Ó

Operative Dentistry, 2015, 40-2, 190-200

Bulk-Fill Resin Composites:

Polymerization Contraction, Depth

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of Cure, and Gap Formation
AR Benetti  C Havndrup-Pedersen  D Honoré
MK Pedersen  U Pallesen

Clinical Relevance
The filling of deep, wide cavities with bulk-fill resin composites is appealing. However, in
Class II cavities some bulk-fill resin composites result in larger gaps on dentin walls than
observed for a conventional resin composite.

SUMMARY aim of this study, therefore, was to compare

The bulk-filling of deep, wide dental cavities is the depth of cure, polymerization contraction,
and gap formation in bulk-fill resin composites
faster and easier than traditional incremental
with those of a conventional resin composite.
restoration. However, the extent of cure at the
To achieve this, the depth of cure was assessed
bottom of the restoration should be carefully
in accordance with the International Organi-
examined in combination with the polymeri- zation for Standardization 4049 standard, and
zation contraction and gap formation that the polymerization contraction was deter-
occur during the restorative procedure. The mined using the bonded-disc method. The gap
*Ana R Benetti, DDS, MSc, PhD, assistant professor, formation was measured at the dentin margin
Department of Odontology, University of Copenhagen, of Class II cavities. Five bulk-fill resin compos-
Copenhagen, Denmark ites were investigated: two high-viscosity (Te-
Cæcilie Havndrup-Pedersen, undergraduate dental student, tric EvoCeram Bulk Fill, SonicFill) and three
Department of Odontology, University of Copenhagen, low-viscosity (x-tra base, Venus Bulk Fill, SDR)
Copenhagen, Denmark materials. Compared with the conventional
Daniel Honoré, undergraduate dental student, Department of resin composite, the high-viscosity bulk-fill
Odontology, University of Copenhagen, Copenhagen, Den- materials exhibited only a small increase (but
mark significant for Tetric EvoCeram Bulk Fill) in
Maiken K Pedersen, undergraduate dental student, Depart- depth of cure and polymerization contraction,
ment of Odontology, University of Copenhagen, Copenhagen, whereas the low-viscosity bulk-fill materials
Denmark
produced a significantly larger depth of cure
Ulla Pallesen, DDS, chief dental officer, Department of and polymerization contraction. Although
Odontology, University of Copenhagen, Copenhagen, Den-
mark
most of the bulk-fill materials exhibited a gap
formation similar to that of the conventional
*Corresponding author: Norre Allé 20, Copenhagen, 2200,
Denmark; e-mail: [email protected]
resin composite, two of the low-viscosity bulk-
fill resin composites, x-tra base and Venus
DOI: 10.2341/13-324-L
Bulk Fill, produced larger gaps.
Benetti & Others: Curing vs Gap Formation of Bulk-Fill Resin Composites 191

INTRODUCTION ture. Additionally, if the resin composite has limited

Bulk-filling techniques have become more widely depth of cure, it is likely to generate less contraction
used following the development of materials with stress around the cavity walls and margins, thus
improved curing,1,2 controlled polymerization con- possibly disguising an improved marginal adapta-
traction stresses,3,4 and reduced cuspal deflection.5 tion due to poor polymerization. The complexity of
Using this approach, the number of increments interaction between some of these factors1,13,15 may
required to fill a cavity is reduced in comparison be further aggravated in cavities with an increased
with traditional incremental filling techniques. In C-factor24,25 or in the deeper and wider cavities,

