Article published online: 2021-09-10

THIEME
Review Article 1

The Use of Bulk Fill Resin-Based Composite in

the Sealing of Cavity with Margins in Radicular
Cementum
Puleio Francesco1 Cervino Gabriele1, Luca Fiorillo1,2 Miragliotta Giuseppe1 Squillacioti
Antonella1 Bruno Giancarlo1 Pinizzotto Mirta1 João Paulo Mendes Tribst3 Roberto Lo Giudice4

1 Department of Biomedical and Dental Sciences and Address for correspondence Luca Fiorillo, DDS, MSc,
Morphofunctional Imaging, Messina University, Messina, Italy PhD, Department of Biomedical and Dental Sciences and
2 Multidisciplinary Department of Medical-Surgical and Morphofunctional Imaging, Messina University, Messina 98100, Italy
Odontostomatological Specialties, University of Campania “Luigi (e-mail: lfiorillo@unime.it).
Vanvitelli,” Naples, Italy
3 Department of Dental Materials and Prosthodontics, Institute of
Science and Technology, São Paulo State University, São José dos
Campos, Brazil
4 Department of Clinical and Experimental Medicine, Messina
University, Messina, Italy

Eur J Dent 2022;16:1–13.

Abstract The aim of this systematic review was to evaluate if the newly introduced bulk fill
resin-based composite provides a better marginal sealing in cavity preparations with
margins in dental cementum. The population investigation comparison outcome
(PICO) framework was: in cavity preparation with margins in dental cementum of
human extracted teeth, do bulk fill resin base composites provide a better marginal
sealing than non-bulk fill resin-based composites? We performed our research on
April 21, 2020. Two authors independently evaluated the abstract and titles for eligi-
bility criteria. Two authors independently extracted the data and assessed the risk of
bias in single studies. After the initial screening of 400 abstract and titles, the full text
of the articles, that could meet the eligibility criteria, were obtained via the university
library. A total of 36 full-text articles were evaluated; 11 articles were finally eligible
for the review. Eight studies showed statistically differences, but not significant, in the
marginal sealing between bulk fill and nonbulk fill resin-based composite (p > 0.05).
One study showed statistically significant differences: SonicFill and Grandio showed
better marginal sealing than GrandioSo and SDR(r) (Sirona Dentsply, New York, United
States) and the latter two showed better marginal sealing than Filtek Supreme (p <
Keywords 0.05). One study showed statistically significant less marginal gap of SDR than Filtek
► bulk fill resin Bulk Fill (p = 0.0015) and Filtek Supreme (p < 0.0001). One study showed SDR to have
► composite a significantly higher microleakage than the other materials tested (p < 0.05). Based
► conservative dentistry on our current literature review, there are not enough data to establish if bulk fill resin
► radicular cementum base composite provides a better or a worse marginal sealing at cementum margins.
► sealing

published online DOI https://doi.org/ © 2021. The Author(s).

September 10, 2021 10.1055/s-0041-1731834 This is an open access article published by Thieme under the terms of the Creative
ISSN 1305-7456 Commons Attribution License, permitting unrestricted use, distribution, and repro-
duction so long as the original work is properly cited. (https:// creativecommons.
org/licenses/by/4.0/).
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2 Bulk Resins in the Sealing with Margin in Reticular Cementum Francesco et al.

