Clinical Case

Bulk filling versus layering technique:

What has changed?

Prof. Joseph Sabbagh

Bulk filling versus layering
technique: What has changed?
Prof. Joseph Sabbagh
DDS, MSc, PhD, FICD
Is an Associate Professor in the department of restorative and aesthetic dentistry at the Lebanese
University. He is also a fellow researcher and a post-graduate lecturer at UCL (Cribio division),
Belgium. He is a member of the Academy of Operative Dentistry USA, the editorial board of
Reality Endodontics Journal, USA, and the International Association of Dental Research, as well
as a fellow of the International College of Dentists. His private practice is limited to cosmetic
dentistry and endodontics.

Introduction
Despite the continuous use of dental amalgam in several
countries, the use of resin based composites have surpassed
amalgam during the last 10 years. Every year over 500 million
direct restorations are placed worldwide, and of these, 261
million are composites (Heintze and Rousson, 2012). When
placed in optimal conditions, and in low caries risk patients,
composite restorations have demonstrated comparable or even
better performance (10-12 years) to that of dental amalgam
(Opdam et al. 2010).
Placement of posterior composites has a number of
disavantages, polymerization shrinkage, long placement
procedure and obtaining an adequate contact point. The layering
technique is still considered as the standard technique for
anterior and posterior restorations. The thickness of each layer
is limited to the maximum of 2 mm for optimal polymerization
and degree of conversion. Combined with the three steps total
etch bonding technique, the restoration of a posterior cavity can
be considered a time consuming procedure, extending to nearly
twice the time taken to complete an equivalent dental amalgam
(Lynch et al. 2014).
The development and use of self-adhesive systems has allowed
the dentist to shorten the bonding procedure and at the same
time reduce the postoperative sensitivity, due to a partial removal
of the smear layer from the cavity walls.
flowable and fiber based bulk filling materials, and the other two
are the high density and sonically activated bulk filling materials.
When using flowable or fiber-based bulk filling materials in class
II cavities, care must be taken not to place the materials on
occlusal surfaces, or on cavity margins. The final two millimeters
occlusally are filled with a microhybrid composite, making the
restorative procedure longer and more complex.
Recent in-vitro studies have shown that flowable bulk filling
materials suffer from low mechanical properties mainly hardness
and flexural modulus of elasticity (Czasch et Ile, 2013, Leprince
et al. 2014) and a high translucency. Their coverage by a thin
layer (1 to 2 mm) of a nanohybrid resin composite will ensure
optimal occlusal functioning, and mechanical resistance.
Compared to flowable bulk fill materials, high density bulk fill
composites, such as SonicFill, have been shown to have
high mechanical properties making them suitable for use on the
occlusal surface of a restoration.
The use of a bulk fill material to restore a class II cavity requires
the placement of a matrix, the application of an adhesive
system (total or self etch system) and the use of a high intensity
light curing unit. If a liner is required, a recent literature review
recommend the use of bioactive dental materials only if the pulp
is exposed or if the remaining dentine thickness is less than 0.5
mm (Mouawad et al. 2014).

