Efficiency of polymerization of bulk-fill composite resins: a systematic review

REIS, André Figueiredo; VESTPHAL, Mariana; AMARAL, Roberto Cesar do; RODRIGUES, José Augusto; ROULET, Jean-François; ROSCOE, Marina Guimarães

doi:10.1590/1807-3107BOR-2017.vol31.0059

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Critical Review • Braz. oral. res. 31 (suppl 1) • Aug 2017 • https://doi.org/10.1590/1807-3107BOR-2017.vol31.0059 linkcopy

Efficiency of polymerization of bulk-fill composite resins: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This systematic review assessed the literature to evaluate the efficiency of polymerization of bulk-fill composite resins at 4 mm restoration depth. PubMed, Cochrane, Scopus and Web of Science databases were searched with no restrictions on year, publication status, or article’s language. Selection criteria included studies that evaluated bulk-fill composite resin when inserted in a minimum thickness of 4 mm, followed by curing according to the manufacturers’ instructions; presented sound statistical data; and comparison with a control group and/or a reference measurement of quality of polymerization. The evidence level was evaluated by qualitative scoring system and classified as high-, moderate- and low- evidence level. A total of 534 articles were retrieved in the initial search. After the review process, only 10 full-text articles met the inclusion criteria. Most articles included (80%) were classified as high evidence level. Among several techniques, microhardness was the most frequently method performed by the studies included in this systematic review. Irrespective to the “in vitro” method performed, bulk fill RBCs were partially likely to fulfill the important requirement regarding properly curing in 4 mm of cavity depth measured by depth of cure and / or degree of conversion. In general, low viscosities BFCs performed better regarding polymerization efficiency compared to the high viscosities BFCs.

Composite resins; Polymerization; Curing lights, Dental; Dentistry

Bulk Fill Composites	Viscosities	Maximum depht	Time / Irradiance
EverX Posterior (GC)	Regular	4 mm	9-sec / Plasma arc (2000 mW/cm²); 10-sec / High Power LED Light (>1200 mW/cm²); 20-sec / Halogen - Normal LED Light (700 mW/cm²)
Filtek Bulk Fill (3M ESPE)	Regular	5 mm	20-sec / (>1000 mW/cm²)
Filtek Bulk Fill Flowable (3M ESPE)	Flow	4 mm	20-sec (>1000 mW/cm²)
QuiXX Fill (DENTSPLY)	Flow	4 mm	20-sec / (500-800 mW/cm²); 10-sec / (>800mW/cm²)
SonicFill (KERR)	Regular	5 mm	20-sec (>1000mW/cm²)
SureFil SDR (DENTSPLY)	Flow	4 mm	20-sec (U) or 40-sec (A1/A2/A3) / (>1000mW/cm²)
Tetric EvoCeram Bulk Fill (IVOCLAR)	Regular	4 mm	20-sec / (>500mW/cm²); 10-sec / (>1000mW/cm²)
Venus Bulk Fill (HERAEUS KULZER)	Regular	4 mm	20-sec / (>1000mW/cm²)
XTra Base (VOCO)	Flow	4 mm	10-sec / (> 1000mW/cm²)
XTra Fill (VOCO)	Regular	4 mm	10-sec / (> 1000mW/cm²)

Criteria assessed	Score
I. Study design (Maximum score = 11 points)
A. Control group	Conventional resin based composite: 1 point
	Bottom:Top ratio: 2 points
	Both groups: 3 points
B. Sample size	Number of evaluated sample per experimental group (n):
	n < 5: 1 point
	5 ≤ n ≤ 10: 2 points
	n > 10: 3 points
C. Experimental groups	High and low viscosities: 2 points
	High viscosity: 1 point
	Low viscosity: 1 point
D. Mechanical testing	Scraping ISO 4049 Method or Acetone Shake Test: 1 point
	FTIR, mRaman, Microhardness: 2 points
	If 2 or more methods were combined: 3 points
II. Methodological soundness (Maximum score = 8 points)
A. Light curing protocol	If clearly described time, power density and LCU: 3 points (1 point each)
B. Aging evaluation	If clearly describe time, temperature and medium of storage: 2 points
C. Post-cure time evaluation	Immediate or less than 24 hours post-cure: 1 point
	24 hours post-cure: 2 points
	more than 24-hours / cycling: 3 points