Introduction where they show better in vivo performances than glass ion-
omer cements.18
Rationale One of the major drawbacks of traditional composite
With the increase in the average age and with the general materials is their polymerization shrinkage, which can also
improvement in the oral health conditions of the population, be considerable and can reach 3 to 7% of the initial mass,19-22
there is more and more often a greater presence of dental contributing to the formation of marginal gap.
elements in the oral cavity of older patients than in previ- Traditional composites must be deposited using the incre-
ous times.1 The prevalence of root surface exposures cor- mental technique both to reduce the effects of polymerization
relates positively with the age of the patient: consequently, shrinkage and to promote complete polymerization of the
the prevalence of carious involvement of the root surface material.23-26 It has also been shown that the use of the compos-
increases.2 Root cementum is a surface with a reactivity3 ite with the bulk technique produces a high cusp deflection.27,28
greater than that of enamel and this makes it more suscepti- The need for a material with low polymerization shrinkage
ble to the action of endogenous metalloproteases as well as has led to the development of a several resin-based compos-
bacterial ones.4 ite materials (siloranes, ormocers, nano-filled composites)
Microleakage is defined as the passage of bacteria and that exhibit lower polymerization shrinkage than conven-
their toxins through the margins of the restoration and the tional composites. However, they still need to be deposited
tooth surface of the cavity preparation.5 The anatomical in maximum increments of ~2 mm due to their limited depth
basis of this phenomenon is the marginal gap between the of polymerization29 and some are also impractical due to the
restoration and the dental tissues; the clinical implications need for a specific adhesive system.30,31 A further improve-
could be postoperative sensitivity, dentinal sensitivity, and ment in the technology has led to the development of mate-
development of secondary caries.6 Hydrolytic degradation rials that have both a reduced polymerization shrinkage and
of the adhesive bond, which can occur both on the adhesive an increased depth of cure (DOC). The combination of these
component and on the collagen of the dental tissue, happens two characteristics allows the material to be deposited in
more frequently when the margins of the restoration are not increments greater than 2 mm of the nonbulk composite.
placed in enamel.7 The optimization of the DOC is achieved through different
As highlighted by Lo Giudice et al,8 a restoration that has strategies:
a cement margin represents challenge for adhesive dentistry
• An increase in translucency32,33 typical of all bulk compos-
techniques: in fact, the higher percentage of organic mate-
ites, with the exception of SonicFill (Kerr);
rial (23%) of the root cementum, compared with enamel
• A modulation of the photo-polymerization that is
(1–2%), makes cementum a substrate that exhibits weaker
obtained, in addition to the presence of camphorqui-
and less predictable adhesion parameters. Furthermore, it
none and tertiary amines, by specific modulators. Tetric
must be emphasized that the presence of failure and mar-
EvoCeram Bulk Fill (Ivoclar Vivadent) contains an addi-
ginal fractures is not eliminated by the use of new adhesives tional photo-initiator: Ivocerin (derivative of dibenzoyl
with higher adhesion values.9,10 Adhesion to cement/dentin germanium).34
is in fact the weak point of the adhesive restoration due to • By new functional monomers: many bulk composites
several factors: hydrolysis of the adhesive layer, inadequate contain modified Uretandimetacrylate (UDMA) with
infiltration of the adhesive into the substrate, and incomplete photo-active groups that would act as modulators of
evaporation of the solvent. Some of these drawbacks can photo-polymerization.35
be modified by varying the type of adhesive strategy11: for
example, the use of functional monomers inside the adhe- In 2010, the first resin-based composite was developed
sive makes possible to obtain an adhesive layer through the that could be deposited in increments of up to 4 mm.36 This
phenomenon of “nano layering”12 preventing hydrolytic deg- new class of materials is collectively referred to as “bulk fill
radation of the adhesive layer.13 Evidence also suggests that resin-based composites.” These composites are heteroge-
a total etch approach produces less marginal discoloration neous in composition and commercial presentation there-
in vivo, without improving postoperative sensitivity,14 but fore a satisfactory classification is difficult, if not impossible.
However, classifying bulk composites according to viscos-
in conclusion neither a total etch approach nor a self-etch
ity, we can divide bulk composites into three classes (see
approach can guarantee the development of a hybrid layer
►Tables 1 and 2 ).
without porosity.15
The marginal gap is directly correlated to the shrinkage • Bulk-fill resin based composite (RBC) with low viscosity
stress of the material and its elastic modulus. The elastic or “base,” used as the base of the restoration that must be
modulus is a characteristic of the material, while the shrink- covered by a layer of no-bulk composite (according to the
age stress is related both to the material and to other factors manufacturer's instructions).
(for example the cavity configuration).16 The gold standard • Bulk-fill high viscosity or “full body” that can be used
materials for restorative dentistry are resin-based compos- throughout the restoration, but may sometimes require a
ites due to their characteristics.17 These materials also find nonbulk composite cap (according to the manufacturer's
application in the cervical region of the dental element instructions).

European Journal of Dentistry Vol. 16 No. 1/2022 © 2021. The Author(s).

 Table 1 Main studies results (Part I)
Juloski et al 201338 Poggio et al 201339 Al-Harbi et al 201643 de Assis et al201644 Scotti et al 201440 García Marí et al 201948 Haak et al 201846

Numerosity 50 cavities 100 cavities 91 cavities 40 cavities 48 cavities 80 cavities 64 interproximal box (128 cavities
MOD)
Cavity 7(x2og) (md)4(ov) 4(ov)mm, gingival wall 4mm (ov) × 1.5mm (md) 5x2x2mm: n 20 2 mm × 2 mm × 2 4mm (og)x4mm (ov), MOD designed:
dimensions mm 2mm below CEJ. 5x4x2mm:n 20 mm 2mm (md) 4mm buccolingual, 4mm
occlusoapical
Box interproximal: 2mm mesio-
distal, 5mm buccolingual, 1–2mm
below la CEJ
Material 1-G-aenial Bond/G- Filtek TM Supreme1 XTE 1-Tetric Ceram HB (TC)(SE/ “Surefil SDR Flow Venus Diamond(1A) FiltekTM Bulk Fill SonicFill (SF) OFL/X,
tested aenial Flo bulk (GB/ Flowable2 TE) vs. (Dentsply) (1B) A2(Group 1) vs.
GF) vs. 2-Tetric EvoFlow (EF) (SE/ vs. vs. Venus diamond vs. Tetric EvoCeram Bulk fill (TEC)
1-GB/G-aenial SDR3 TE) TPH3 Spectrum flow(2A)(2B) Filtek Supreme XTE A2B OFL/X,
Universal Flo bulk vs. vs. (Dentsply)” vs. Surefil SDR (Group 2) vs.
(GUF) Sonic Fill4 3-Smart Dentin flow(3A)(3B) x-tra fil (XF) OFL/X
3-GB/GC Kalore bulk vs. Replacement (SD) (SE/TE) vs.
fill (GK) Grandio5 vs. Premise (P) OFL/X
4-DeTrey 4-SonicFill (SF) bulk(SE/TE)
Conditioner 36 vs.
etching gel (EG)/XP 5-Tetric N-Ceram Bulk Fill
Bond(XB)/ SureFill (TN), bulk (SE/TE)
SDR flow (SDR) vs.
5- Prime (PSA) and 6-Tetric EvoCeram Bulk Fill
bond (BSA) silorane (TE). (SE/TE)
Adhesive System/ vs.
Filtek Silorane (FS) 7 Filtek P90 Low Shrink
Posterior Restorative (P9)
(SE)
Aging Storage in distilled Thermocycling Thermocycling and occlu- Storage in distilled No one Thermocycling Storage in distilled water 37°C for
procedures water 37°C per 24 h sal load water 37°C 24 h or for 180 d
Evaluation Immersion in Immersion in 0.5% Analysis of the copies in Adhesive interface Analysis before and Immersion in 0.5% basic Analysis of the copies in epoxy
of marginal silver nitrate, then basic fuchsin solution epoxy resin. observation of the after artificial aging. fuchsin solution resin

