Kooistra Bulk Fill Sandiegojan2015

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

[email protected]

BULK FILL Materials

Definition

Light-cured composite materials that can

be placed and cured in bulk increments

of 4 – 5 mm thickness

BULK FILL Materials

Advantages of “New Class” of materials • Saves Time

• Easier

• Better adaptation to tooth

– Reduce chance for air entrapment

– Better conformity to cavity walls

– Better marginal integrity

• Less shrinkage stress

• Greater Depth of cure

– 4-5 mm

Why do we need bulk fill?

National Institute for Dental and

Craniofacial Research

“… Studies have shown that dental resin composites have an average replacement time of 5.7 years due to secondary decay and fracture of the restoration.”

MODES of FAILURE #1 - secondary caries #2 - fracture

Other reasons . . . . - Marginal breakdown - Wear - Discoloration - Pulpal death - Tooth fracture

Volumetric Shrinkage

1-3 % conventional composites

Marginal leakage, recurrent caries, sensitivity

Why do we need bulk fill?

Why incremental filling?

- Limited depth of cure

- Reduce shrinkage stress

Delipari et al JADA 2002

Not in my hands !

1

2

3

4

2

1

3

C-Factor

# bonded surfaces /

# unbonded surfaces

Fundamental Concept

Composites must be adequately polymerized to function

properly in the mouth

Bluephase LED manual - Ivoclar

Undesirable Consequences of

Inadequate Polymerization

- Inadequate physical properties - Reduced bond strengths - Increased breakdown at margins with use - Decreased biocompatibility - Potentially increased DNA damage due to leachates - Increased bacterial colonization of resin

J Can Dent Assoc 2010;76:a23

How do you measure polymerization ??

In the lab . . . . “Evaluate for monomer-to-polymer conversion using a

Fourier transform infrared spectrophotometer (FTIR) with an

attenuated total reflectance (ATR) detector . . . . Measure the

top, irradiated surface and also bottom of sample . . .”

F. Rueggeberg – SonicFill Scientific Portfolio

▫ Laboratory Studies

▫ Manufacturer’s Guidelines

0 mm tip-to-surface distance

ISO 4049 Depth of Cure - Scrape Back Method

10mm X 10mm mold

Light cure from top x 20 sec

Scrape soft material from bottom

Divide thickness by 2

Polymerization decreases from light

90% of max polymerization

How do you measure polymerization ??

Schattenberg et al, Dent Mater. 2008

BOTTOM

TOP = 80%

PROBLEM

Calculations of energy density based on manufacturer’s

recommendations ASSUME intimate contact with composite

material is possible (< 1.0 mm)

This MAY be possible for some anterior teeth

“Clinically Relevant Distance” can be much greater:

▫ 7+ mm in Class II box

▫ molar / premolar cusp tips on deep Class I

▫ Class Vs second molars

J Can Dent Assoc 2010;76:a23

Select BULK fill materials

• SonicFill Kerr

• Surefill SDR Flow Dentsply Caulk

• Filtek Bulk Fill 3M ESPE

• Venus Bulk Fill Heraeus Kulzer

• X-tra base VOCO

• X-tra Fil VOCO

• Tetric EvoCeram Bulk Fill Ivoclar Vivadent

• QuiXfil Denstply Caulk

BULK FILL Materials

They are NOT all the same!

• Increment thickness - 4mm, 5mm

• Single increment use vs. “capping layer”

• Sculptable (paste-like) or flowable (syringe)

Feb 2013 Tech Manual - Tetric EvoCeram Bulk Fill

BULK FILL Materials Questions / Concerns

• Depth of cure [degree of conversion]

• Adaptation – microleakage

• Strength

• Mechanical properties

• Wear

• Contraction force and rate

• Handling

• Durability – clinical performance over time

SureFil SDR Flow – Dentsply - 2009

SDR™ = Stress Reducing Resin technology

SELF-LEVELING flowable base

2.0 mm “capping layer” of esthetic composite

Low Stress – 1.5 Mpa contraction force at margin

Bulk Fill – place in 4.0 mm increment

Filler: 68% weight / 45% volume Barium & Strontium aluminofluorosilicate glasses Resin: Urethane Dimethacrylate (UDMA)

www.surefilsdrflow.com

STATED INDICATIONS Base Class I & II restorations Class II box liner Pit & Fissure Sealant Conservative Class I restorations Filling of defects and undercuts in crown, inlay and onlay preparations (Core Buildup)

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

LOW STRESS – WHY?

