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The Effect of Different Placement Strategies of Bulk Fill

Composite on Marginal Leakage of Classii Restoration
(Comparative in Vitro Study)
Sura Y Alani, Abdulla MW Al-Shamma*

Department of Restorative and Esthetic Dentistry, College of Dentistry, Baghdad University, Iraq

ABSTRACT
Introduction: In spite of huge revolution in composite materials and techniques, some drawback still exist which may
hindered the success of composite especially in class II restorations such as volumetric shrinkage, micro-leakage and
secondary caries.
Aims: The purpose of this in vitro study was to evaluate the effects of different placement strategies of bulk fill composites
on the gingival micro leakage of class II restorations.
Material and methods: forty human extracted premolars teeth had received 2 proximal box preparation with the following
criteria (Mesiodistal width: 2 mm, buccolingual width: 3 mm and the gingival margin located 1 mm above CEJ on mesial
cavity while for the distal cavity located 1 mm below CEJ. All prepared cavities had received etch and rinse adhesive strategy
and had been divided randomly to four groups. Group 1: Restored with bulk fill composite alone. Group 2: Restored with 1
mm flow able composite followed by bulk fill composite cured separately. Group 3: (Snow plow technique) which restored by
application of 1 mm flow able and bulk fill composite and curing them simultaneously. Group 4: (Injection molding
technique) Teeth were restored with adhedive+1 mm flowable+bulk fill composite and co-curing the three layers
concurrently.
After one week storage in water, all specimens were thermo cycled for 500 cycle between 5°C and 55°C for dwell time of 30
sec. Using model wax, the root apices of the teeth were sealed. All specimens had received double coats of nail varnish except
1 mm around the restoration, and then all specimens had been immersed with 2% methylene blue dye for 24 hrs. After
rinsing thoroughly with water, all specimens were embedded in self-curing epoxy resin and allowed to set for 24 h before
sectioning.
Then one section had been made from mesial to distal margins and then examined under digital microscope 40X and the
depth of dye penetration had been analysed according to 0-3 scoring system. All data were subjected to kruskal Wallis
followed by Mann Whitney tests at p>0.05.
Results: Statistical significant differences between the tested groups was observed in enamel margin (mesial) with lower
micro leakage were revealed in snow plow and injection molding techniques, while no significant difference was noticed in
dentin (distal) margin. For intragroup comparison, all tested groups showed higher micro leakage score in dentin than
enamel margin.
Conclusion: According to the results the present study, co-curing the flow able with overlaying bulk fill composite reduce
gingival micro leakage. For dentinal margin, higher micro leakage score were presented compared to enamel.

Key words: Bulk fills, Snow plow and Injection molding technique
HOW TO CITE THIS ARTICLE: Sura Y Alani, Abdulla MW Al-Shamma, The Effect of Different Placement Strategies of Bulkfill Composite on Marginal
Leakage of Classii Restoration (Comparative in Vitro Study), J Res Med Dent Sci, 2022, 10 (8): 101-108.

Corresponding author: Abdulla MW Al-Shamma large attention and development in its properties such
E-mail: [email protected] as wear resistance, adhesion, mechanical properties,
Received: 01-Jun-2022, Manuscript No. JRMDS-22-52927;
Editor assigned: 03-Jun-2022, Pre QC No. JRMDS-22-52927 (PQ);
shade selection, colour stability, polish ability and
Reviewed: 17-Jun-2022, QC No. JRMDS-22-52927; handling properties [1,2].
Revised: 02-Aug-2022, Manuscript No. JRMDS-22-52927(R);
Published: 08-Aug-2022
Even though many researches documented high failure
INTRODUCTION rate in class II posterior composite restorations as a result
of some restriction. One of them is polymerizations
Tooth colored posterior restoration has emerged as an shrinkage with its detriments effect such as micro leakage,
essential and vital component of the restorative procedure marginal gap, marginal staining, recurrent caries and post-
instead of dental amalgam due to aesthetic and operative sensitivity [3].
conservative demand. So composite material received

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Alani SY, et al. J Res Med Dent Sci, 2022, 10 (8):101-108