Study	Bulk- fill composites	Viscosities	Mechanical test	Light curing protocol	Post-cure time evaluation	Can BFCs be placed and cured properly in 4 mm increments?
Benetti et al., 2015 ³	Tetric EvoCeram Bulk Fill, SonicFill, x-tra base, Venus Bulk Fill, and SureFil SDR	High and low	Scrapping Method ISO 4049	20-sec; 950 ± 50 mW/cm ² ; LED LCU	Immediate	PARTIALLY. With a mean depth of cure of 3.43 mm, SonicFill failed to comply the value stated by the manufacturer (up to 5-mm increments). Tetric EvoCeram Bulk Fill also showed a depth of cure slightly lower (3.82 mm) than the value advertised by its manufacturer (4 mm). However, the other investigated low-viscosity bulk-fill resin composites (SDR, Venus Bulk Fill, and x-tra base), demonstrated higher and sufficient depth of cure at more than 4 mm (4.34, 5.57, and 5.68, respectively).
Czasch and Ilie, 2013 ¹⁸	SureFil SDR, and Venus Bulk Fill	Low	FTIR and Microhardness	10-, 20-, and 40-sec; 1,226 mW/cm ² ; LED LCU (Elipar Freelight)	Microhardness (24 hours)	YES. Both RBCs may be placed in 4 mm bulks without a loss in mechanical properties or degree of cure. A polymerization time of 20 seconds and bulk placement up to 4 mm can be recommended.
Flury et al., 2012 ¹⁶	SureFil SDR, Venus Bulk Fill, QuiXX Fill, Tetric EvoCeram Bulk Fill	High and low	Scrapping Method ISO 4049 and Microhardness	10- and 20- sec, 1000 mW/cm ² , LED LCU (Demi)	Immediate	PARTIALLY. The Scrapping Method showed that only Tetric EvoCeram Bulk Fill (light-cured for 10-sec according to the manufacturer indication) did not meet the ISO requirement (DOC = 3.32 mm). The percentage of VHN ^max attained at the depth D ^ISO was assessed and expressed as p ^ISO . Whereas p ^ISO was above 80% for one of the control materials (Filtek Silorane), p ^ISO was much lower particularly for the bulk fill materials, which showed in the median a p ^ISO of only 40%, reflecting the different forms of the VHN profiles.
Garcia et al., 2014 ³⁴	SureFil SDR, Venus Bulk Fill, and SonicFill	High and low	Scrapping Method ISO 4049 and Microhardness	20- sec, 800 mW/cm ² , LED LCU (SmartLite iQ2)	Microhardness (24 hours)	PARTIALLY. The Scrapping Method showed that only SonicFill could not be cured properly in 4 mm (DOC = 3.46 mm), while both Venus Bulk Fill and SureFil SDR flow demonstrated full depth of cure at 5 mm.
Garcia et al., 2014 ³⁴	SureFil SDR, Venus Bulk Fill, and SonicFill	High and low	Scrapping Method ISO 4049 and Microhardness	20- sec, 800 mW/cm ² , LED LCU (SmartLite iQ2)	Microhardness (24 hours)	Regarding microhardness values, all bottom:top ratio values for the materials evaluated in this study were less than the 80% critical value for depth of cure.
Ilie et al., 2013 ¹⁰	Tetric EvoCeram Bulk Fill and x-tra base	High	FTIR and Microhardness	10-, 20-, and 40-sec; 1.703 mW/cm ² (0 mm distance) and 500 mW/cm ² (7 mm distance from the particular mould); LED LCU (Elipar Freelight2)	Microhardness (24 hours)	YES. The results of the study proved that both analyzed bulk-fill materials – Tetric EvoCeram Bulk Fill and x-tra base – enable, as described by the manufacturer, at least 4 mm thick increments to be cured in one step under clinically relevant curing conditions.
Lempel et al., 2016 ³⁵	SureFil SDR, X-tra Base, Filtek Bulk Fill	Low	Micro-Raman Spectroscopy	10- (X-tra Base) and 20-sec (Filtek Bulk Fill and SureFil SDR) ; 1100 mW/cm ² ; LED LCU (LED.C)	24 hours	PARTIALLY. SDR showed the highest DC value at the top and bottom surface of the samples and not significant lower %DC compared to 0 mm. X-tra Base and Filtek Bulk Fill presented about 35% lower DC compared to the top.
Miletic et al., 2016 ³⁶	Tetric EvoCeram Bulk Fill, SonicFill, SureFil SDR, EverX Posterior, and Filtek Bulk Fill flowable	High and low	FTIR, Acetone-Shaking Test, and Microhardness	10- and 20-sec;	FTIR and Microhardness (24 hours)	PARTIALLY. Tetric EvoCeram Bulk, EverX Posterior, and SonicFill, bulk-filled as 4-mm-thick specimens, showed bottom-to-top hardness ratios above 80 % after 20-sec curing. Still, 10-sec curing time was sufficient for flowable bulk-fills (SureFil SDR and Filtek Bulk Fill flowable).
Miletic et al., 2016 ³⁶		High and low	FTIR, Acetone-Shaking Test, and Microhardness	1337 mW/cm ² ; polywave LED LUC (Bluephase 20i)	FTIR and Microhardness (24 hours)
Nagi et al., 2015 ³⁷	Tetric EvoCeram, and X-traFil	High and low	Microhardness	10-, 20-, 40-, and 60-sec; ≥ 800 mW/cm ² ; LED LCU (Elipar S10)	24 hours	YES. The bulk-fill resin composites used in this study can be placed and cured properly in the 4 mm bulk. A short curing time 10 seconds was enough to reach VHN (bottom to top) ratio >80 % when both tested bulk fill RBCs are placed in 4 mm bulks.
Pongprueksa et al., 2015 ³⁸	Filtek Bulk Fill flowable	Low	Micro-Raman Spectroscopy	20-sec;	Immediate	YES. The cure at depth is considered adequate if DC measured at the bottom reaches at least 90% of the maximum DC measured at the top surface. Strictly applying this guideline, an adequate cure at 4-mm depth was achieved by the flowable bulk-fill composite (Filtek Bulk Fill Flowable: 92%).
				1100 mW/cm ² ; polywave LED LUC (Bluephase 20i)

