35-37) although more
good-quality data is needed.
A recent randomized clinical trial utilizing a bulk-fill base RBC compared with
a conventional layered technique found comparable success over five years (35).
Another study has shown bulk-fill base RBCs to be as successful as stainless
steel crowns in the restoration of primary teeth having undergone a pulpotomy (38).
However, the reality is that currently bulk-fill RBC restorative materials have
little clinical research to support their use. Clinicians must weigh up the potential
advantages and disadvantages of a material to the particular clinical scenario.
Aesthetics are greatly improved with all RBC materials compared to amalgam,
although bulk-fill materials may be limited in terms of shade and translucency of the
materials in comparison to conventional hybrid RBCs. For patients in which ultimate
aesthetics are a key factor, a capping layer of conventional hybrid RBC is indicated
and is compatible with most bulk-fill materials.

3.3 The potential advantages of bulk-filling are:

• Fewer voids may be present in the mass of material, since all of it is placed at one
time.
• The technique would be faster than placing numerous increments if curing times
were identical.
• It may be easier than placing numerous increments. (39)
3.4 The potential disadvantages of bulk-filling are:
• it may be difficult to control the mass placement.
• Making adequate contact areas may be challenging unless adequate matrices are
used.
• Effects due to shrinkage stress may be more pronounced when bulk-filled than
when placed in increments, since the entire mass polymerizes at one time rather than
in small increments.
• Polymerization of resin in deep preparation locations may be inadequate. (39)

3.6 Commercially available bulk fill materials

3.6.1 3M™ ESPE™ Filtek™ Bulk Fill Posterior Restorative material
3.6.1.1 Product Description
3M™ ESPE™ Filtek™ Bulk Fill Posterior Restorative material is a visible, light
activated restorative composite optimized to create posterior restorations simpler and
faster. This bulk fill material provides excellent strength and low wear for durability.
The shades are semi-translucent and low-stress curing, enabling up to a 5 mm depth
of cure.
With excellent polish retention, Filtek Bulk Fill Posterior Restorative is also
suitable for anterior restorations that call for a semi-translucent shade. All shades are
radiopaque. Filtek Bulk Fill Posterior Restorative is offered in A1, A2, A3, B1 and
C2 shades.
3.6.1.2 Composition
The fillers are a combination of non-agglomerated / non-aggregated 20 nm silica
filler, non-agglomerated / non-aggregated 4 to 11 nm zirconia filler, aggregated
zirconia/silica cluster filler (comprised of 20 nm silica and 4 to 11 nm zirconia
particles) and a ytterbium trifluoride filler consisting of agglomerate 100 nm
particles. (39)
The inorganic filler loading is about 76.5% by weight (58.4% by volume).
Filtek™ Bulk Fill Posterior Restorative contains AUDMA, UDMA and 1, 12-
dodecane-DMA. Filtek Bulk Fill Posterior Restorative is applied to the tooth
following use of a methacrylate-based dental adhesive, such as manufactured by 3M,
which permanently bonds the restoration to the tooth structure. Filtek Bulk Fill
Posterior Restorative is packaged in traditional syringes and single-dose capsules.(39)
 Fig. (3) 3M™ ESPE™ Filtek™ Bulk Fill Posterior Restorative material
3.6.2 Tetric EvoCeram® Bulk Fill composite
Tetric EvoCeram® Bulk Fill composite is a nanohybrid, medium viscosity
composite suitable for the bulk filling technique. It allows a new level of efficiency to
be achieved in posterior tooth restoration: one filling, one material, one increment
(Ivoclar Vivadent, 2013).
This radiopaque composite contains patented polymerization boosters and light
sensitivity filters for a deeper depth of cure with extended working time, with high
marginal adaptation to the floor and walls of cavitypreparations, without need for a
flow able liner (Ivoclar Vivadent, 2013; Olitsky, 2013).
3.6.1.3 Indications for Use
• Direct anterior and posterior restorations (including occlusal surfaces)
• Base/liner under direct restorations
• Core build-ups
• Splinting
• Indirect restorations including inlays, onlays and veneers
• Restorations of deciduous teeth
• Extended fissure sealing in molars and premolars
• Repair of defects in porcelain restorations, enamel and temporaries
3.6.2.1 Composition of Tetric EvoCeram ® Bulk Fill composite
Tetric EvoCeram® bulk fill has a total content of inorganic fillers of 79–81% by
weight or 60–61% by volume. The particle size with a mean of 550 nm and the
monomer matrix mass is composed of dimethacrylates BIS-GMA, BIS-EMA and
UDMA which exhibit low polymerization shrinkage by volume (Table 1-2) (Ivoclar
Vivadent, 2013).
Table (2): Composition of Tetric EvoCeram® Bulk Fill composite (Ivoclar Vivadent,
2013).