Polymerization shrinkage may result from: (average crown length 6.9: mesiodistal: 6.5 and
Volumetric shrinkage, viscoelastic behaviour, effect of buccolingual dimension: 9.2). To preserve homogeneity of
Configuration factor (C-factor) and water sorption [3]. tooth measurements between groups, a one-way ANOVA
test was done for each measurement among the four
Many techniques were suggested to reduce the adverse
groups, which revealed no statistically significant
effects of shrinkage stress. Among these suggestions are:
difference.
Altered light curing cycles (Intensity and time curing),
polymerization-induced phase separation, ring-opening Any extrinsic stains, soft tissue or calculus deposits were
polymerization, hybrid polymerization reactions, thiol- removed by ultrasonic scalar then all teeth stored in
ene photo polymerization, preheating, vibration, stress (0.1%) thymol solution for 2 days in order to prevent
absorbing layers with low elastic modulus liners and bacterial and fungal growth and then kept in deionized
diverse composite layering techniques [4]. distilled water at room temperature to avoid dehydration
of extracted teeth. The teeth were kept no more than 1
Different placement techniques of posterior composite
month. The sample teeth was positioned by dental
were adopted to reduce polymerization shrinkage.
surveyor in dental manikin (maxilla) and fixed by aid of
Among these techniques, a widely used method named
light body polyvinyl siloxane impression material in the
incremental technique which relies on applying
socket of maxillary first premolar. All teeth attached to
composite in 2 mm increment in different suggested
manikin to stimulate clinical condition (Figure 1).
ways such as: Horizontal technique, oblique successive
cusp build-up technique, centripetal incremental
technique, split horizontal technique and three site
technique [5].
Although polymerization shrinkage has been reduced by
incremental technique, researches documented some
drawback such as voids, cuspal deflection and time
consuming. Bulk fill composite which allow 4-5 mm bulk
placement, has been developed to overcome some of
these shortenings [6].
Some authors advocated the use of flow able composite
underneath the bulk fill to improve the adaptation of Figure 1: a) Dental manikin with adjustment of place
composite and help in increase relaxation stress [7]. of first premolar; b) Dental manikin after attachment
of examined teeth.
In addition to traditional technique in the application of
composite, two advanced methods have been suggested. Cavity preparation: Each teeth had received 2 proximal
First technique known as snow plow technique which box preparations with following criteria (mesiodistal
involves the placement of a layer of flow able composite width: 2 mm, buccolingual width: 3 mm and gingival
on the pulpal floor and the gingival margin of the margin located 1 mm above Cementoenamel Junction
proximal box of a posterior composite resin restoration. (CEJ) on mesial cavity and for distal cavity the gingival
However, the layer of flow able composite is not cured margin located 1 mm below CEJ.
followed by application of packable composite and curing The cavity preparation had done by parallel sided; flat
the 2 layers simultaneously [8]. ended carbide fissure burs with high speed water cooled
While another technique were suggested by David Clark hand piece which was fixed to modified dental survey or
named injection molding technique, who proposed using each bur was discarded after four cavity preparation to
one layer of adhesive followed by flow able composite ensure maximum cutting efficiency Figure 2.
then finally injecting the paste composite. The resin flow
able paste mass is polymerized together in a single [9].
So the aim of this study is to evaluate the effects of
different placement strategies of bulk fill composites on
the gingival micro leakage of class II restorations the null
hypothesis stated that neither the placement techniques
of bulk fill composite nor the location of margin can
affect the marginal leakage of class II restoration.

MATERIALS AND METHODS

Specimens
Human maxillary first premolar teeth free from caries,
restorations, defect and cracks were collected from Figure 2: a) Cavity preparation by dental surveyor; b)
specialized orthodontic centre in Baghdad University. 40 Checking the dimension of cavity preparation by
teeth with comparable size and morphology are selected dental Vernier.

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Alani SY, et al. J Res Med Dent Sci, 2022, 10 (8):101-108