European Journal of Dentistry

integrity in development SEM 200X epoxy resin copies at Methylene blue 1:10 SEM 200X
solution, then ana- 400X
lyzed sections at 2x

Vol. 16
magnification
(Continued)

No. 1/2022
Bulk Resins in the Sealing with Margin in Reticular Cementum

© 2021. The Author(s).

Francesco et al.
3
 4

Table 1 (Continued)
Juloski et al 201338 Poggio et al 201339 Al-Harbi et al 201643 de Assis et al201644 Scotti et al 201440 García Marí et al 201948 Haak et al 201846

Results Median score Group 4 e 5”score 0” Perfect margin percentage Marginal integrity Marginal microle- Microleakage percent- Marginal gap formation (%). SF/
(25–75%) significantly prev- value (PMP%): TC/SE 70.0 (%). Conservative/ akage percentage age. Group1: “score0” OFL-24h 1.5 ± 2.4, SF/OFL-6mesi
Group1: median alent, Group 2 e 3 ±21.5; TC/TE 82.3 ±22.1; bulk: 95.9 ± 2.6; before (A) and after 10%, “score1” 25%, 5.4 ± 4.7; SF/X-24h 21.7 ± 22.5,
score 0 (0–0), “score1”significantly TC+EF/SE 88.7 ±19.3; Extended/ bulk 94.4 aging(B): 1A 45.69, “score2” 40%, “score3” SF/X-6mesi 42.8 ± 31.4; TEC/
Group2: median prevalent, Group 1 TC+EF/TE 88.3 ±20.1; ± 6.7; Conservative/ 2A 32.32, 3A 30.45. 25%. OFL-24h 8.9 ± 9.1, TEC/OFL-6mesi

European Journal of Dentistry

score 0 (0–1) prevalenza significativa TC+SD/SE 79.3 ±25.9; Incremental 93.5 1B 53.10, 2B 40.04, Group2 “score0” 5%, 20.0 ± 22.0; TEC/X-24h 5.5 ± 6.4,
Group3: median di “score 2”significantly TC+SD/TE88.0 ±20.8; SF/ ± 5.8; Extended/ 2C 37.18. “score1” 50%, “score2” TEC/X-6mesi 12.1 ± 12.4; XF/OFL-

Vol. 16
score 0 (0–1) prevalent. SE 90.1 ± 17.2; SF/TE 93.3 Incremental 90.9 ± 35%, “score3” 10%. 24h 2.2 ± 3.8, XF/OFL-6mesi 3.9 ±
Group4: median ±17.8; TN/SE 86 ± 24.0; 8.4. 3.8; XF/X-24h 17.2 ± 24.8; XF/X-
score 2 (2–2) TN/TE 81.4 ± 23.5; TE/ 6mesi 23.1 ± 15.1; P/OFL -24h
Group5: median SE 91.0 ±23.8; TE/TE 76.9 6.2 ± 9.8, P/OFL-6mesi 9.6 ± 16.4,

No. 1/2022
score 0 (0–0) ±29.3; P9/SE89.4 ±28.0 P/X-24h 5.1 ± 2.9, P/X-6mesi 26.3
± 16.5
Statistical p<0.05 p<0.05 p = 0.848 p = 0.77 p<0.204 p = 0.468 p>0.05
analysis

© 2021. The Author(s).

Bulk Resins in the Sealing with Margin in Reticular Cementum
Francesco et al.
 Table 2 Main studies results (Part II)
Webber et al 201441 Kalmowicz et al 201542 Behery et al 201845 Peutzfeldt et al 201847