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contrast to the maximum 2-mm increments recom- which are often encountered in the occlusal and
mended for conventional resin composites, manufac- approximal surfaces of posterior teeth.
turers recommend 4- or 5-mm increments of the Earlier research has demonstrated lower cuspal
bulk-fill resin composites. The use of the bulk-fill deflection after restoration of mesio-occlusodistal
technique undoubtedly simplifies the restorative (MOD) cavities with two bulk-fill materials when
procedure and saves clinical time in cases of deep, compared with a nanohybrid resin composite.5 This
wide cavities. However, the data available for these corroborates the previously reported findings of lower
materials are currently limited,6 and therefore polymerization contraction stresses for a bulk-fill
further laboratory studies are required in order to resin composite.3 Finally, under fatigue testing,
provide insight into likely clinical outcomes. similar marginal integrity was observed in MOD
The use of thicker increments in bulk-fill resin cavities restored with one type of bulk-fill material
composites is due to both developments in photo- and conventional resin composites.26 Despite the
initiator dynamics and their increased translucen- positive results reported from previous studies, bulk-
cy,7 which allows additional light penetration and a fill resin composites are somewhat recent materials
deeper cure.8,9 Other than the improved depth of with varied composition and handling characteristics,
cure, recently developed bulk-fill resin composites and thus have different physical properties.2,3,6,27-30
exhibit lower polymerization contraction stress and Additionally, the availability of newer bulk-fill mate-
contraction rates than hybrid and flowable resin rials justifies further investigations because the
composites.3 However, a higher modulus of elasticity overall properties of resin composite materials are
and increased plastic deformation suggest that the usually composition-dependent.6,27 Therefore, the aim
interfacial stress accumulation generated when of this study was to investigate the polymerization
using these bulk-fill materials, as well as the contraction, depth of cure, and gap formation of bulk-
resulting consequences such as cuspal deflection fill resin composites. The null hypotheses investigated
and marginal gaps, may be difficult to predict.3 were that 1) the polymerization contraction, 2) the
depth of cure, and 3) the gap formation of bulk-fill
Gap formation may result from excessive contrac-
resin composites are similar to those observed for a
tion stresses at the interface between the restoration
conventional resin composite.
and the tooth,5,10,11 which can be a consequence of
the polymerization rate of the material12 and the
METHODS AND MATERIALS
magnitude of polymerization contraction.11,13 Addi-
tionally, contraction stresses are influenced by the The polymerization contraction and depth of cure of
composition and filler content of the resin compos- high-viscosity (Tetric EvoCeram Bulk Fill, Ivoclar
ite,1,13,14 its elastic modulus,12,15 and its ability to Vivadent, Schaan, Liechtenstein; SonicFill, Kerr
flow, and thus compensate for the stresses generated Corporation, Orange, CA, USA) and low-viscosity
during polymerization.11-13,16 The degree of conver- (x-tra base, Voco GmbH, Cuxhaven, Germany;
sion12,13,17 as well as depth of cure18 of the material Venus Bulk Fill, Heraeus Kulzer GmbH, Hanau,
are also likely to influence the development of Germany; SDR, Dentsply Caulk, Milford, DE, USA)
stresses, which may affect the quality of the bond bulk-fill resin composites were compared with a
at the interface of restorations. In materials with conventional resin composite (Tetric EvoCeram,
increased polymerization contraction, the interfacial Ivoclar Vivadent). The investigated materials were
stresses are more likely to be higher than can be extruded from their respective capsules with the
compensated for by relaxation of the material 16 and help of a manual applicator, with the exception of
cuspal deflection.5,19,20 If these interfacial stresses SonicFill, which due to its higher viscosity was
exceed those that can be supported by the adhesive extruded using its respective sonic handpiece (Kavo
layer, gap formation will occur,21-23 thus compromis- SonicFill, Kavo Dental GmbH, Biberach, Germany)
ing the adhesive reinforcement of the tooth struc- attached to pressurized air.
192 Operative Dentistry

Table 1: Investigated Restorative Materials and Their Composition According to Information Provided by the Respective
Manufacturers
Composite Monomers Fillers
Venus Bulk Fill, Heraeus, Lot: 010031 Urethane dimethacrylate Barium glass
Ethoxylated bisphenol A dimethacrylate Ytterbium trifluoride
Silicon dioxide (65 wt%, 38 vol%)
SDR, Dentsply Caulk, Lot: 1106281 Modified urethane dimethacrylate Barium glass
Ethoxylated bisphenol A dimethacrylate Strontium glass (68 wt%, 45 vol%)