Zorzin et al., 2015 ³⁹	Filtek BulkFill, SureFil SDR, TetricEvoCeram BulkFill, Venus BulkFill, and X-traBase	High and low	FTIR and Microhardness	10-, 20-, and 30-sec; 1200 mW/cm ² ; polywave LED LUC (Bluephase 20i)	24 hours	PARTIALLY. All investigated bulk-fills had sufficient polymerization properties at 4 mm increment thickness in terms of not significant lower %DC compared to 0 mm. Still, when the 80% bottom-top-ratio criterion was applied as a minimum acceptable threshold, all investigated materials, with exception of TBF and FSF in the manufacturers’ light-curing time (TBF 10 s, FSF 20 s at 1200 mW/cm2), showed adequate hardness at 4 mm. At higher radiant exposure (30 s at 1200 mW/cm ² ) all materials reached at least 80% bottom-top-ratio.

Articles	Control group	Sample size	Experimental groups	Mechanical test	Score
Benetti et al., ³ 2015	1	1	2	1	5
Czasch and Ilie, ¹⁸ 2013	2	2	1	3	8
Flury et al. ¹⁶ , 2012	3	3	2	3	11
Garcia et al., ³⁴ 2014	3	2	2	3	10
Ilie et al., ¹⁰ 2013	2	2	1	3	8
Lempel et al., ³⁵ 2016	3	2	2	2	9
Miletic et al., ³⁶ 2016	3	2	2	3	10
Nagi et al., ³⁷ 2015	2	2	2	2	8
Pongprueksa et al., ³⁸ 2015	3	2	1	2	8
Zorzin et al., ³⁹ 2015	3	2	2	3	10

Articles	Light curing protocol	Aging evaluation	Post-cure time evaluation	Score
Benetti et al., ³ 2015	3	0	1	4
Czasch and Ilie, ¹⁸ 2013	3	2	2	7
Flury et al. ¹⁶ , 2012	3	0	1	4
Garcia et al., ³⁴ 2014	3	2	2	7
Ilie et al., ¹⁰ 2013	3	2	2	7
Lempel et al., ³⁵ 2016	3	0	2	5
Miletic et al., ³⁶ 2016	3	2	2	7
Nagi et al., ³⁷ 2015	3	2	2	7
Pongprueksa et al., ³⁸ 2015	3	0	1	4
Zorzin et al., ³⁹ 2015	3	2	2	7

Articles	Study design	Methodological soundness	% Score	Classification
Benetti et al., ³ 2015	5	4	47%	Low
Czasch and Ilie, ¹⁸ 2013	8	7	79%	High
Flury et al. ¹⁶ , 2012	11	4	79%	High
Garcia et al., ³⁴ 2014	10	7	89%	High
Ilie et al., ¹⁰ 2013	8	7	79%	High
Lempel et al., ³⁵ 2016	9	5	74%	High
Miletic et al., ³⁶ 2016	10	7	89%	High
Nagi et al., ³⁷ 2015	8	7	79%	High
Pongprueksa et al., ³⁸ 2015	8	4	63%	Moderate
Zorzin et al., ³⁹ 2015	10	7	89%	High

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[TFN1] BFCs:– bulk fill composites; LED: light emitting-diode; LCU: light curing unit; FTIR: Fourier transform infrared spectrometer; VHN: Vickers Hardness; DOC:depth of cure; DC: degree of conversion.