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Marginal adaptation of class II cavities restored

with bulk-fill composites

Edson Alves Campos a,*, Stefano Ardu b, Dorien Lefever b,

Fernanda Ferreira Jassé a, Tissiana Bortolotto b, Ivo Krejci b
a
UNESP – Univ Estadual Paulista, Araraquara School of Dentistry, Department of Restorative Dentistry,
Rua Humaita 1680, 14801-903 Araraquara, SP, Brazil
b
Division of Cariology & Endodontology, Dental School, University of Geneva, Rue Barthélemy-Menn 19, 1205 Geneva,
Switzerland

article info abstract

Article history: Objectives: To determine the marginal adaptation of bulk-fill composites in class II MO
Received 26 November 2013 cavities.
Received in revised form Methods: Standardized class II MO cavities with bevelled enamel margins were prepared in
6 February 2014 40 extracted human molars. The teeth were randomly assigned to one of the five experi-
Accepted 10 February 2014 mental groups (n = 8). The teeth were restored with two horizontal increments of composite
Available online xxx (4 mm and 2 mm thickness). The experimental groups were (1st/2nd increment): Gr. A –
Venus Bulk-Fill/Venus Diamond; Gr. B – Tetric EvoCeram BulkFill/Tetric EvoCeram; Gr. C –
Keywords: Surefil SDR/Ceram-X; Gr. D – SonicFill; Gr. E – Ceram-X/Ceram-X (control). After finishing
Composites procedures, impressions were made using a polyvinyl siloxane and epoxy resin replicas
Bulk-fill were obtained. Thermo-mechanical stressing was carried out 24 h after the restorative
Marginal adaptation procedure. All specimens were submitted to 240,000 occlusal loading and simultaneous 600
thermal cycles in water at 5 8C and 50 8C. After loading, a new set of epoxy resin replicas was
obtained. Scanning electron microscopy was carried out at 200 magnification. Results for
the marginal adaptation were expressed as percentages of continuity relative to the exposed
interface and analyzed by ANOVA and Duncan post hoc test ( p < 0.05).
Results: In enamel, no significant differences were detected before and after thermo-me-
chanical loading between groups. In dentine, the worst results were observed in Gr. A.
Conclusion: By applying simple layering techniques, bulk-fill materials do not allow better
marginal adaptation than a standard composite.
Clinical significance: A new class of resin-base composite (bulk-fill) was recently launched on
the market. The bulk-fill composites exhibited adequate marginal adaptation and similar to
the results of the standard composite.
# 2014 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +55 16 33016522; fax: +55 16 33016395.

E-mail addresses: edson.campos@foar.unesp.br, edalvescampos@hotmail.com (E.A. Campos).
http://dx.doi.org/10.1016/j.jdent.2014.02.007
0300-5712/# 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Campos EA, et al. Marginal adaptation of class II cavities restored with bulk-fill composites. Journal of Dentistry
(2014), http://dx.doi.org/10.1016/j.jdent.2014.02.007
JJOD-2242; No. of Pages 7