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Triethyleneglycol dimethacrylate
x-tra base, Voco, Lot: 1137400 Dimethacrylates Inorganic fillers (75 wt%)
Tetric EvoCeram Bulk Fill, Ivoclar Vivadent, Lot: P48869 Urethane dimethacrylate Barium glass
Bisphenol A dimethacrylate Ytterbium trifluoride
Mixed oxide
Prepolymer (79-81 wt%, 60-61 vol%)
SonicFill, Kerr, Lot: 3739797 Ethoxylated bisphenol A dimethacrylate Barium glass
Bisphenol A dimethacrylate Silicon dioxide (83.5 wt%)
Triethyleneglycol dimethacrylate
Tetric EvoCeram, Ivoclar Vivadent, Lot: P40104 Urethane dimethacrylate, Barium glass
Bisphenol A dimethacrylate Ytterbium trifluoride
Mixed oxide
Prepolymer (82-83 wt%)

Polymerization Contraction In order to calculate the strain from the displace-

Polymerization contraction of the investigated mate- ment of the plotter tip on the graph paper, it was
rials (Table 1) was assessed with the bonded-disc necessary to determine the values of the variables c1,
method.31 Triplicates were conducted for each inves- c 2, and L0. The value of c 1 was obtained by
tigated material. Standard amounts of the different performing a calibration of the LVDT. This calibra-
materials (0.22 6 0.02 g), which corresponded tion involved measuring the voltage output of the
approximately to one application capsule, were LVDT while displacing the LVDT rod in controlled
inserted on top of a glass plate attached to a metallic increments using a micrometer head. A linear
ring. On top of the ring, a thin glass lamina was regression was performed on these points, which
positioned. A linear variable differential transformer led to a value of c1 equal to 951 V/m (R2=0.9999). The
(LVDT; 7DCDT-100, Hewlett-Packard, Waltham, value of c2 corresponded to the scale factor set on the
MA, USA) connected to a power output of 5 V rested plotter and was equal to 4 m/V. The original sample
on the surface of the thin glass lamina. A light- length L0 corresponded to the thickness of the
emitting-diode device (950650 mW/cm2, bluephase, metallic ring in the experimental setup and was
Ivoclar Vivadent) placed underneath the glass lamina equal to 1.93 mm. Substituting these values of the
was used to light-activate the investigated materials variables into equation (1) demonstrated that 1 mm
for 20 seconds. When light-activation was initiated, of displacement on the graph paper corresponded to
the materials contracted and deformed the glass a polymerization contraction of 0.26 lm, or the
lamina, thus resulting in displacement of the LVDT. equivalent strain of 0.014%. The error associated
The displacement of the LVDT was registered at two, with these measurements was approximately 2%.
five, 20, and 60 minutes after irradiation in a plotter
(LKB Bromma 2210 2-channel recorder, Bromma, Depth of Cure
Sweden). Values of vertical linear displacement of the The depth of cure of the investigated materials
LVDT after 60 minutes were converted to polymeri- (Table 1) was assessed according to International
zation contraction (strain measured as a percentage) Organization of Standards 4049.32 Each material
using the formula: was inserted in a metallic mold with an orifice of 4
mm in diameter and 12 mm in depth. The mold was
e% ¼ ðdp 3 100Þ=ðc1 3 c2 3 L0 Þ ð1Þ pressed between polyester strips covered by glass
slides and placed on white filter paper. The material
where e% = strain (%); dp = displacement of plotter was light-activated (950650 mW/cm2, bluephase,
tip on graph paper (m); c1 = LVDT scale factor (V/m); Ivoclar Vivadent) from the upper orifice during 20
c2 = plotter scale factor (m/V); and L0 = original seconds. Each specimen was removed from the mold,
length of sample (m). and the uncured material in the bottom was scraped
Benetti & Others: Curing vs Gap Formation of Bulk-Fill Resin Composites 193

off with a plastic spatula. The height of the hardened the conventional resin composite (Tetric EvoCeram,
material was measured in the center of the specimen Ivoclar Vivadent) that was light-activated for 20
with a micrometer (Carl Mahr GmbH, Esslingen, seconds. The control group was restored with four
Germany), and this value was divided by two in oblique increments of the conventional resin com-
order to determine the depth of cure. Triplicates posite (Tetric EvoCeram), each light-activated for 20
were conducted for each investigated material. seconds.
After the restorative procedure, the teeth were
Gap Formation