Numerosity 20 cavities 40 cavities 80 cavities 78 cavities

Cavity dimensions MOD cavity proximal margin 1mm above CEJ, 3mm buccolingual × 3mm (ov) × 1.3mm (md) 4mm (ov), 6mm (oc), 2mm (md)
Distal margin 1mm below CEJ. 1.5mm axial depth × 4mm
3mm occlusopulpal height
3mm (ov).
Material tested SureFil SDR (Dentsply)1 SonicFill (B) Tetric EvoCeram Bulk Fill(1)24h/6mesi, Filtek SupremeXTE(1)
vs. vs. vs. Filtek Bulk Fill(2)
TPH3 composite (Dentsply)2 Herculite Ultra (D) X-tra Fil (2) 24h/6mesi SDR(3)
vs.
QuiXX (3) 24h/6mesi
vs.
TPH Spectra HV (Control) (4) 24h/6mesi
Aging procedures Thermocycling No one and thermocycling Storage for 24h and 6 mo Storage in water for 24h, then mechanical
brushing and thermocycling
Evaluation of marginal 0.5% basic fuchsin immersion In a solution of 1% methyl- 2% procion red solution Analysis before and after artificial aging
integrity ene blue (Imperial Chemical Industries, London, Analysis of the copies in epoxy resin
England) SEM 200X
Results Group 1: 10 “score 2”; Group 2: 2 “score 0,” 1 Group B: median score Gingival score microleakage. Marginal gap formation (%). Group1(SM)
“score1,” 5 “score 2,” 2 “score3,” 2,487 ± 1,091; Group D: Group1/24h 0.30 ± 0.48, Group 1/mo 0.90 ± baseline 2.9 ± 4.8, finale 4.1 ± 6.2, (T)
median score 2,775 ± 1.29; Group2 /24h 0.50 ± 0.71, Group2/6 mo baseline 4.6 ± 8.5, final 4.6 ± 8.9. Group2
0,795 1.10 ± 1.10; Group 3/24h 0.40 ± 0.70, Gruppo (SM) baseline 7.9 ± 27.7, final 9.1 ± 26.9,
3/6mo 0.90 ± 0.88; Group 4/24h 0.40 ± 0.70, (T) baseline 7.9 ± 27.5, final 19.1 ± 28.6.
Group 4/6mo1.00 ± 1.05. Group3(SM) baseline 0 ± 0, final 7.0 ± 19.6,
(T) baseline 0 ± 0, final 0 ± 0
Statistical analysis p = 0.195 p = 0.0586 Difference at 24 h p = 0.945, Difference at 6 Group3 less gap than Group 1 (p < 0.0001),
mo, p = 0.928. Group3 less gap than Group2 (p = 0.0015).
Group 1 e group 2 non no difference (p =
0.4919)
Cavity dimensions 7(og)x2(md)4(ov)mm 4(ov)mm, gin- 4mm (ov) × 1.5mm 5x2x2mm: n 20 2 mm × 2 mm × 2 mm 4mm (og)x4mm (ov), MOD designed:
gival wall 2mm (md) 5x4x2mm:n 20 2mm (md) 4mm buccolingual, 4mm

European Journal of Dentistry

below CEJ. occlusoapical,
Box interproximal: 2mm

Vol. 16
mesiodistal, 5mm buccolingual,
1–2mm below la CEJ
(Continued)

No. 1/2022
Bulk Resins in the Sealing with Margin in Reticular Cementum

© 2021. The Author(s).

Francesco et al.
5
 6

Table 2 Main studies results (Part II)

Webber et al 201441 Kalmowicz et al 201542 Behery et al 201845 Peutzfeldt et al 201847

Material tested 1-G-aenial Bond/G-aenial Filtek TM 1-Tetric Ceram HB “Surefil SDR Flow Venus Diamond(1A)(1B) FiltekTM Bulk Fill SonicFill (SF) OFL/X
Flo bulk (GB/GF) Supreme1 XTE (TC)(SE/TE) vs. (Dentsply) vs. Venus diamond A2(gruppo1) vs.
1-GB/G-aenial Universal Flo Flowable2 2-Tetric EvoFlow (EF) vs. flow(2A)(2B) vs. Tetric EvoCeram Bulk fill (TEC)
bulk (GUF) vs. (SE/TE) TPH3 Spectrum vs. Surefil SDR flow(3A) Filtek Supreme XTE OFL/X
3-GB/GC Kalore bulk fill SDR3 vs. (Dentsply)” (3B) A2B (gruppo2) vs.

European Journal of Dentistry

(GK) vs. 3-Smart Dentin x-tra fil (XF) OFL/X
4-DeTrey Conditioner Sonic Fill4 Replacement (SD) vs.
36 etching gel (EG)/XP vs. (SE/TE) Premise (P) OFL/X

Vol. 16
Bond(XB)/ SureFill SDR Grandio5 vs.
flow (SDR) 4-SonicFill (SF)
5- Prime (PSA) and bond bulk(SE/TE)
(BSA) silorane Adhesive vs.

No. 1/2022
System/Filtek Silorane (FS) 5-Tetric N-Ceram
Bulk Fill (TN), bulk
(SE/TE)
vs.
6-Tetric EvoCeram
Bulk Fill (TE). (SE/TE)
vs.

© 2021. The Author(s).

7 Filtek P90 Low
Shrink Posterior
Restorative (P9)(SE)
Aging procedures Storage in distilled water Thermocycling Thermocycling and Storage in distilled No one Thermocycling Storage in distilled water 37°C for
Bulk Resins in the Sealing with Margin in Reticular Cementum

37°C per 24h occlusal load water 37°C 24h or for 180 d
Evaluation of mar- Immersion in silver nitrate, Immersion in Analysis of the cop- Adhesive interface Analysis before and after Immersion in 0.5% Analysis of the copies in epoxy
ginal integrity then in development solu- 0.5% basic fuch- ies in epoxy resin. observation of the artificial aging. basic fuchsin solution resin.
tion, then analyzed sec- sin solution SEM 200X epoxy resin copies at Methylene blue 1:10 SEM 200X
tions at 2x magnification 400X
Results Median score (25–75%) Group 4 e 5”score Perfect margin Marginal integrity Marginal microleakage Microleakage percent- Marginal gap formation (%). SF/
Francesco et al.