3.6.2.2 Filler technology of Tetric EvoCeram ® Bulk Fill composite

The filler technology is based on the clinically proven glass fillers with low wear,
favorable polishing properties, low surface roughness and a high gloss. It
incorporates two types of glass fillers with different mean particle sizes: Barium
aluminium silicate glass filler with a mean particle size of 0.4 μm and Barium
aluminium silicate glass filler with a mean particle size of 0.7μm (Ivoclar Vivadent,
2013).

3.6.3 Sonic Fill ™ composite

Sonic Fill™ composite (Kerr Corp., USA) is a nanohybrid, low-shrink, resin-
based, radiopaque, sonic-activated, bulk fill composite material designed for direct
placement for all cavity classes in posterior teeth without additional capping layer. It
is also used as build up material for cusp reconstruction. It allows a depth of cure of 5
mm. Proprietary sonic activation enables a rapid flow of composite into the cavity for
easy placement and good adaptation). The low viscosity varietyoffers superior
adaptability, while the medium viscosity type is better for carving and sculptability .

Fig.4. Sonic fill composite

Sonic Fill™ system is a bulk fill system comprised of a specially designed handpiece
and new bulk fill composite material in unidose tips. Sonic Fill™ composite
incorporates a highly-filled proprietary resin with special rheological modifiers that
react to sonic energy. As sonic energy is applied through the hand piece, the modifier
causes the viscosity to drop (up to 87%), increasing the flow ability of the composite
and enabling quick placement and precise adaptation to the cavity walls. When the
sonic energy is stopped, the composite returns to a more viscous, non-slumping state
for carving and contouring
3.6.4 x-tra fil
X-tra fil is a posterior, universal shade composite, that allows the clinician to
cure 4mm layers in 10 seconds. It is the perfect match for patients with a limited
budget where esthetics are secondary and your office time counts. Use with
Futurabond DC and you can complete a 4mm posterior restoration in less than 2
minutes. X-tra fil has a smooth and non-sticky consistency that does not slump. A
high radiopacity of 330% Al makes x-ray identification easy.
3.6.4.1 Indications
• Restorations class I and II
• Core build-up
3.6.4.2 Advantages
• x-tra fast
• – 4mm cure in 10 sec.
• x-tra durable
• Low shrinkage of 1.7% through multi hybrid filler technology
• 86% filled by weight for great wear resistance x-tra easy.
• One universal shade fits all. High translucency provides excellent. chameleon
effect for good esthetics.
• Perfect for fast core build-ups.
 Fig. (5) x-tra fil by voco

3.6.5 SDR®flow+ Bulk Fill Flowable Material

The evolution of composite materials is aimed at meeting esthetic requirements
of the filling. Besides permanent and esthetic restoration of the tooth, also fast,
comfortable and easy treatment is expected. Most clinicians recommend a 2mm layer
of a composite placed in a single layer due to the limitation of hardening depth and
polymerization shrinkage of the composite material (53,54).
The size of the layer is also connected with polymerization shrinkage which
varies between 2.5% and 3.5% of the volume. The value rises with the increase in the
portion of the composite material (54).
Therefore, the technique of layer application, which can be time consuming in
case of big cavities of hard tissues, seems to be a must.
According to present studies, the polymerization stress is definitively lower (3-
4fold) during SDR polymerization when 4-mm-layer is applied (55-57). SDR
technology is based on a unique chemical structure of the organic phase which
includes a polymerization modulator. A component- urethane dimetacrylate resin is a
kind of a monomer which controls the course of polymerization by being a so called
chemical ‘soft start’. A polymerization network is formed in a more straight and
slower way. Shrinkage tension can be limited to a great extent (57,58).
Moreover, SDR has similar physical properties to traditional composites, such as
susceptibility, surface roughness, shine, and shade. It is a particularly useful feature
while restoring hard tissue defects on contact surfaces (54). The base material seems
to be a great turning point in the conservative dentistry.