The dimension was checked by dental Vernier and Group 2: the cavity restored by 1 mm layer of flow able
Williams graduated periodontal probe the teeth were composite (3 M, USA) cured for 20 seconds (the amount
rinsed and dried. The teeth randomly divided into 4 of flow able composite required to fill 1 mm in the cavity
groups based on restoration placement techniques. was predetermined in a pilot study) after that 4 mm of
bulk fill composite was applied and cured for 40 second
Bioclear matrice was placed adjacent to each preparation
as in group 1 (Figure 5).
and secured by ring and plastic wedge Figure 3a. All teeth
received etch and rinse strategies by etching with
phosphoric acid 37% for 15 second and washed for
another 15 second then dried with cotton pellets one
layer of adhesive Scotchbond Universal bonding adhesive
(3 M, USA) were applied and rub it for 20 seconds. After
that, a gentle stream of air was directed over the adhesive
for about 10 seconds until it stopped moving after that,
an LED light was used to cure the adhesive (x lif Cure-L
LED curing light, wavelength (430-480 nm) light
Figure 5: a) 1 mm flow able application; b) Curing of
intensity, (1300 mw/cm2 cured for 10 seconds Figures 3b
flow able for 10 seconds; c) Application of 4 mm bulk
and c.
fill composite d) Curing of bulk fill for 40 seconds.
Group 3 (Snow plow technique): Similar to group 2, 1
mm flow able composite was injected in the gingival floor
however; this layer was left uncured. Followed by
application of predetermine amount of bulk fill
composite (that fill 4 mm depth of the cavity). A
condenser was used to pack the two layers ending with
final thickness of 4 mm, all the excess of composite was
removed thoroughly and then the 2 layers was curing
simultaneously for 40 seconds. The rest of the cavity
Figure 3: a) Adjustment of bio clear matrices, plastic restored as group 1 Figure 6.
wedge and ring; b) Adhesive application; c) Curing
for 10 seconds.

Restorative procedure
Group 1: Bulk fill composite (Filtek, 3 m, USA) composite
was applied to fill the deepest 4 mm of the cavity and
cured for 40 seconds from occlusal direction then
another bulk increment was applied to fill the full cavity
and cured as for the first increment, to ensure optimum
polymerization. Additional curing from buccal and
palatal directions for 10 seconds had been done after
removal of the ring (Figure 4). Figure 6: a) Application of 1 mm flow able composite
6; b) Application of 4 mm bulk fill composite; c)
Curing of the two layers for 40 seconds.
Group 4 (Injection molding technique): similar to
group 3 except the application of adhesive coating
without curing before flow able and bulk fill composite.
And the three layers were occurred as a one layer for 40
seconds. The full of the cavity restored as group Figure 7.

Figure 4: a) Bulk fills application in 4 mm increment; Figure 7: a) Adhesive coating; b) Application of 1 mm

b) Curing of composite for 40 seconds. flow able composite; c) Application of 4 mm bulk fill
composite; d) Curing of the three layers
simultaneously.

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Alani SY, et al. J Res Med Dent Sci, 2022, 10 (8):101-108

All the restorations were finished and polished by • Score 0-no dye penetration.
enhancing finishing system The teeth were placed in • Score 1-dye penetration less than ½ gingival floors.
deionized distilled water and subjected to 500 thermo • Score 2-dye penetration more than ½ gingival floors.
cycling ISO/TR 11405:1994. After completing the thermo • Score 3-dye penetration involving the axial wall.
cycling, the teeth were dried and the apex of the roots
sealed by model wax and the teeth were painted with All data analysed by SPSS (BM Corp. Released 2013)
double coating of nail varnish al around except 1 mm shapero Wilk normality test was used and showed that
around the restoration. Then all examined teeth were the data were not normally distributed. The statistical
submerged in 2% methylene blue for 24 hours at 37ᵒC. analysis for micro leakage had been performed using the
Kruskal Wallis test followed by the Mann Whitney U-tests
After 24 h the teeth removed from the dye and rinsed with a significance level of p<0.05.
thoroughly by running water and dried for 5 seconds.
The teeth were embedded in self-curing epoxy resin and
RESULTS
allowed for complete setting before sectioning.
The scoring data showed variable range from 0-3 score in
Then the teeth were sectioned from mesial to distal side
four groups as show in Figure 8 (Table 1).
with water cooled slow speed diamond sectioning saw to
obtain to similar fragment. The sectioned restoration
were examined under stereomicroscope 40X to evaluate
the extent of gingival marginal micro leakage.
The degree of gingival micro leakage were analysed
according to scoring system suggested by Araujo as
following [10].
Figure 8: Scoring data showed variable range from
0-3 score in four groups.
Table 1: kruskal wallis test.
margin Subgroups N Minimum Maximum Mean Medium SD Mean rank P value SIGNIFICANCE
CE