Group1: median score 0 0” significantly percentage value (%). Conservative/ percentage before (A) and age. Group1: “score0” OFL-24h 1.5 ± 2.4, SF/OFL-6mesi
(0–0), Group2: median prevalent, Group (PMP%): TC/SE 70.0 bulk: 95.9 ± 2.6; after aging(B): 1A 45.69, 10%, “score1” 25%, 5.4 ± 4.7; SF/X-24h 21.7 ± 22.5,
score 0 (0–1) 2 e 3 “score1”- ±21.5; TC/TE 82.3 Extended/ bulk 94.4 2A 32.32, 3A 30.45. 1B “score2” 40%, “score3” SF/X-6mesi 42.8 ± 31.4; TEC/OFL-
Group3: median score 0 significantly ±22.1; TC+EF/SE ± 6.7; Conservative/ 53.10, 2B 40.04, 2C 37.18 25%. 24h 8.9 ± 9.1, TEC/OFL-6mesi
(0–1) prevalent, Group 88.7 ±19.3; TC+EF/ Incremental 93.5 ± 5.8; Group2 “score0” 5%, 20.0 ± 22.0; TEC/X-24h 5.5 ± 6.4,
Group4: median score 2 1 prevalenza TE 88.3 ±20.1; Extended/Incremental “score1” 50%, “score2” TEC/X-6mesi 12.1 ± 12.4; XF/
(2–2) significativa di TC+SD/SE 79.3 90.9 ± 8.4 35%, “score3” 10%. OFL-24h 2.2 ± 3.8, XF/OFL-6mesi
Group5: median score 0 “score 2”signifi- ±25.9; TC+SD/ 3.9 ± 3.8; XF/X-24h 17.2 ± 24.8;
(0–0) cantly prevalent. TE88.0 ±20.8; SF/ XF/X-6mesi 23.1 ± 15.1; P/OFL
SE 90.1 ± 17.2; SF/ -24h 6.2 ± 9.8, P/OFL-6mesi 9.6
TE 93.3 ±17.8; TN/ ± 16.4, P/X-24h 5.1 ± 2.9, P/X-
SE 86 ± 24.0; TN/ 6mesi 26.3 ± 16.5
TE 81.4 ± 23.5; TE/
SE 91.0 ±23.8; TE/
TE 76.9 ±29.3; P9/
SE89.4 ±28.0
Statistical analysis p <0.05 p <0.05 p = 0.848 p = 0.77 p<0.204 p = 0.468 p>0.05
(Continued)
 Bulk Resins in the Sealing with Margin in Reticular Cementum Francesco et al. 7

Table 3 Risk of bias (Part I)

Item Poggio Juloski Scotti et Webber et Kalmowicz Al-Harbi et de Assis Haak et al
et al et al al 201440 al 201441 et al 201542 Al 201643 et al 201846
201339 201338 201644
Adequate sequence Unclear Unclear No No Unclear No No Unclear
generation
Allocation concealment No No No No No No No No
Blinding of participants No No No No No No No No
and personnel
Blinding of outcome Yes No No Yes Yes No Yes Yes
assessment
Incomplete outcome No No No No No No No No
data addressed
Free of selective Yes Yes Yes Yes Yes Yes Yes Yes
reporting
Free of other bias Yes Yes No Yes No Yes Yes Yes

Bulk-Fill RBC That Require Sonic Activation standardization of the cavity, which would not be possible to
The practical consequences are considerable. The position- obtain in an in vivo study.
ing of a restoration with a cement margin represents a chal- Were included studies that explicitly described that a cav-
lenge for the clinician associated with the problem of time: ity margin of the preparation was in the root cement. Finally,
the cervical area, in fact, is difficult to control and to access; comparative studies between a bulk fill composite and a non-
moreover, it is difficult to maintain adequate isolation for a bulk composite were chosen.
relatively long period. Moreover, it is shown that the contam-
ination of the cavity preparation with a hemostatic agent sig- Information Sources
nificantly reduces the marginal seal on cement, interfering To identify the literature of our interest, a search was per-
with the adhesive procedures.37 formed on PubMed, Scopus, Google Scholar, Semantic
Therefore, the possibility of using a material that has opti- Scholar, and on gray literature via OpenGrey.eu.
mized physical characteristics and also allows shorter pro-
cessing times is fascinating. Search
In the construction of this research, we wanted to combine
Objectives three fundamental concepts: the anatomical site, the concept
Our aim is to answer the following question according to the
of microinfiltration, and the material (►Fig. 1).
PICOS scheme: in cavity preparation with margins in dental
On April 21, 2020, the following searches were performed:
cementum of human extracted teeth, do bulk fill resin base
composites provide a better marginal sealing than non-bulk
Search on PUBMED
fill resin-based composites?
# 1. “dental cementum” OR “root caries” OR “tooth root” OR
dentin
Methods
# 2. “dental leakage” OR “dental marginal adaptation”
Eligibility Criteria # 3. “filtek bulk fill” OR “SDR composite” OR “composite res-
The search strategy, performed using the PubMed controlled ins” OR “dental bonding” OR “dentin-bonding agents”
vocabulary and free terms, was defined on the basis of the OR “dental cement” OR “resin cements”
following elements of the PICO question: (“Tooth Root” [Mesh] OR “Dentin” [Mesh] OR “Dental
Population (P): Cavity preparations with at least one mar- Cementum” [Mesh]) AND (“Dental Leakage” [Mesh] OR
gin in root cementum of human teeth. “Dental Marginal Adaptation” [Mesh]) AND (“Filtek Bulk Fill”
Intervention (I): restoration made with a bulk fill [Supplementary Concept] OR “Composite Resins” [Mesh]
composite. OR “SDR composite” [Supplementary Concept] OR “Dental
Comparison (C): restoration made with a nonbulk com- Bonding” [Mesh] OR “Dentin-Bonding Agents” [Mesh] OR
posite (resin-based composite). “Dental Cements” [Mesh] OR “Resin Cements “[Mesh])
Outcome (O): marginal integrity and/or microleakage
Study design (S): in vitro studies. Search on Scopus
The eligibility criteria are: in vitro studies, published in
the last 10 years (given the date of introduction of the mate- # 1 Cementum OR “root surface” OR “dental cementum” OR
rial on the market) and written in English, it was decided to “tooth root” OR “cement enamel junction” OR “tooth
include studies on human teeth and in vitro studies to have a cementum” OR “tooth cervix” OR “dental cementum”
OR “dental cementum” OR “root caries”