3.6.5.1 Desirable features of SDR

• low polymerization shrinkage and stress
 • large increments up to 4 mm thickness
• optimized handling and adaptation
• pre-dose compoul tips for direct intra-oral apliction
• can be capped with any composite materials
• self leveling
• fluoride containing glass fillers
• up to 40% time saving over conventional layering composites (59).
Based on SDR ®Technology , Dentsply Sirona now is introducing the next
generation bulk fill flowable with a new formulation. SDR® flow+bulk fill flowable
provides Three additional shades, A1, A2 and A3, to simplify esthetic matching in a
wider range of applications Enhanced wear resistance with a modified glass filler
package that significantly increases durability. Increased radiopacity to provide
improved X-ray visibility.
With these enhancements, SDR®flow+ bulk fill flowable is now approved for
an expanded range of indications including Class III and V restorations in addition to
Class I and II. The new shades also provide dentists with additional esthetic options
for creating Class V and Class II restorations as well as primary posterior dentition
when the restoration is visible at the smile line.
 Fig 6. Show the shades of SDR flow+bulk fill composite

3.6.6 Filtek™ Bulk Fill Flowable composite

• A 4 mm depth of cure – reducing the need for incremental layering and risk of
contamination.
• A flowable viscosity for easy adaptation– less instrument manipulation.
• Up to 50 % more strength and nearly twice the wear resistance compared to
competitve bulk fill flowables*
• Choice of deliveries: capsules or syringes in orange colour for easy identification
• 4 Shades: A1, A2, A3, Universal (60)

3.6.6.1 Indications
Filtek™ Bulk Fill Flowable Restorative is especially suited for the following
indications:
• Base under Class I and Class II direct restorations
• Liner under direct restorative materials
• Pit and fissure sealant (60)

Fig. (7) filtek-bulk-fill-flowable

3.6.7 Venus® Bulk Fill
Venus Bulk Fill is a low stress, flowable posterior composite used as a base in
Class I and II restorations. The product can be placed in 4 mm increments and is used
in conjunction with a universal restorative material as the surface layer. The
composite is a radiopaque nano-hybrid composite. Venus Bulk Fill has self-adapting
characteristics to enable the material to adapt to the cavity walls.

Table (3) physical properties of Venus® Bulk Fill (61)

3.6.8 Tetric EvoFlow ® Bulk Fill

Just like Tetric EvoCeram Bulk Fill, Tetric EvoFlow Bulk Fill is a posterior
composite suitable for the bulk-filling technique. Similarly to Tetric EvoCeram Bulk
Fill, it can be applied and cured in large increments of up to four millimeter
thickness, and requires minimal light exposure time. When a state-of the- art curing
light with a light intensity of at least 1,000 mW/cm2 such as Bluephase® Style (1,100
mW/cm2) is used, a four millimeter increment of Tetric EvoFlow Bulk Fill can be
cured in just ten seconds. Due to its higher monomer content and the resulting lower
surface hardness compared with sculptable composites, Tetric EvoFlow Bulk Fill
needs to be covered with a high-viscosity composite just like other flowable
composites
Tetric EvoCeram Bulk Fill has been successfully used in clinical applications
for almost four years. The highly reactive photo initiator Ivocerin (62-64) in Tetric
EvoCeram Bulk Fill substantiated the confidence in the effectiveness of bulk-fill
composites.
The time was ripe to take this technology a step further. The key technologies
incorporated into Tetric EvoCeram Bulk Fill formed the cornerstones for the new
development.
• Highly reactive initiator system (= Ivocerin and camphorquinone).
• Shrinkage stress control via incorporation of a composite filler (shrinkage stress
reliever).
• Long working time (= light sensitivity filter).