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stored in water for 10 minutes prior to preparation
Gap formation was assessed in Class II cavities for the gap analysis. Specimens were not subjected to
(vertical slot cavities) in extracted human molars thermocycling or cyclic loading, so that the effect of
using a method modified from Dewaele and others.23 the restorative material alone could be assessed. The
The teeth were extracted for therapeutic reasons; gap formation between the restorative materials and
the research complies with the Use of Anonymous the dentin was assessed in faciolingual (n=6) or
Human Biological Material Act on Research Ethics mesiodistal (n=10) sections. Each section was se-
Review of Health Research Projects (from June 14, quentially ground with wet paper discs #220, #500,
2011), the National Committee on Health Research and #1000 (Labopol-1, Struers A/S, Rødovre, Den-
Ethics, Denmark. A total of 96 standardized cavities mark) and polished with aluminum oxide powder to
were prepared under water cooling in the approxi- obtain a flat and regular surface. After polishing,
mal surfaces of the molars, with these dimensions each section was rinsed with pressurized water,
(60.5 mm): width, 4 mm; height, 6 mm; depth, 2 mm. dried with absorbent paper, and then analyzed in the
The teeth were then divided into six groups (n=16): light microscope (Orthoplan, Ernst Leitz GmbH,
five experimental and one control. In the experi- Wetzlar, Germany) under 5103 magnification. The
mental groups, the cavities were filled with a bottom dentin-restoration interface was analyzed at seven
layer of the bulk-fill materials and an occlusal layer sites in the faciolingual sections (Figure 1): the
of the conventional resin composite. Cavities in the midgingival wall, the faciogingival and linguogingi-
control group were filled incrementally with the
val angles, and two sets of points along the dentinal
conventional resin composite. Because the manufac-
facial and lingual walls where the largest gaps and
turers recommend an occlusal coverage of the low-
its corresponding direct opposite locations were
viscosity bulk-fill materials with a conventional
observed. In the mesiodistal cuts, six reference
resin composite to offer improved esthetics and
points were used to analyze the dentin-restoration
mechanical performance,27 the same condition was
interface (Figure 1): the gingival cavosurface mar-
reproduced for all the investigated materials, in-
gin, half the distance of the gingival wall, the
cluding the high-viscosity bulk-fill materials (al-
axiogingival angle, and respectively one-fourth,
though this is not a recommendation from the
one-half, and three-quarters of the height of the
manufacturers).
dentinal axial wall. The size of the gaps in the
The enamel and dentin surfaces of each cavity different locations was measured using a reference
were etched with 37.5% phosphoric acid (Gel scale visible in the objective of the microscope. A
Etchant, Kerr Italia Srl, Scafati, Italy) for 30 and mean gap was calculated for each individual section,
10 seconds, respectively. After rinsing for 15 seconds, and an average gap formation was obtained for each
the excessive water was removed without dehydrat- investigated material from the combined mesiodistal
ing the dentin. The primer (Optibond FL, 1 Prime, and faciolingual sections.
Kerr Italia Srl) was actively applied in the cavity,
followed by air-drying for five seconds. The adhesive
Statistical Methods
(Optibond FL, 2 Adhesive, Kerr Italia Srl) was then
actively applied, air-dried for three seconds, and Polymerization contraction and depth of cure were
light-activated for 20 seconds (950650 mW/cm2, analyzed by a one-way analysis of variance test and
bluephase, Ivoclar Vivadent). In the experimental the Tukey honestly significant difference (HSD) post
groups, a 4-mm increment of the designated bulk-fill hoc test. Due to their lack of normal distribution, gap
resin composite (Table 1) was inserted into the cavity measurements were analyzed by the Mann-Whitney
and against a metallic matrix (Hawe Contoured U-test, each group being compared against the
Matrices, KerrHawe SA, Bioggio, Switzerland) and control group. Possible correlations between the
then light-activated for 20 seconds. This increment investigated properties were analyzed using the
was subsequently covered by a 2-mm increment of Pearson test. The level of significance was 5%.
194 Operative Dentistry

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Figure 1. The schematic drawing represents with dots the locations where the gaps between the restorative materials and dentin were assessed,
both in faciolingual (FL) or mesiodistal (MD) sections.