European Journal of Dentistry Vol. 16 No. 1/2022 © 2021. The Author(s).

8 Bulk Resins in the Sealing with Margin in Reticular Cementum Francesco et al.

Table 4 Risk of bias (Part II)

Behery et al 201845 Peutzfeldt et al 201847 García Marí et al 201948
Adequate sequence generation? No No No
Allocation concealment? No No No
Blinding of participants and personnel? No No No
Blinding of outcome assessment? No No Yes
Incomplete outcome data addressed? No No No
Free of selective reporting? Yes Yes Yes
Free of other bias? Yes Yes Yes

Table 5 Risk of bias (Part III)

Item Poggio Juloski Scotti Webber Kalmowicz Al-Harbi de Assis Haak Behery et Peutzfeldt et García Marí et
et al et al et al et al et al et al et al et al al 201845 al 201847 al 201948
2013 2013 2014 2014
39 38 40 41
2015 42
2016 43
2016 44
2018 46

Random
sequence
generation
Allocation
concealment

Blinding of
participants and
personnel
Blinding of
outcome
assessment
Incomplete
outcome data

Selective
reporting

Other bias

# 2 Microleakage OR “dental leakage” OR “cervical micro- The results were limited to the last 10 years and to studies
leakage” OR “dental restoration failure” OR “mineral performed on the human species.
interfaces” OR “marginal quality” OR “gap formation”
OR “thooth hypersensitivity” Study Selection
Two reviewers independently assessed the titles and
# 3 “Composite resins” OR “dental composites” OR
abstracts of all of the studies. Any disagreement regarding
“resin-based composite” OR “bulk fill” OR “resin compos-
the eligibility of the included studies was resolved through
ite” OR “bulk-fill” OR “composite resin” OR “filtek bulk discussion and consensus or by a third reviewer.
fill” OR “composite resin” OR “SDR composite” OR “dental
bonding” OR “dentin bonding agents” OR “dental cement” Data Collection Process
OR “resin cement” The data collection strategy was defined on the basis of the
Additional searches were performed on Google scholar characteristics of the PICOS model, to these characteristics
and semantic Scholar using the terms “bulk fill” and were added explicitly through a predefined table. Data was
“microleakage” collected based on the default table by the two reviewers.
A further search, which did not exclusively include
PubMed indexed literature, was performed by combining the Data Items
term “bulk fill,” using the AND operator, from time to time to The ►Tables 1 and 2 evaluate the general data (year, title,
the terms II class, III class and V class to try to introduce the and author), the size of the sample (the number of cavities),
studies that referred to the design of the cavity rather than the dimensions of the cavity, the materials tested, whether
the concept of “root cement” an artificial aging procedure has been performed, and the

European Journal of Dentistry Vol. 16 No. 1/2022 © 2021. The Author(s).