2 journal of dentistry xxx (2014) xxx–xxx

The aim of the present study is to determine the marginal

1. Introduction adaptation of contemporary bulk-fill composites in class II MO
cavities with bevelled enamel margins. Marginal adaptation was
The polymerization of resin-based composites generates assessed with observation of epoxy replicas under scanning
stresses due to their contraction during this process. Shrink- electron microscopy (SEM), before and after thermo-mechanical
age stress occurs when the contraction is obstructed and the loading. The null hypothesis tested was that there would be no
material is rigid enough to resist sufficient plastic flow to differences in marginal adaptation in cavities restored with
compensate for the original volume.1 The magnitude of conventional and different bulk-fill composites.
contraction stresses is highly dependent on the visco-elastic
properties of the material.1 Clinically, these stresses may be
transferred to the margins of the restoration, possibly 2. Materials and methods
affecting marginal quality.2 When marginal quality is not
adequate, problems like leakage, recurrent caries and pulpal Forty extracted caries-free human molars stored in 0.1%
irritation may occur.3,4 Even by considering that an absolutely thymol solution were selected. The extracted teeth used in the
perfect marginal seal is not achievable clinically, a good study were obtained from the human tooth bank of the Section
marginal quality should be the main objective for clinicians.3 of Dental Medicine of the University of Geneva in conformity
Restoration placement techniques are widely recognized as with the requirements of the local ethical committee. The
a major factor in the modification of shrinkage stresses.5 To inclusion criteria were absence of carious lesions and a
avoid the clinical consequences of polymerization shrinkage, complete root formation.
incremental filling techniques are usually preferred over the The teeth were fixed with light-curing composite on metallic
bulk filling method to obtain effective marginal seal.6,7 holders and then the root base was embedded with self-curing
Incremental techniques have been suggested to compensate acrylic resin. Large class II MO cavities with parallel walls and
the polymerization shrinkage of composites,8,9 by reducing bevelled enamel margins were prepared, with cervical margin
the stresses developed within the tooth-restoration system.10 established 1 mm below the enamel–cementum junction. The
In some studies, better marginal quality with incremental overall dimensions and depth of the cavities were standardized
methods of composite placement was observed.11,12 However, as follows: 5 mm wide and 4 mm deep at the occlusal box, and
other studies found no significant differences in marginal 5 mm wide and 2 mm deep at the proximal box. The cavities
quality using different stratification methods.13–18 Although were prepared using coarse diamond burs in a red contre-angle
incremental technique may be important for adequate light with profuse water spray and finished with fine-grained burs.
penetration, its disadvantages are the possibility of trapping All enamel cavosurface angles were bevelled with a fine-grained
voids between layers and the time required to place the bur. The 40 teeth were randomly assigned to one of the five
restoration. Bulk application technique is simpler and it experimental groups, corresponding to the different bulk-fill
makes the work quicker by reducing the number of clinical restorative composites and control group (n = 8).
steps.13 All restorations were made by one operator. Adhesive
Despite the developments in adhesive systems, significant procedures were performed with Optibond FL (Kerr Co,
advances in composite technology are not so frequent. In this Orange, CA, USA) adhesive system following manufacturer’s
context, a group of products was recently introduced, the so- instructions. An individual metallic matrix (Metafix, Kerr,
called ‘bulk fill composites’. These materials are suitable for Bioggio, Switzerland) was used to build up the proximal wall.
insertion in a 4 mm bulk placement due to their reduced The teeth were restored with two horizontal increments of
polymerization stress and their high reactivity to light composite (4 mm and 2 mm thickness) and each of them was
curing.19 Depending on the material, this layer should be light-cured for 40 s with a LED light curing unit (Demi Plus,
covered by a layer of standard composite.3 Until now, there is Serial n. 760004898, Kerr Co., Middleton, WI, USA) with output
only one study assessing the marginal adaptation of a flowable irradiance of approximately 1100 mW/cm2. SonicFill compos-
bulk-fill composite in class II cavities with unbevelled enamel ite was inserted by sonic-activation using SonicFill handpiece.
margins.3 However, it remains to be determined if flowable The experimental groups were (1st/2nd increment): Gr. A –
and not-flowable bulk-fill composites provide the same Venus Bulk-Fill/Venus Diamond; Gr. B – Tetric EvoCeram
marginal adaptation quality under thermo-mechanical stres- BulkFill/Tetric EvoCeram; Gr. C – Surefil SDR/Ceram-X; Gr. D –
sing in cavities with bevelled enamel. SonicFill; Gr. E – Ceram-X/Ceram-X (control). Table 1

Table 1 – Materials used in this study.

Material Manufacturer LOT Exp. date
Optibond FL Kerr Co, Orange, CA, USA 3749427 2012–12
Venus1 Bulk Fill Heraeus Kulzer GmbH, Hanau, Germany 010030 2014–07
Venus1 Heraeus Kulzer GmbH, Hanau, Germany 010036 2014–07
Surefill SDRTM DENTSPLY DeTrey GmbH, Konstanz, Germany 1105121 2013–05
Tetric EvoCeram1 Ivoclar Vivadent AG, Schaan, Liechtenstein P18603 2015–01
Tetric EvoCeram1 Bulk Fill Ivoclar Vivadent AG, Schaan, Liechtenstein P48872 2015–06
SonicFillTM Kerr Co, Orange, CA, USA 3691651 2013–02
Ceram-XTM DENTSPLY DeTrey GmbH, Konstanz, Germany 1106000932 2013–04

Please cite this article in press as: Campos EA, et al. Marginal adaptation of class II cavities restored with bulk-fill composites. Journal of Dentistry
(2014), http://dx.doi.org/10.1016/j.jdent.2014.02.007
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journal of dentistry xxx (2014) xxx–xxx 3