RESULTS resin composite (Tetric EvoCeram) (Table 2). No

Significantly different polymerization contraction significant difference in gap formation was observed
(Figure 2) was observed between the investigated between the conventional resin composite and SDR
materials (p,0.001). The conventional resin com- (p=0.880), Tetric EvoCeram Bulk Fill (p=0.925), or
posite Tetric EvoCeram presented the lowest poly- SonicFill (p=0.243) (Table 2).
merization contraction, not significantly different Gap formation was positively correlated with
from SonicFill (p=0.061) but significantly lower than depth of cure of the investigated materials
Tetric EvoCeram Bulk Fill (p=0.001, Table 2). The (r2=0.736, p=0.029). No significant correlation was
low-viscosity bulk-fill resin composites demonstrated observed between gap formation and polymerization
higher polymerization contraction: SDR and x-tra contraction of the investigated resin composites
base showed an intermediate behavior, whereas (r2=0.599, p=0.71). However, because a pattern
Venus Bulk Fill presented the highest polymeriza- was identified within the results and one particular
tion contraction (p,0.001, Table 2). material seemed to stand out from the others, a
Depth of cure (Figure 3) was, in general, improved second Pearson correlation test was conducted, this
for the bulk-fill resin composites when compared time excluding SDR. With the exclusion of SDR, a
with the conventional resin composite (p,0.001). strong positive correlation was identified between
SonicFill demonstrated depth of cure statistically gap formation and polymerization contraction (ex-
similar to that of the conventional resin Tetric cluding SDR: r2=0.975, p=0.002), thus indicating
EvoCeram (p=0.056; Table 2). The low-viscosity that this material has a different behavior from the
bulk-fill resin composites x-tra base and Venus Bulk other investigated materials (Figure 5).
Fill demonstrated significantly higher depth of cure
compared with the low-viscosity bulk-fill resin DISCUSSION
composite SDR (p,0.001) or the high-viscosity Gap formation is the consequence of an interaction
bulk-fill resin composite Tetric EvoCeram Bulk Fill among several factors,1,13,15 which adds complexity
(p,0.001) (Table 2). to understanding this phenomenon. This study
In general, the low-viscosity bulk-fill resin com- focused on two of the factors involved in gap
posites investigated in this study demonstrated formation: polymerization contraction and depth of
higher polymerization contraction and depth of cure. cure.
A significant positive correlation was identified Because the polymerization contraction of most of
between the polymerization contraction and the the bulk-fill materials was higher than that of a
depth of cure of the investigated materials conventional resin composite (Figure 2), the first
(r2=0.806, p,0.001). null hypothesis was rejected. The low-viscosity bulk-
Gap formation (Figure 4) was significantly larger fill resin composites containing lower filler volume
for x-tra base (p=0.005) and Venus Bulk Fill (Venus Bulk Fill, SDR, and x-tra base) demonstrated
(p=0.016) when compared with the conventional higher polymerization contraction values. Converse-
Benetti & Others: Curing vs Gap Formation of Bulk-Fill Resin Composites 195

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Figure 2. Polymerization contraction (%) for the investigated materials obtained 60 seconds after light-activation using the bonded-disc method. The
horizontal lines indicate the homogeneous grouping obtained from the Tukey HSD post hoc test.

Table 2: Average Contraction (%) and Depth of Cure (mm), With Respective Standard Deviations, as well as Median Dentin Gap
Formation and Range (lm) for Each Investigated Resin Composite
Composite Contraction, %a Depth of Cure, mma Gap, lmb
Venus Bulk Fill, Heraeus 3.36 (0.13) D 5.57 (0.28) D Median, 10.2*
Range, 3.6-31.7
SDR, Dentsply Caulk 2.80 (0.06) C 4.34 (0.15) C Median, 6.1
Range, 3.3-33.0
x-tra base, Voco 2.76 (0.13) C 5.68 (0.21) D Median, 9.3*
Range, 5.2-36.6
Tetric EvoCeram Bulk Fill, Ivoclar Vivadent 2.03 (0.05) B 3.82 (0.08) BC Median, 6.6
Range, 3.2-21.1
SonicFill, Kerr 1.83 (0.10) AB 3.43 (0.07) AB Median, 7.1
Range, 3.9-18.0
Tetric EvoCeram, Ivoclar Vivadent 1.58 (0.04) A 2.90 (0.28) A Median, 6.2
Range, 3.0-12.3
a
For contraction and depth of cure, different letters represent significant differences (Tukey HSD post hoc test, p,0.05).
b
Median dentin gap formation and range (lm) from the combined mesiodistal and faciolingual sections of teeth restored with the investigated materials.
* For dentin gap formation, indicates significant differences between the bulk-fill resin composites and the conventional composite (Mann-Whitney U-test, p,0.05).
196 Operative Dentistry