 Bulk Resins in the Sealing with Margin in Reticular Cementum Francesco et al. 9

method used to evaluate the marginal integrity (immersion In the study of Scotti et al,40 48 cavities restored with
in dye and which dye or Scanning electron microscope evalu- three different materials: Venus Diamond (1A) (1B), Venus
ation of the epoxy replicas) and the results. diamond flow (2A) (2B), and Surefil SDR flow (3A) (3B). The
Within each publication, the data and statistical signif- samples were evaluated before (A) and after artificial aging (B)
icance characteristics of the only interfaces between the by thermocycling. The results show that the influence of the
restoration and the margin of the cavity preparation in root material is not statistically significant on the microleakage.
cement were collected. In the study by Webber et al,41 20 cavities were prepared,
restored with SureFil SDR (Dentsply)1 and TPH3 composite
Risk of Bias in Individual Studies (Dentsply).2 The samples were subjected to thermal cycling
To define the validity of the individual studies, the risk of bias and immersed in basic fuchsin. The results show that there
was determined using the “Cochrane Collaboration's tool for is no statistically significant difference in microinfiltration.
assessing risk of bias in randomized trials” (►Tables 3–5). In the study Kalmowicz et al,42 40 cavities SonicFill (B),
Herculite Ultra (D) were considered. An analysis was per-
Synthesis of Results formed before and after thermocycling by immersion in
A narrative summary of the studies included in the review methylene blue and observation. There were no statistically
was made. It was not possible to carry out a meta-analysis significant differences in microinfiltration.
due to the heterogeneity of the studies. In the study of Al-Harbi et al,43 91 cavities assigned to
13 restorative approaches were considered: in particular,
the different materials were combined with a self-etch or
Results
total etch adhesive technique, with the exception of Filtek
Study Characteristics P90 applied only with self-etch technique: Tetric Ceram HB
The 11 selected studies were deemed eligible based on the (TC) (SE / TE), TetricEvoFlow (EF) (SE / TE), Smart Dentin
predetermined PICOS criteria. Methods: selected studies are Replacement (SD) (SE / TE), SonicFill (SF) bulk (SE / TE), Tetric
in vitro studies, in English language N-Ceram Bulk Fill (TN), bulk (SE / TE), Tetric EvoCeram Bulk
Participants: The studies evaluate experimental cavity Fill (TE) (SE / TE), Filtek P90 Low Shrink Posterior Restorative
preparations in human teeth, which expressly present at (P9) (SE). The specimens were subjected to thermal and
least one root cement margin, have a total of 691 (►Fig. 1). occlusal cycling. SEM analysis of the copies in epoxy resin
Intervention: The intervention was the restoration with was performed. There is no statistically significant difference
a bulk fill composite and the outcome evaluated was the in marginal integrity.
degree of marginal adaptation. In the study of de Assis et al,44 40 cavities were considered,
Outcome: Data relating microinfiltration or marginal assigned to two different restorative protocols: Surefil SDR
integrity were evaluated using different systems. Flow (Dentsply) and TPH3 Spectrum (Dentsply). Samples
The summary data can be found in ►Tables 1 and 2. were stored in distilled water at 37°C, and copies in SEM
epoxy resin were observed. There is no statistically signifi-
Risk of Bias cant difference in marginal integrity between the materials
The risk of bias was performed using the “Cochrane tested.
Collaboration's tool for assessing risk of bias in randomized In the study of Behery et al,45 80 cavities were prepared
trials” (►Tables 3–5). for restoration with four different materials: Tetric EvoCeram
Bulk Fill(1) 24 hours/6 months, X-traFil(2) 24 hours/6 months,
Results of Individual Studies QuiXX(3) 24 hours/6 months, and TPH Spectra HV (control)
In the study of Juloski et al,38 50 cavities were prepared, then (4) 24 hours/6 months. The samples were stored at standard
the following materials were tested SureFil SDR flow versus conditions for 24 hours or 6 months. Then dipped in Procyon
Filtek Silorane versus G-ænial Flo bulk fill versus G-ænial red solution. The results show that there is no statistically
Universal Flo bulk fill versus Kalore bulk fill, and the sam- significant difference between the gingival microleakage
ples were stored for 24 hours at 37°C in distilled water, then of the four groups after 24-hour storage and after 6-month
immersed in silver nitrate, then in developer solution, and storage.
then sections were analyzed at 2x magnification. In the study of Haak et al,46 64 interproximal boxes were
The results show that SDR has greater microleakage than considered, restored with four different materials. The mate-
other materials. rials were used with two different adhesives each: SonicFill
In the study of Poggio et al,39 100 cavities were prepared (SF) OFL/X, TetricEvoCeram Bulk fill (TEC) OFL/X, x-tra fil (XF)
and then were restored with four different materials: Filtek OFL/X, Permise (P) OFL/X. Following storage in distilled water
TM Supreme XTE Flowable(1), SDR(2), Sonic Fill(3), and at 37°C for 24 hours or 180 days, an analysis of the copies in
Grandio(4). The samples were subjected to thermocycling epoxy resin was performed with SEM. The results highlight
and then immersed in a 0.5% basic fuchsin solution. The that there is no statistically significant difference between
results show that there is a difference according to the differ- bulk fill composites and control.
ent composite used: In the study of Peutzfeldt et al,47 78 cavities restored
Sonic Fill and Grandio perform better than the, GrandioSo with three different materials: Filtek SupremeXTE(1), Filtek
and SDR. Worst performance is seen with Filtek supreme.

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10 Bulk Resins in the Sealing with Margin in Reticular Cementum Francesco et al.