Table 2 – Experimental groups of the study. were expressed as percentages of continuous margins for
Group 1st increment 2nd increment the total margin length and then separately for occlusal,
(4 mm thick) (2 mm thick) proximal and cervical margins.20 For the dependent variable
‘‘material groups’’ statistical evaluation was performed with
A Venus1 Bulk Fill Venus1 Diamond
B Tetric EvoCeram1 Bulk Fill Tetric EvoCeram1 One-Way ANOVA and Duncan post hoc test at a 5% level of
C Surefill SDRTM Ceram-XTM significance. Differences between loading intervals (before
D SonicFillTM SonicFillTM and after loading) were assessed with a paired t-test.
E Ceram-XTM Ceram-XTM

3. Results
summarizes the materials used in this study. The experimen-
tal groups are described in Table 2. The results of total marginal adaptation expressed as
A single adhesive (Optibond FL) was used in the present percentages of continuous margins (%CM) are shown in
study to emphasize the influence of restorative composites. Table 3. When considering the entire margin length, the
This material is considered as a gold standard etch-and-rinse lowest scores of %CM were observed in Gr. A (Venus BulkFill
adhesive, providing adequate adhesion to dentine and and Venus Diamond) both before and after thermo-mechani-
enamel.3 To standardize the protocol, all the materials, even cal loading. No significant differences were observed between
standard composite, were inserted using the same technique. Gr. E, restored with standard composite, and the rest of the
Occlusal margins were finished with 25 mm diamond burs groups ( p = 0.164 before loading, p = 0.381 after loading).
and proximal margins were finished with flexible disks (SofLex As the class II cavity margins consisted of an occlusal and
Pop-On, 3M ESPE, St. Paul, USA). After finishing procedures, proximal margin located on enamel, and of a cervical margin
impressions of the teeth were made using a polyvinyl siloxane located on dentine, the results of marginal adaptation were
material (President light body, Coltène/Whaledent AG, Alt- also reported for these segments (Table 4). After thermo-
stätten, Switzerland) and epoxy resin replicas were obtained mechanical loading, no significant differences between the
(Epofix, Struers, Copenhagen, Denmark).20 different groups were detected on occlusal enamel margins
Thermo-mechanical loading was carried out 24 h after the ( p = 0.060) and on proximal enamel margins ( p = 0.091). On
restorative procedure. During this period, the teeth were dentine (cervical margins), the lowest %CM was observed in
stored in water at 37 8C. All specimens were submitted to Gr. A and the highest in Gr. D and Gr. B. Representative SEM
240,000 mechanical and simultaneous 600 thermal cycles by micrographs are shown in Figs. 1–5.
alternating immersion in water at 5 8C and 50 8C with a dwell Mean values of occlusal enamel integrity varied from
time of 2 min. The occlusal loading was at max. 49 N at a 1.7 Hz 87.86% (Gr. D) to 93.80% (Gr. C) before thermo-mechanical
frequency. Restored teeth were contacted by natural cusps.21 loading and from 72.45% (Gr. A) to 83.93% (Gr. C) after thermo-
After loading, a new set of epoxy resin replicas was obtained. mechanical loading. For proximal enamel, the mean values
Scanning electron microscopy (SEM) evaluation (Digital varied from 63.63% (Gr. A) to 88.54% (Gr. C) and from 43.31%
SEM XL20, Philips, Eindhoven, Netherlands) was carried out at (Gr. A) to 60.17% (Gr. E) before and after thermo-mechanical
a standard 200 magnification. Results for the marginal loading, respectively. In cervical dentine, percentages of
adaptation, before and after thermo-mechanical loading, marginal integrity varied from 47.44% (Gr. A) to 76.97%

Table 3 – Results of marginal adaptation at the total margin length expressed as percentages of continuous margins (mean
(WSD)) for the groups (n = 8) before and after loading.
Group A Group B Group C Group D Group E
Before loading 71.96 (7.63)B,a 82.45 (5.52)A,a 87.22 (5.62)A,a 82.45 (5.35)A,a 86.14 (6.19)A,a
After loading 53.65 (8.61)B,b 63.88 (9.10)A,b 68.27 (10.09)A,b 65.45 (7.81)A,b 67.08 (9.07)A,b
Comparisons between groups apply to each line. Means with same capital letter are not statistically different at p = 0.05 (ANOVA and Duncan
post hoc). Comparison between loading condition are identified with lower case letters and apply to each column (paired t-test).