Clinician’s Report Mar 2010; Vol 3, Issue 3

* Polymer Shrinkage Tensometer

Contraction Stress * SDR Flow = 1.5 Mpa Flowables = 3-5 Mpa Restoratives = 2-3 Mpa

Stress RATE SDR Flow = 4 MPa/min Flowables = 5-13 MPa/min Restoratives = 3-10 MPa/min


Polymerization Modulation

With SDR™ Technology, a “Polymerization Modulator” was

chemically embedded in the polymerizable resin backbone of

the SDR™ resin monomer. Based on scientific evidence

gathered to date, the “Polymerization Modulator” in SDR™

resin reduces stress build-up upon polymerization without a

reduction in the polymerization rate or conversion. Through

the use of the Polymerization Modulator, the SDR™ resin

forms a more relaxed network and provides significantly lower

polymerization stress than any other conventional resin.



Shrinks, but with less stress . . .


“Adapts perfectly to matrix band and internal aspects of the preparation, even sharp angles” SDR Flow Demo Video

www.dentaladvisor.com

www.dentaladvisor.com

Research

Investigations on a methacrylate-based flowable composite

based on the SDR technology

Ilie and Hickel. Dental Materials 27(2011)348-355

-Surefill SDR Flow

-EsthetX

-EsthetX Flow

-Filtek Supreme Plus Flow

-Filtek Silorane

Shrinkage Stress

Shrinkage Rate

Micromechanical

Properties

RESULTS:

Shrinkage stress and stress rate were significantly lower for the SDR Flow compared to flowables and conventionals.

Stress: SDR Flow (1.1 Mpa) EsthetX Flow (5.3 Mpa)

Silorane (3.6 Mpa) Filtek Supreme Flow (6.5 Mpa)

Micromechanical properties of SDR Flow (and other flowables) were significantly lower than the conventional composite materials

SIGNIFICANCE:

The effect on the interfacial stress build-up difficult to predict.

Research

Bulk filling of high C-factor posterior cavities: Effect on

adhesion to cavity-bottom dentin.

Van Ende et al. Dental Materials 29(2013)269-277

Microtensile Bond Strength to bottom of cavity

preparations of different C-factor configurations

Manuf.

Surefill SDR Flow 68% Wt / 45% vol 4.0 mm

G-aenial Universal Flow 69% Wt / 50% vol 1.5 mm

Z100 85% Wt / 71% vol 2.5 mm

METHODS:

Cavity preparations with different C-facors

3.5mm X 3.5mm X 4mm deep Bulk filled

3.5mm X 3.5mm X 2.5mm deep Bulk filled

Incremental

3.5mm X 3.5mm X flat dentin surface Bulk filled

RESULTS:

Surefill SDR Flow

No significant difference in bond strenth regardless of C-factor or filling technique (bulk vs. incremental)

Z100 & G-aenial Universal Flow

No significant difference with SDR when layered, but significantly lower than SDR (clinically unacceptable) when bulk filled [4 mm deep, 2.5 mm deep]

solutions.3m.com

solutions.3m.com

Filtek Bulk Fill - Flowable

Filler Loading = 64.5% wt (68)

= 42.5% vol (45)

Depth of Cure = 4 mm (4)

Class I and II Restorations

must be “capped” 2.0 mm

restorative composite

INDICATIONS

- Pit & Fissure Sealant

- PRR – non-stress bearing

- Undercut blockout

- Repair small enamel defects

- Repair small defects in composites

- Repair resin temporaries

- Base under Class I / Class II

- Liner under direct restoratives (Class II box)

- Class III and V restorations

- Core build-up where at least half the

coronal tooth structure remains to provide

support

Filtek Bulk Fill - Flowable

Filler Loading = 64.5% wt (68)

= 42.5% vol (45)

Depth of Cure = 4 mm (4)

Class I and II Restorations

must be “capped” 2.0 mm

restorative composite

Filler Load = 75% wt

Depth of Cure = 4 mm

Volumetric shrinkage = 2.54 %

2 shades - universal, A2

10 sec cure (≥ 1,000 mW / cm2)

Liner / base Class I and II

Golf

courses

are scary

places

Filler Load = 61% vol



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


Filler Loading = 86% wt



1 Universal shade

10 sec cure

Load-bearing Class I and II, Core build-up

10 μm


Filler Load = 86% wt, 66% vol



1 Universal shade

10 sec cure (≥ 800 mW / cm2)

20 sec cure (≤ 800 mW / cm2)