Mesial Groups 1 10 1 3 1.9 2 0.876 28.85 0.008 S

Groups 2 10 1 3 1.3 1 0.823 22.85

Groups 3 10 0 2 0.8 1 0.675 15.6

Groups 4 10 0 3 0.8 1 0.966 14.7

Distal Groups 1 10 0 1 2.3 2.5 0.422 27.85 0.96 NS

Groups 2 10 0 3 1.6 1.5 0.85 19.4

Groups 3 10 0 3 1.5 1.5 0.853 18.35

Groups 4 10 1 3 1.4 1 0.883 16.4

The kruskal wallis test revealed significant difference

among tested groups in mesial margin (enamel) with the Mann-Whitney U Test
highest marginal leakage score in group 1 (bulk fill) while Mann-Whitney U test results show in Table 2 and 3.
the lowest score reported in both group 3 and group 4. In
distal margin (dentin), non-significant differences had
been resulted.

Figure 9: Bar chart descriptive the mean values for each group
and subgroups.

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Table 2: Mann-Whitney U test results.

Groups Mean Rank Mann-Whitney U p-value Significance

Groups 1 12.3 32 0.143 NS

Groups 2 8.7

Groups 1 13.9 16 0.004 S

Groups 3 7.1

Groups 1 13.65 18.5 0.012 S

Groups 4 7.35

Groups 2 12.6 29 0.061 NS

Groups 3 8.4

Groups 2 12.55 29.5 0.093 NS

Groups 4 8.45

Groups 3 11.1 44 0.588 NS

Groups 4 9.9

Table 3: Mesial and Distal margins Mann-Whitney U test results.

Subgroup Mean rank Mann–Whitney U p-value Significance

Control enamel 7.65 21.5 0.021 S

dentin 13.35

Flow able enamel 7.95 24.5 0.038 S

dentin 13.05

Snowplow enamel 8 25 0.032 S

dentin 13

Injection enamel 8.2 27 0.048 S

dentin 12.8

DISCUSSION highest mean marginal leakage in bulk fill composite may

attributed to high viscosity of bulk fill which result in less
Micro leakage is one of these detrimental drawback in in
adaptation to cavity walls hence increased magnitude of
class II composite restorations, which define as clinically
micro leakage [12]. Non-significant difference between
dynamic undetectable passage of chemical substances
group 1 and 2 was result. This had agreement with other
bacteria, fluids, molecules and ions between the cavity
study which advocate that the use of intermediate layer
walls and the restoration material applied [11].
underneath the bulk fill composite did not reduce the
Micro leakage is regarded as indication of marginal gap micro leakage. This may result from the higher resin
which result in Postoperative sensitivity, Marginal content and less filler loading of the flow able composite
percolation and secondary caries. resins causes more polymerization shrinkage and
eventually more micro leakage [11,13].
The aim of present study was to evaluate the effect of
bulk fill composite with different placement technique Although non-significant difference between group 1 and
and the effect of margin location on marginal leakage of group 2 had been reported in this study, slight reduction
class II composite restoration. in marginal leakage result from the use of flow able
underneath the bulk fill composite which attributed to
To our knowledge this is the first study that evaluates the
the high adaptation of flow able composite at the gingival
marginal leakage of snow plow and injection molding
margin and it is act as a flexible intermediate layer which
techniques using of bulk fill composite.
helps to relieve stresses during polymerization
The result of this study revealed the different placement shrinkage. Also, the flow ability and inject ability of fluid
techniques significantly affect the magnitude of marginal composites make them very attractive when placing in
leakage and thus the null hypotheses had been rejected. difficult areas, such as the proximal boxes [14] and this
agree with results obtained from two other studies in
Group 1 and group 2 showed the highest marginal
which mentioned that the addition of flow able
leakage with no significant difference among them. The
composite in first layer before bulk fill can greatly reduce
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Alani SY, et al. J Res Med Dent Sci, 2022, 10 (8):101-108