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Figure 3. Depth of cure (mm) of the investigated materials according to ISO 4049. The horizontal lines indicate the homogeneous grouping obtained
from the Tukey HSD post hoc test.

ly, high-viscosity bulk-fill resin composites with a mean depth of cure of 3.43 mm, SonicFill also failed
higher filler fraction (SonicFill and Tetric EvoCeram to comply with the requirement from ISO 4049,
Bulk Fill) presented polymerization contraction which states that the individual values for depth of
values closer to the conventional resin composite cure of a material shall be no more than 0.5 mm
(Tetric EvoCeram). An increase in the filler content below the value stated by the manufacturer.32 The
can, to a certain extent, reduce the polymerization manufacturer of SonicFill states that the material
contraction13,14 due to the decrease in the monomer has adequate depth of cure up to 5-mm increments
content in relation to the filler-to-monomer ratio. In based on hardness and degree of conversion data;
general, the polymerization contraction of all the yet, this study followed the ISO 4049. Because the
investigated materials was between 1.58% and method proposed by ISO 4049 tends to overestimate
3.36%, which is considered acceptable when com- the depth of cure when compared with hardness
pared with the polymerization contraction of the profiles,8,33 especially for bulk-fill resin composites,8
resin composites currently available on the market. it is surprising that SonicFill did not perform better
in the current study. Tetric EvoCeram Bulk Fill also
The depth of cure for most of the bulk-fill showed a depth of cure slightly lower than the value
materials was improved when compared with the advertised by its manufacturer, as has been previ-
conventional resin composite (Figure 3). Neverthe- ously reported.8 However, together with the other
less, the second null hypothesis was partially investigated low-viscosity bulk-fill resin composites
accepted due to the fact that SonicFill demonstrated (SDR, Venus Bulk Fill, and x-tra base), Tetric
a depth of cure statistically similar to that of the EvoCeram Bulk Fill demonstrated higher depth of
conventional resin composite Tetric EvoCeram. With cure when compared with the conventional resin
Benetti & Others: Curing vs Gap Formation of Bulk-Fill Resin Composites 197

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Figure 4. Gap formation (median, minimum, and maximum, in lm) between the investigated materials and the dentin from combined mesiodistal
(MD) and faciolingual (FL) sections. The striped boxes identify the materials for which gap formation was significantly larger than that of the
conventional resin composite (Tetric EvoCeram), according to the Mann-Whitney U-test.

composite. Higher depth of cure has been reported Despite the use of a bonding system of recognized
earlier for bulk-fill resin composites8,9 due to quality, none of the restorations were gap-free, as
improvements in their initiator system8 and in- shown previously.11 Some of the bulk-fill materials
creased translucency.7,8 resulted in wider gaps than those observed for a
Among the many factors involved in gap forma- conventional resin composite (Figure 4), despite
tion, the quality and compliance of the adhesive bond their lower contraction stresses and the lower
play an important role in maintaining good contact flexural modulus reported in an earlier study.4
between the resin composite and the cavity Therefore, the third null hypothesis was rejected.
walls.1,11,13,24-26,34 This is most critical in the In the present study, the gaps were wider at the
absence of enamel, which was the case in the gingival walls, which is in accordance with previous
gingival margins of the cavities examined in this data.35 Gap formation was observed in all specimens,
study. Therefore, a recognized, good-quality bonding although to different extents. This is in contradiction
system34 was used that minimized the chance of gap with the data published by Roggendorf and others,26
formation due to poor bonding and allowed exami- who observed predominantly gap-free margins in the
nation of the role of restorative materials in gap absence of thermomechanical loading. Possible ex-
formation. It should be emphasized, however, that planations for the different results, other than the
different outcomes may result from diverse bonding different methods used for analyzing the gaps, are
systems,26 and perhaps a distinct behavior would that the previously mentioned authors used MOD
have been observed had other bonding systems been cavities. The increased compliance of an MOD
investigated in this study. cavity, when compared with the vertical slot cavities
198 Operative Dentistry