Load-bearing Class I and II,

Core build-up

10 μm


- High molecular weight aromatic dimethacrylate

- Limits # of reactive groups in resin

- Moderates volumetric shrinkage and stiffness, reducing

stress

2 novel monomers unique to Filtek Bulk Fill Posterior

- Addition-fragmentation monomers [AFM]

- Cleaves during polymerization = stress relief

- Can still then react with the developing polymer

- Stress relief possible while maintaining physical properties

Filler Loading = 76.5% wt

= 58.4% vol


Volumetric Shrinkage =

5 shades – A1, A2, A3, B1, C2

Class I (4mm) – 20 sec cure (1,000-2,000 mW / cm2)

Class II (5 mm) – 30 sec (10 occl, 10 buccal, 10 lingual)

All direct restorations

Indirect inlays, onlays, veneers

Core build-ups

Questions?

www.sonicfill.com

Questions?

www.sonicfill.com

Questions?

www.sonicfill.com

Feb 2013 Tech Manual - Tetric EvoCeram Bulk Fill

©2012 Trademarks are property of their respective owners

SonicFill™ Sonic-Activated, Bulk Fill Composite

Side View

Top View

• Handpiece is activated, pressure is

applied

• Small tube fills with air

• Air escapes from small holes in tube

• Imbalance is created

• Handpiece works on any MULTIflex coupler

• Similar sterilization and maintenance protocol to other

air-driven instruments

Handpiece Technology



To change the Class II Composite

restoration from a tedious, time

consuming process to an EFFICIENT and

PRACTICAL procedure without

compromising QUALITY.

The SonicFill Objective:

www.sonicfill.com

www.sonicfill.com Watch the video

Full 5-mm depth of cure in 20 seconds *

Light output of 550 mW/cm2

Filler = 83.5% wt, 69% vol

Depth of

Cure = 5 mm

Vol. Shrinkage

= 1.6%

Flexural Strength

= 187 MPa

PERFECTION

www.sonicfill.com

www.sonicfill.com

“All bulk fill composites in this study have a degree of

cure well above 80% of their top, irradiated surface

value when evaluated at a depth of 6mm. Thus, it is

reasonable to assume that restorations employing

SonicFill as a bulk fill material have the potential to

produce clinically successful restorations.” Dr. Fred Rueggeberg, Georgia Health Sciences University



Polymerization ration (bottom/top)

Medical College of Georgia – Dr. Fred Rueggeberg



Cure Depth

550 mW/cm2 for 20 Seconds

97%*

= 80% or more

5.1mm

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

80% = Fully cured

- Dental Advisor

- CR

- Reality

ISO 4049 Depth of Cure - Scrape Back Method

10mm X 10mm mold

Light cure from top x 20 sec

Scrape soft material from bottom

Divide thickness by 2

Polymerization decreases from light

90% of max polymerization

SonicFill SureFil SDR Flow X-tra base

10 μm

Clinical Case SonicFill #28-29

Filtek P-60 3M SonicFill

http://www.afms.af.mil/decs/



Recommendations – SonicFill

• Promising product, but limited studies

• Utilized to enhance internal adaptation and

have less voids

• Recommend 2-3 mm increments

• It may cure adequately to 6+ mm, but that

doesn’t solve the volumetric shrinkage issue

Research Microleakage in Class II composite restorations below the

CEJ: In vitro evaluation of different restorative techniques.

Poggio et al Med Oral Patol Oral Cir Bucal. 2013 Sep

1;18(5):e793-8.

Evaluate microleakage Class II box – below CEJ

Filtek Flowable (1mm) + Filtek Supreme incremental

GrandioSO Heavy Flow (1mm) + GrandioSo incremental

Surefill SDR Flow (4mm) + Esthet-X HD

SonicFill (4+ mm) bulk

Grandio Layered incremental [CONTROL]

CONTROL

– layered

hybrid

Flowable

Liner

Sonic Fill

Bulk fill

entire prep

SDR flow +

capping

layer

1-mm

flowable

liner

Dye Penetration Scores 0 = no dye penetration 1 = slight penetration short of the DEJ 2 = dye penetration < 2/3 to axial wall 3 = dye penetration > 2/3 to the axial wall 4 = dye penetration to the axial wall

3 2 1

4

3 2 1

4

NO

leakage

Within

enamel

< 2/3 to

axial wall

> 2/3 to

axial wall

To and up

axial wall

Score 0 Score 1 Score 2 Score 3 Score 4

Filtek Flow +

Filtek

4 (20%) 3 (15%) 10 (50%) 1 (5%) 2 (10%)