3.6.9.1 Indications
• Base for class I and II cavities
• Cavity liner under direct restorative materials in class I and II cavities
• Small, non occlusal stress-bearing class I restorations according to minimally
invasive filling therapy
• Class III and V restorations
• Extended fissure sealing
• Undercut blockout
• Repair of small enamel defects
• Repair of small defects in aesthetic indirect restorations
• Repair of temporary C&B-materials
• Core build-up

3.6.9.2 Advantages
• 4 mm cure in 10 sec. saves time (Universal shade)
• Low shrinkage stress allows bulk fill speed
 • Smart self-leveling properties without slumping out of maxillary restorations
• High Radiopacity (350 %Al) for easy x-ray
• Non-dripping NDT-Syringe technology
• Unit dose caps with extra long bendable needle tip
• Available in Universal and A2 shade
3.6.9 x-tra base
fast bulk fill Flowable Posterior Composite Cure 4mm in 10 sec .

Fig. (8) x-tra base by voco.

3.6.10 Coltène Fill-Up

Fill-Up is a dual curing, medium viscous bulk composite of the newest
generation applied in a single step.
It combines the advantages of resin-based composites with a simplified and
time-efficient handling. Owing to its dual curing property, fillings with Fill-Up! can
be administered in arbitrary filling depth without the need of an additional covering
layer.
• Faster than the conventional increment technique
• More economical than the two layer bulk fillings
Conventional light curing bulk filling materials are limited in their curing depth,
putting into question whether the restoration fully cures. On the contrary, the dual
curing property of Fill-Up guarantees a thorough curing down to the bottom of every
cavity. Moreover, chemical curing minimises shrinkage stress dramatically,
preventing microfractures and postoperative sensitivities.
The bonding partners ParaBond and ONE COAT 7 UNIVERSAL (together with
the activator) caters for a perfect marginal seal comparable to the one of conventional
composite - before and after thermo cycling and chewing abrasion – ensuring a
secure long-term restorative solution(66).
3.6.10.1 Preventive Effects of Giomer Materials
BEAUTIFIL-Bulk Flowable is particularly suitable for use as a cavity base,
thanks to its good self-leveling and handling characteristics.
All Beautifil-Bulk products are multifunctional Giomer composites, characterized by
bioactive filler particles. In the manufacturing process, these fillers are coated with a
durable glass ionomer phase (“S-PRG”) before being embedded in the matrix.
This technology allows the composites to recharge and release fluoride and
other ions. In numerous studies conducted at leading universities, this class of
materials has been shown to effectively re-mineralize the tooth structure, inhibit
plaque formation and neutralize acids.

Fig. (9) Step by step coltene fill-up application.

3.6.10.2 Features:
• Arbitrary filling depth
• Minimized shrinkage stress
• Optimized marginal seal
• One layer
• Universal color, fluorescent and radiopaque
• Contains zinc oxide
• Fast and easy procedure
3.6.10.3 Indication:
• Class I and Class II fillings
• Cavity linings
• Core build-ups

3.6.11 Parkell HyperFIL™

HyperFIL™ Dual Cure Restorative Composite is a true bulk-fill material.
HyperFIL can be filled to any depth and left on the occlusal surfaces because it can
cure to any depth and is strong enough to withstand occlusal forces.
• Nanofilled with 80% inorganic filler for providing greater wear resistance
• Slower rate of self-curing reduces stresses at bonded interface
• Material flows just enough when extruded from mixing tip to adapt to the tooth
surface
• Eliminates the need for flowable liners and incremental curing

• Hit material with curing light for 30 seconds (or wait for a total self-cure) and
start finishing restoration
 Fig 10 parkell hyperfil