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Figure 5. Linear fit for gap formation (median from combined mesiodistal and faciolingual sections) and polymerization contraction (%) from the
Pearson correlation test for all investigated materials (solid line, r2=0.599) and with the exclusion of SDR (dotted line, r2=0.975).

used in this study, is a consequence of the flexibility tion. Nevertheless, polymerization contraction is one
of the cusps and the possibility of cuspal deflec- of the most important factors13 affecting the devel-
tion.5,13,19 The vertical slot, on the other hand, is a opment of contraction stresses,11,12,14 which may to a
more rigid model with less mobility of the cavity certain extent help to explain gap formation. The
walls, and induced stresses are therefore more likely results from the present study further support the
to result in the rupture of the bonding, with fact that the polymerization contraction plays a role
subsequent gap formation. in stress development, and consequent gap forma-
A further analysis of our results demonstrated tion, around cavity margins. Indeed, when a second
that the high-viscosity bulk-fill resin composites Pearson correlation test excluding SDR was per-
with reduced polymerization contraction (SonicFill formed between gap formation and polymerization
and Tetric EvoCeram Bulk Fill) resulted in similar contraction, a significant and strong correlation was
gap formation when compared with the conventional present (Figure 5). A strong linear correlation
resin composite. It is acknowledged that polymeri- between polymerization contraction and its resulting
zation contraction of a material is not the sole factor stresses has been previously reported for most resin
involved in the development of contraction stress- composites by Kleverlaan and Feilzer.14
es 12,15 and gap formation around cavity mar- Despite the higher polymerization contraction of
gins.5,10,11 This fact was confirmed in part during SDR when compared with Tetric EvoCeram, Sonic-
this study: When all of the investigated materials Fill, and Tetric EvoCeram Bulk Fill, its gap
were taken into account, no correlation was observed formation was not significantly higher. Previous
between polymerization contraction and gap forma- results for Tetric EvoCeram Bulk Fill have demon-
Benetti & Others: Curing vs Gap Formation of Bulk-Fill Resin Composites 199

strated lower contraction stresses than for a conven- ite, although their depth of cure was marginally
tional resin composite.4 Positive results regarding below the values claimed by their respective manu-
gap formation were reported earlier for SDR, in a facturers. Conversely, some of the investigated low-
thermomechanical loading setup, when compared viscosity bulk-fill materials (x-tra base and Venus
with conventional resin composites using different Bulk Fill) demonstrated higher contraction and
adhesive systems.26 Other than the previously unfavorably larger gap formation despite improved
reported reduced polymerization contraction stress- depth of cure, when compared with the conventional
es,3-5 a possible explanation for the positive results composite. One particular bulk-fill material (SDR)

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around SDR margins may be its lower flexural had improved depth of cure and comparatively low
modulus3,4,27 combined with its slower contraction gap formation despite higher polymerization con-
rate,3,4 which allowed the material to partially traction.
counteract the effect of polymerization contraction,
thus resulting in gap formation similar to that of the Acknowledgements
conventional resin composite. The elastic modulus of The authors thank Ivoclar Vivadent, Kerr, Voco, Dentsply,
resin composites has been considered an important and Heraeus for supplying the restorative materials used in
aspect for both the polymerization contraction and this study. The authors disclose no interest in the investigated
materials. Special acknowledgements are granted to Liselotte
development of polymerization contraction stress- Larsen, Juliana Antonino Petersen, and Robert Read for
es.4,12,14,15 Furthermore, a direct relationship be- technical support.
tween polymerization stress,21,22 polymerization
contraction,23 and marginal integrity has been Conflict of Interest
demonstrated in vitro. Additionally, in a current The authors of this manuscript certify that they have no
ongoing clinical study, restorations made with the proprietary, financial, or other personal interest of any nature
or kind in any product, service, and/or company that is
recently developed bulk-fill resin composite SDR presented in this article.
covered with a conventional resin composite were
not yet significantly different from restorations (Accepted 16 December 2013)
made with a conventional resin composite following
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