More recently bulk filling materials have been introduced to the
dental market, and today more than twelve systems are available.
The main advantage of these materials is their application in
a 4 mm thick layer, resulting in a shorter placement time for
medium and deep posterior cavities. Other advantages reported
are better adaptation of the first layer of composite and absence
of voids.
Bulk fill materials present in unidoses, syringes or tubes and
can be classified according to their consistencies and mode of
applications into four groups. The first two groups include the
The SonicFill System is a sonically activated high density bulk
fill material used for posterior restorations. It is a closed system,
consisting of a handpiece manufactured by KaVo and a special
composite unidose made by Kerr.
A KaVo multiflex connector will allow the operator to connect
the handpiece to the dental unit. The use of the SonicFill System
combined with a self etch adhesive, represent a real gain of time
for the dentist when compared to the layering technique.
The SonicFill System is indicated for class I and class II posterior
restorations and as a build up material for cusp reconstruction,
as well as a base after root canal treatment. The long handpiece
allows easy access in the molar area.
The following clinical case illustrates teeth restoration using the
SonicFill System compared to layering technique.
Case report
A 32 year-old man presented for sensitivity in the posterior lower
left region. Upon clinical and radiographic examination, the first
and second left lower molars (#36 and 37) showed respectively
an occluso-distal caries and a secondary caries under the existing
composite restoration (Figure 1).
After shade selection and local anesthesia, the cavities were
prepared under copious irrigation using a pear shape diamond
bur. A class II cavity (OD) was prepared on tooth 36 and a class I
on tooth 37. For optimal isolation and moisture control during the
restorative procedure, a preformed 3D-rubber dam OptiDam
(Kerr) was applied and fixed from the first left premolar to the
second molar (Figure 2) using a Softclamp and a Fixafloss (Kerr).
1. Preoperative view
2. Metafix placement
3. Application of Optibond XTR etch and prime
4. Gentle air dry
5. Application of Optibond XTR bonding agent
6. Polymerization of the bonding
1 2
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After rubber dam application, a medium size Metafix matrix (Kerr)
was placed around tooth (#36) and tightened manually as indicated
by the manufacturer. The two cavities (36 and 37) were restored
simultaneously since only one contact point reconstruction is
involved. Tooth 36 was restored using the SonicFill System, while
tooth 37 was restored with a layering technique with Herculite
XRV Ultra (Kerr) nanohybrid composite.
A sixth generation two component self etch adhesive, OptiBond
XTR, was used during the restorative procedure for both cavities.
The self etch primer is first applied using a microbrush and rubbed
for 20 seconds (Figure 3) then gently air dried (Figure 4).
Then the adhesive is brushed actively for 15 seconds to allow
bonding penetration in the dentinal tubules (Figure 5), air thinned
for 5 seconds and polymerized for 20 seconds using the new LED
Demi Ultra curing light (Figure 6).
Tooth 36 was bulk filled using an A3 compula of SonicFill composite.
The size and the shape of the unidose tip allowed easy access to
the cavity (Figure 7). The viscosity change of the composite results
in perfect adaptation to the cavity walls and avoids any stickiness
of the composite to the instrument. Following placement of the
composite into the cavity the composite is adapted and shaped
occlusally then polymerized during 40 seconds from the occlusal
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side. Tooth 37 was filled using three layers of Herculite XRV Ultra
composite A3 Dentin, A2 Enamel, and Incisal (Figures 8-10).
The occlusal anatomy was recreated, and almost no excess is
observed. Each layer of composite is polymerized for 20 seconds.
After the Metafix matrice removal, (figure 11) adequate occlusal
anatomy is observed in both cavities, with no overbuild or over
contour.
Finishing the restorations is achieved using an egg shaped fine
diamond bur (Figure 12). This is followed by a silicone point and
an Occlubrush, a silicone filled brush (Kerr) used to give a high
luster and polish to the restorations (Figures 13 and 14). Figure
15 is a postoperative view of the final restorations after finishing
and polishing.
Composite used in posterior cavities must fulfill the criteria of
high percentage of filler to withstand occlusal forces and a
low polymerization shrinkage. Materials must allow for good
adaptation to the cavity walls, thus reducing voids and allowing
the development of a tight contact point. According to the
available literature, SonicFill demonstrates optimal mechanical
and physical properties that allows its use safely for posterior
restorations. Compared to the conventional layering technique,
the SonicFill bulk filling concept is a fast and reliable technique.
Unlike the layering technique, SonicFill is an easy technique to
learn allowing operators to achieve excellent results in a very
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short time. It has an improved handling and delivers of a non-
sticky, non-slumpy composite with optimal sculptability. The
material is easily visible on bitewing radiographs. In most cases
the restorative phase is reduced of at least 50 %.
References
Heintze S & Rousson V. Clinical effectiveness of direct class II
restorations:
A meta-analysis. Journal of adhesive dentistry 2012;14 (5):
407-431. Opdam et al., 12-years survival of resin composites
vs amalgam restorations. Journal of Dental Research 2010,
89: 1063-1067. Lynch CD, Opdam N, Hickel R, Brunton P
et al., Guidance on posterior resin composites: Academy of
Operative Dentistry - European Section. Journal of Dentistry,
2014; 42: 377-383. Czasch P & Ilie N. In vitro comparison of
mechanical properties and degree of cure of bulk fill composites.
Clinical and Oral Investigation 2013; 17(1):227-235. Leprince
JG, Palin W, Julie Vanacker J, Sabbagh J, Devaux J, Leloup G.
Physico-mechanical characteristics of commercially available
bulk fill composites. Journal of Dentistry 2014, http://dx.doi.
org/10.1016/j.jdent.2014.05.009 Mouawad S, Artine S, Hajjar P,
McConnell R, Fahd J, Sabbagh J. Frequently asked Questions in
Direct Pulp Capping: Dental Update 2014; 41(4): 298-304.
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