Table 4 – Results of regional marginal adaptation at the different segments (occlusal, proximal and cervical) expressed as
percentages of continuous margins (mean (WSD)) before and after loading (n = 8).
Group Occlusal enamel Proximal enamel Cervical dentine

Before loading After loading Before loading After loading Before loading After loading
A 88.10 (11.20)a 72.45 (17.42)a 63.63 (15.82)b 43.31 (15.24)a 47.44 (26.81)a 19.89 (13.32)b
B 91.47 (9.00)a 75.38 (9.08)a 76.35 (10.19)a 51.49 (15.50)a 67.25 (26.71)a 51.74 (29.61)a
C 93.80 (6.38)a 83.93 (8.62)a 88.54 (6.91)a 57.64 (16.70)a 62.15 (26.89)a 42.97 (33.32)ab
D 87.86 (7.18)a 73.10 (7.81)a 78.11 (12.12)a 56.19 (17.13)a 76.97 (16.44)a 61.70 (26.61)a
E 92.11 (5.97)a 80.86 (6.55)a 87.38 (8.67)a 60.17 (21.68)a 69.64 (34.31)a 46.62 (30.65)ab
Comparisons between groups apply to each columns. Means with same lower case letter are not statistically different at p = 0.05 (ANOVA and
Duncan post hoc).

Please cite this article in press as: Campos EA, et al. Marginal adaptation of class II cavities restored with bulk-fill composites. Journal of Dentistry
(2014), http://dx.doi.org/10.1016/j.jdent.2014.02.007
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4 journal of dentistry xxx (2014) xxx–xxx

Fig. 1 – Representative SEM (200T) image of continuous Fig. 3 – Representative SEM (200T) image of non-
margins in enamel at occlusal surface (arrows). continuous margins in enamel at occlusal surface
(arrows).

(Gr. D) before and from 19.89% (Gr. A) to 61.70% (Gr. D) after

thermo-mechanical loading. Considering the total marginal microcracking of restorative material and/or enamel. If
adaptation, the mean values varied from 71.96% (Gr. A) to adhesion is maintained after contraction stress following
87.22% (Gr. C) and from 53.65% (Gr. A) to 68.27% (Gr. C) before placement, deformation of tooth structure or material will
and after thermo-mechanical loading. occur. If adhesion is not strong enough, gaps will be formed. It
is known that placement techniques are an important factor
in the modification of shrinkage stresses and the magnitude of
4. Discussion the stress is mediated by the stiffness of the composite, its
stress relieving capacity, its curing rate and the constraint
The results of this study demonstrated that all materials under applied by bonding to the cavity preparation.23 If the
investigation exhibited satisfactory marginal adaptation polymerization of composite occurs in a unconstrained
before thermo-mechanical loading, mainly in enamel. Unfor- condition, the internal stresses will be minimized.23 However,
tunately, the level of marginal adaptation was not maintained volumetric contraction during the polymerization of compo-
after thermo-mechanical loading. As previously observed by sites in combination with effective bonding to the hard dental
some authors,22 cervical marginal adaptation was inferior to tissues result in stress transfer and inward deformation of the
that observed in proximal and occlusal enamel margins. These cavity walls of the restored tooth.5
results confirm the importance of phosporic-acid etching to The incremental technique has been largely recommended
obtain enamel adhesion resistant to ageing. Venus Bulk Fill because it is expected to decrease the C-factor.24 A technique
produced the worst results for cervical dentine marginal that uses a large number of small, thin increments is normally
adaptation. Therefore, the null hypothesis had to be rejected. considered the most appropriate placement technique to
Stresses generated during polymerization shrinkage of prevent excessive stress generation.23 However, in a previous
composites have potential to cause an adhesive failure or work employing simulated restoration using numeric analysis

Fig. 2 – Representative SEM (200T) image of continuous

margins in enamel and dentine at the cementum–enamel Fig. 4 – Representative SEM (200T) image of non-
junction level (arrows). continuous margins in cervical dentine (arrows).

Please cite this article in press as: Campos EA, et al. Marginal adaptation of class II cavities restored with bulk-fill composites. Journal of Dentistry
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composites with less filler load or greater proportion of diluent