Bulk Fill(2), and SDR(3) were made. The samples were a tissue that is not ideal for adhesive techniques, exposed to
treated by storage in water for 24 hours, then aging with the high risk of infiltration during the isolation phase. The
mechanical brushing (SM) and thermocycling (T). Analysis cavity margin of the cement preparation therefore represents
of the SEM epoxy resin copies before and after artificial a weak point in the interface of the adhesive restoration.49-54
aging showed that the SDR material has the smallest mar- In the presence of these anatomical assumptions, new tech-
ginal gap. There is no difference between Filtek Supreme nologies can be useful providing materials with high adapt-
and Filtek Bulk Fill. ability and marginal seal, with low polymerization shrinkage
In the study by García Marí et al,48 80 cavities were ana- and therefore with reduced tension forces on the adhesive
lyzed. Restored with two different materials: FiltekTM Bulk interface. Successfully Lo Giudice et al8 used a flowable com-
Fill A2 (group1) and Filtek Supreme XTE A2B (group2). The posite at the interface with the root cementum to exploit the
samples were subjected to thermocycling, then immersed in low elastic modulus of the material to reduce the effects of
a 0.5% basic fuchsin solution. The analysis showed that the polymerization stress; however, it was impossible to obtain a
percentages of the microleakage score show nonstatistically marginal seal. Better standardization of the cavity would be
significant differences between the various groups. useful; also in reference to the fact that bulk-fill composites
seem to be more advantageous especially in deep cavities.16,55
A great variability is also present in the evaluation phase
Discussion
due to the presence of different techniques and consequently,
A narrative summary of the studies included in the review of different methods for evaluating marginal integrity.
was made. It was not possible to carry out a meta-analysis A further confounding factor is that materials with very
due to the heterogeneity of the methods and the evaluation heterogeneous characteristics are included in the class of
of the results of the individual studies. bulk fill resin-based composite materials, which are further
Despite the lack of a standardized protocol for the evalua- classified, in a variously incomplete way, based on viscosity.
tion of bulk fill composites at the root cement interface, the However, with all the limitations described above, the
studies analyzed do not reveal statistically significant differ- selected studies show that there is substantially no statisti-
ences in terms of marginal adaptation between the class of cally significant difference in the marginal integrity of the
nonbulk fill composites and the class of bulk fill composites cement margins of cavity preparations restored with bulk
in eight of the studies analyzed40-46,48 (463 cavities). fill composites compared with those restored with non-bulk
However, three studies show statistically significant dif- composite.
ferences between tested materials: Our results are in line with previous research: there is a
Poggio et al39 showed that there is a statistically significant significant heterogeneity within the class of bulk fill compos-
difference in terms of microinfiltration following immersion ites55,56 not a better or worse seal is clearly observed.40,43,52,57-60
in basic fuchsin dye: in particular in their study the products Furthermore, there is no need for the incremental tech-
SonicFill (bulk) and Grandio (nanohybrid) have better per- nique that is highly sensitive, operator dependent, and prone
formances compared with GrandioSo (nanohybrid) and SDR to inevitable errors (contamination between the layers,
(bulk fill), with Filtek Supreme having the worst infiltration. incorporation of air bubbles between the layers) that can
Peutzfeldt et al47 instead show that the SDR material has compromise the quality of the restoration.54,61,62
the smallest marginal gap compared with Filtek Supreme
(control) and Filtek bulk fill (bulk fill), which do not show Limitations
statistically significant differences between them. Unfortunately, must be highlighted, an extreme heteroge-
Juloski38 et al point out that the SDR material presents the neity of the studies: even though these are in vitro experi-
greatest microleakage. ments, it is not possible to define the standard dimensions of
Even in the studies that show a statistically significant dif- the cavities of each study, since each investigator has chosen
ference between the materials tested, it should be empha- slightly different dimensions.
sized that the best or worst marginal seal performance is not The extreme variability is found event in the choice of the
relative to the overall class of bulk composites, but is the pre- material. Considering that it is difficult to classify bulk com-
rogative of the individual products. posites on the basis of their chemical characteristics, we carry
Technical skill, the need for isolation under the dam, and out a classification on the basis of the macroscopic physical
the time required to carry out the restoration are elements characteristics, which, however, is largely incomplete as they
that cannot always be fully satisfied due to factors related to are also minimal variations in the content of filler or mono-
the skill of the operator, the anatomical site of the restoration, mer63 or molecules that accompany and modulate the photo-
and errors that cannot be completely eliminated. To com- polymerization is accompanied by variability of the physical
plete a restoration quickly, the industry has developed in the behavior of the material, variability of the elastic modulus
last 10 years resin-based composite materials with peculiar are significant even within the same category of materials in
characteristics that allow them to be deposited in incremen- consideration of the fact that the filler content, which varies
tal layers up to 4 mm while reducing the time required and between the different bulk composites strongly influences
the possibility of making technical errors. These operational the elastic modulus of the material. Certainly, a learning
possibilities become particularly useful in conditions such as curve in the use of these materials is essential and further-
cavity preparations with root cement margin where we find more it is necessary to consider the operator-addiction. The

European Journal of Dentistry Vol. 16 No. 1/2022 © 2021. The Author(s).

 Bulk Resins in the Sealing with Margin in Reticular Cementum Francesco et al. 11

use of magnification systems, for example, as already evalu- Conflict of Interest

ated in the literature, can be essential in the clinical results of None declared.
this type of practice.33,64-66
Acknowledgment
The variability is also reflected in the absence or presence
A brief version of this manuscript has been presented in
of artificial aging of the restoration and in the method of
XXVII Congresso Nazionale CDUO, Italy. We would like
evaluating the marginal adaptation that, in fact, is performed
to thank Cristina Tamà, Giuliano Calapaj, and Manuele
in different ways in these studies: immersion in 0.5% basic
Arcudi for those early version preparations.
fuchsin solution, immersion in 10% methylene blue, immer-
sion in 1% methylene blue, immersion in 2% Procion Red
solution, and SEM analysis of the copies in epoxy resin. References
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