the micro leakage and the least micro leakage had technique. In distal cavity where the cavity margin
reported in both snow plow and injection molding located in dentin, the results yield non-significant
techniques with no significant different between them. difference between the groups this result agree with [22].
While both of these two technique reported significant Who found that the restoration techniques did not
difference with group 1 [7,15]. influence the values of micro leakage in dentin and [19]
who stated neither the addition of flow able composite
This result has agreement with many studies that
nor the use of snow plow technique had noticeable
mentioned that the use of uncured flow able composite
decrease in marginal micro leakage in dentin.
underneath the packable composite result in marked
reduction in micro leakage in class II restoration [16,17]. This may result from the distance between the light
curing tip and the surface of the resin (composite and
The use of these techniques in which most of the flow
adhesive). If this distance greater than 2 mm, the light
able composite and therefore its potential disadvantages
intensity is significantly reduced. Which result in
are removed from the cavity. Instead only a small amount
inadequate polymerization of resin composite materials?
of flow able composite remains in the areas of the cavity
As a result, the conversion degree of resin at the dentinal
in which the higher viscosity resin composite does not
margin is expected to be lower than at the enamel
completely adapt to the preparation. Therefore this
margin, which received the curing light directly [23]. In
technique may reduce void formation and increase
addition, the Margins below the CEJ make it difficult to
marginal adaptation. In addition the use uncured resin
achieve efficient results for marginal sealing, polishing
(adhesive and flow able) increase the wettability so can
and longevity [24].
penetrate better into the dentinal tubules and improve
sealing at the margins due to the hydraulic pressure of Regard the effect of margin location, significant
overlying composite with the higher viscosity. Therefore, differences between enamel and dentin are reported.
there would be less gap in the tooth restoration interface Dentin margin revealed highest marginal leakage
and subsequently less leakage with this technique compared to enamel in all groups. These results are
compared to separately curing the flow able liner [2] and supported by the findings of Benetti [25,26]. Who
agreement with [18] that show that the three layers co- observed when a bulk fill composite resin was used; large
cured together results in a monolithic mass to which gaps in dentin margins compared to enamel had been
improve cavity adaptation and reduce gap formation. result. This may be due to the higher adhesive bond to
etched enamel compared to etched dentin resulting in
Another cause which mentioned by David, J Clark who
greater resistance to thermal changes at the enamel.
stated that “air thinning the resin drives it past the
margins, leaving a gingival margin that is not light cured, The findings of this study agree with those of Kalmowicz,
and is prone to dissolution and an eventual void. Which Phebus [27]. Who concluded that micro leakage in
avoided by injection molding technique” [9]. enamel was significantly lower than dentin, regardless of
material, C-factor, or insertion technique?
But this studies show disagreement with other studies
that show there was no decrease in marginal leakage Other reasons for increased micro leakage at the dentinal
from the use of uncured flow able underneath the bulk margin may be: the organic content of dentin, outward
fill [19] and [20]. The reduction in leakage reported in movement of fluids in dentinal tubular and due to the
injection molding techniques opposite to results of other complex and The branching of dentinal tubules in root
two studies [21] and [22] which mentioned that the use dentin is smaller and more numerous than in crown
of a flow able resin composite cured simultaneously with dentin [28,29].
an adhesive yielded the worst results among tested
In the fact that there is limited literature on the use of
groups. And they attributed this result to the
snow plow technique and Injection molding technique, so
displacement of the bonding agent leaving unprotected
to determine its clinical validity further in vitro and in
zone that may cause adhesive failure and subsequent
vivo studies are needed.
increase in the micro leakage score or by a limited depth
of curing of these component layers. However in this
CONCLUSION
study we overcome these two problems by using first
layer of adhesive that cured separately prior restorative Within the limitation of this study
procedure and by using translucent bio clear matrices
• None of the examined groups provide complete
which allow a better curing efficiency.
elimination of marginal leakage of class II restoration
The use of preheating flow able and bulk fill composite neither in enamel nor in dentin.
were advocated newly in injection molding technique to • The different placement techniques of bulk fill
increase the fluidity and the adaptation of composite to composite had significant effect on marginal leakage
cavity walls but in this study we except the use of on enamel margin of class II restoration, with greater
preheating technique to overcome the introduction of reduction in the leakage noticed in snow plow and
variable factor among the comparative groups. injection molding technique.
The use of preheating composite may give different result • Marginal leakage of dentinal margin didn’t get
from our study and may yield a difference marginal affected by placement technique.
leakage for injection molding technique from snow plow

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• For intragroup comparison, higher leakage score 15. Tabona MRZ, A Soetojo, and I Widjiastuti. Bulkfill
were presented in dentin compared to enamel Techniques with Intermediate Layer to Marginal
irrespective of placement techniques. Adaptation Restoration of Class II Composite
Resin. Conserv Dent J 2021; 11:32-37.
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