1.4 Previous studies on bulk fill materials

Thomposon, in (2011),
Measured the volumetric shrinkage, compressive strength, and flextural strength and
flextural modulus of different composite materials including SonicFill™, Quixfil™
and Tetric EvoCeram® composite. He found the volumetric shrinkage of SonicFill™
composite was 1.7% which was the lowest among all tested composite materials, and
that of Quixfil™ was 2.2% and Tetric EvoCeram® 1.9%.
He also found that the compressive strength and flexural strength of Sonic
Fill™ (253 MPa – 185 MPa) were higher than Quixfil™ (227 MPa -156 MPa) and
Tetric EvoCeram® (234 MPa - 132.9 MPa). On other hand, he found that the
flextural modulus of Quixfil™ was (19 GPa) which was higher than SonicFill™
(12GPa) and Tetric EvoCeram® (11GPa).
Muñoz-Viveros and Campillo-Funollet, in (2012),
Found in an vitro study that Sonic Fill™ composite placed in one bulk
increment had the equivalent marginal adaptation to Filtek™ Supreme Ultra filled in
2mm increments and SureFil™
SDR which requires an additional overlay material (Ceram X). Due to the benefit of the
sonic activation, no voids are present in the SonicFill™ composite. Thus, bulk fracture is
less likely to occur reducing the need for reworks. They concluded that clinical longevity
of a SonicFill™ restoration placed in one bulk increment will be thesame or better than a
restoration utilizing incremental placement of Filtek™ Supreme Ultra.
Tiba et al., in (2013),
Measured the volumetric shrinkage, fracture toughness, fracture work, flextural strength,
flextural modulus and performed the polymerization shrinkage stress test for different
composite materials including SonicFill™, Quixfil™ and Tetric EvoCeram® Bulk Fill.
The results showed that SonicFill™ and Quixfil™ showed the lowest volumetric
shrinkage among the tested bulk fill composite materials. Also SonicFill™ composite
had the highest value of fracture toughness and fracture work among all tested bulk fill
materials (1.65 Mpa m1/2 -100 J/m^2).
Quixfil™ had (1.30 MPa m1/2 -. 50 J/m^2) and Tetric EvoCeram® Bulk Fill had (0.9
MPa m1/2 - 47 J/m^2).
The results also showed the flexture strength of SonicFill™ was statistcally
nonsignificant from Quixfil™ but Tetric EvoCeram® Bulk Fill showed lower value than
Sonic Fill™ and Quixfil™. The results also showed that the flexure modulus of
SonicFill™ was (11 GPa), Quixfil™ (15 GPa) and Tetric EvoCeram® Bulk Fill (15
GPa).
The results of polymerization shrinkage stress test of composite materials
showed that SonicFill™ composite had the lowest value (0.45 MPa) compared to
Quixfil™ which had (0.65 MPa) and Tetric EvoCeram® Bulk Fill which had (0.63
MPa).
Furness et al., in (2014),
Examined the effects of composite type (bulk fill/conventional) and placement (4-mm
bulk/2-mm increments) on internal margina l adaptation of class I preparations, using
either a bulk fill (SureFil™ SDR, Quixx, SonicFill™, Tetric EvoCeram® Bulk Fill and
conventional composite designed for 2- mm increments (Filtek Supreme Ultra).
Results showed that the marginal integrity was unaffected by placement method. Bulk-
placement demonstrated significantly fewer gap-free margins at the pulpal floor than in
enamel, for all materials except SDR.
Greater percentages of gap-free margins were found within the mid-dentine
than at the pulpal floor for Filtek Supreme Ultra. Quixx had more gap-free margins in
enamel compared with the mid-dentine. Proportion of gap-free margins within enamel
and mid-dentine was not significantly different for any incrementally placed product.
Excluding Filtek Supreme Ultra, gap-free margins within enamel were
significantly greater than at the pulpal floor. Notably, significantly more gap-free
margins were found within mid-dentine than at the pulpal floor for SonicFill™
(Benetti et al., 2015).
Median of marginal gap in micrometer ranged from 6.1 to 10.2. The same study
assessed the marginal adaptation of paste- like composite, and they found a median
gap ranged from Gap 6.6 – 7.1 micrometer. There was no comparison made to
the conventional composite.
Andre et al in 2017
Concluded that; bulk fill RBCSwhere partially likely to fulfill the important requirement
regarding properly curing in 4 mm of cavity depth measured by depthof cure or degree
of conversion. in general low viscosities BFCs performed better regarding
polymerization efficincy compared to the high viscositiesBFCs. Orłowski et al.,
2018).
The depth of cure for flowable and paste-like composite was higher than that for
conventional composite. Degree of conversion of flowable in comparison to
conventional was contradicting, while paste like bulk fill was higher than condensable
conventional composite. Polymerization shrinkage is higher or comparable in
flowable bulk fill composite in comparison to that in the conventional composite, while
in paste like composite the results was contradicting. The polymerization stress of
flowable and paste-like bulk fill composite was lower than that of conventional
composite.
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