GrandioSO

Heavy Flow +

GrandioSo

4 (20%) 9 (45%) 4 (20%) 1 (5%) 2 (10%)

Surefill SDR

Flow +

EsthetX HD

3 (15%) 10 (50%) 4 (20%) 2 (10%) 1 (5%)

SonicFill 12 (60%) 5 (25%) 2 (10%) 1 (5%) 0 (0%)

Grandio

Layered

CONTROL

11 (55%) 7 (35%) 1 (5%) 1 (5%) 0 (0)%)

Research

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

their mechanical performance. Ilie et al Oper Dent. 2013

38-5,000-000, electronic .

Assess the mechanical performance of the bulk-fill RBCs and compare to flowable and conventional RBCs.

Product Filler Wt% / Vol%

Tetric EvoCeram Bulk Fill 80 / 61

Venus Bulk Fill 65 / 38

SureFil SDR flow 68 / 44

X-tra Base (injectable) 75 /

X-tra Fil (paste) 86 / 70

SonicFill 83.5 /

Filtek Bulk Fill 64.5 / 42.5



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



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



38-5,000-000, electronic .

Research A randomized controlled three year evaluation of “bulk-filled”

posterior resin restorations based on stress decreasing

resin technology. Van Dijken JWV & Pallesen U. Dental

Materials 2014 (30):e245-e251.

METHODS:

3-year follow up 76 Class II and 28 Class I paired restorations

SDR flow (base up to 4 mm)

+ CeramX mono (2 mm capping layer)

VS.

CeramX mono (2 mm layering technique)

__________________________________________

CeramX mono = Nanohybrid 57% volume fillers

RESULTS:

Annual Failure Rates:

SDR + nanohybrid = 0%

Nanohybrid layered = 1.3% (1 tooth fx, 1 comp fx)

NO SECONDARY CARIES OBSERVED

* Materials with a high rate of catastrophic failures can be detected already in 2-3 year follow ups

Research Physico-mechanical characteristics of commercially

available bulk-fill composites. Leprince JG et al. Journal of

Dentistry 2014 (42):993-1000.

Product Category

Venus Bulk Fill Flowable

Surefil SDR Flow Flowable

X-tra base Flowable

Filtek Bulk Fill Flow Flowable

Coletene Dual-cure Bulk-Fill Flowable - Dual Cure

Tetric Evo Ceram Bulk Fill Paste

X-tra fill Paste

Sonic Fill Paste - Sonic HP

Xenius Paste – glass fibers

Grandio Flow Hybrid - flowable

Grandio Hybrid - paste

METHODS:

2mm X 2mm X 25mm samples

Macromechanical properties tested

Flexural strength

Elastic modulus

Micromechanical properties tested

Vickers microhardness

Vickers microhardness [24 hours ethanol immersion]

Polymer Network Density = VHN/dry VHN

Degree of conversion

Filler Content – Wt %

Flexural Strength

Dentin = 12-20

Elastic Modulus

Degree of Conversion

RESULTS:

Filler mass fraction [60.7 Filtek BF – 85.3 Grandio]

Flexural Strength [76 MPa Venus BF – 140.3 SonicF]

AND

Elastic Modulus [3.3 Gpa Venus BF – 15.3 Grandio]

were directly related to filler content . . . . .

CONCLUSIONS:

Filler content important parameter for mechanical properties

Compromised mechanical properties (relative to hybrid)

Use for restorations under high occlusal load ??

Long-term stability (ethanol softening) is questionable and should be prevented from direct contact with oral cavity

SUMMARY - Bulk Fill Materials

• NOT ALL THE SAME !

• The physical properties (flowables) inferior in

every way to a highly-filled restorative composite

• Legitimate 4.0 – 5.0 mm cure ????

• Microleakage no better than current RBCs

SUMMARY - Bulk Fill Materials

• Seem to result in enhanced internal adaptation

and less voids than incremental RBC placement

• Marginal adaptation no better than current RBCs

RECOMMENDATIONS

• We should be using the BEST materials we have

access to ↑ filler = better properties

• IF you do NOT have problems with adaptation or

voids, may not be necessary

• Highly filled materials (pastes) may be good first

increment in deeper Class I and Class IIs

– Enhanced curability

– Thicker increment? (i.e. 3 mm)

• Highly filled materials good core material

Questions ?

Documents

Kooistra Bulk Fill Sandiegojan2015