monomers than conventional composites. Besides facilitating
placement, flowable composites may provide stress relief if
they have a low stiffness. Certain flowable composites with
low elastic modulus are effective to reduce stress, probably by
partially absorbing the composite shrinkage strain.2,23 The
higher the elastic modulus and the polymerization shrinkage
of the composite, the higher the contraction stress. The high
volumetric shrinkage produced by flowable composites may
lead to high stress values, but it is possible that their low
elastic modulus could reduce the stress buildup and maintain
the marginal integrity.2 However, significant stress relief
cannot be guaranteed when flowable composites with elastic
modulus of approximately 5 GPa and higher are used.2
Fig. 5 – Representative SEM (200T) image of enamel crack Incremental filling technique combined with the elastic buffer
(arrows). effect of flowable materials has demonstrated interesting
dentine marginal adaptation in class II cavities.28 Among the
experimental groups, Venus Bulk Fill and Surefil SDR are
considered flowable bulk-fill composites. However, this
it was demonstrated that incremental technique increased the characteristic did not produce better results for these
deformation of the restored teeth. The increase is due the materials in the present study. Another aspect to be consid-
incremental deformation of the preparation, decreasing the ered is the filling technique combined to restorative compos-
total amount of composite needed to fill the cavity and ite. Considering bulk-fill placement technique, it has been
creating a higher-stressed tooth-composite structure.5 More demonstrated that Surefil SDR showed better internal adap-
important than the dimensional change within the cavity tation than conventional composites in high C-factor cavi-
preparation is the internal stress generated within the ties.29 Another study showed similar levels of microleakage of
composite during polymerization.23 Perhaps the most impor- bulk-fill (Surefill SDR and X-tra Base) and standard (GrandioSO,
tant contribution of incremental technique would be an VOCO) composites.30
adequate polymerization even for low-shrinkage materials. It is known that a bevelled margin with enamel prisms
Most of manufacturers recommend increments of 2 mm cut perpendicular to their long axis is a configuration more
thickness for their conventional composites. In the present favourable than a butt margin.10,31 In this work, bevelled
work, Ceram-X was applied in a 4 mm increment to establish margins are probably a crucial point for the generally good
the same conditions for all groups. A high intensity light results observed in enamel (Fig. 1). In our opinion, bevelled
curing unit was employed so it was expected to have an enamel margins should be introduced wherever enamel
adequate degree of conversion of the material in this thickness is 1 mm or more. A qualitative evaluation of the
thickness. non-continuous margin showed significant enamel frac-
Despite important improvements in dental adhesives, tures (Fig. 5). Probably, the bonding strength to enamel was
class II composite restorations with cervical margins in sufficient to resist polymerization stresses, but these
dentine are sensitive to marginal discontinuity. The results of stresses exceeded the cohesive resistance of enamel,
the present study showed that marginal adaptation in originating cracks in the mass of enamel. This phenomenon
dentine was lower than in enamel. After thermo-mechanical was also observed by Stavridakis et al.32 in class I bulk-filled
loading, Gr. A showed a drastic reduction in dentine marginal restoration. Additionally, enamel micro-cracks are normal-
adaptation, reaching a mean value of only 19.89%. Although ly found in in vitro studies with mechanical loading.33 In the
there is no consensus about the most important mechanical present study, enamel cracks were found in all groups,
properties of composites, this result is possibly due to the especially at proximal surface after thermo-mechanical
mechanical characteristics of the restorative material, since loading.
the experimental conditions were the same for all groups. The For direct composite restorations not only marginal
mechanical stability in stress bearing areas in cavities filled adaptation but also adequate polymerization is important to
with bulk-fill composites is still unknown since clinical ensure adequate clinical behaviour. Degree of conversion may
studies are not available at this time.25 A previous study be influenced by material composition (matrix and filler) and
comparing the mechanical properties of bulk-fill composites translucency.34 The main concern regarding a bulk technique
demonstrated that Venus Bulk Fill has mechanical properties is whether the composite cures enough in the deeper
(flexural strength, flexural modulus and Vickers hardness) portions35 and, at this moment, there are few studies
similar to or lower when compared to all the other bulk-fill evaluating the degree of conversion36 and polymerization
composites (Tetric EvoCeram Bulk Fill, Surefil SDR and kinetics of bulk-fill composites. One of them revealed that
SonicFill).26 Surefil SDR, Tetric EvoCeram BulkFill and Venus Bulk Fill
It has been hypothesized that the elastic modulus is more exhibited adequate curing at the deepest portion of a 4-mm
important than shrinkage in determining the stress.23,27 In increment.37 In general, the claims of the manufacturers about
this sense, elastic modulus of restorative materials influences the depth of polymerization of bulk-fill composites can be
their behaviour under stress. Flowables are low viscosity considered reliable.38,39

Please cite this article in press as: Campos EA, et al. Marginal adaptation of class II cavities restored with bulk-fill composites. Journal of Dentistry
(2014), http://dx.doi.org/10.1016/j.jdent.2014.02.007
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Please cite this article in press as: Campos EA, et al. Marginal adaptation of class II cavities restored with bulk-fill composites. Journal of Dentistry
(2014), http://dx.doi.org/10.1016/j.jdent.2014.02.007