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Bulk Fill Optional Restorations Todd C. Snyder

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Dentistry keeps evolving with the advent of faster, simplified placement materials to make the dentist’s life easier. The ability to place a composite restoration quickly and to be more productive while still providing a quality product is very appealing to most dentists. There are many options available to practitioners today for restoring posterior teeth with direct tooth colored restorations. Some techniques are very time consuming while more recent materials when utilized can offer a significant time savings.

Although traditional placement techniques utilizing 2mm incremental layering of composite has worked very well it does have some shortcomings in the amount of time it takes to properly place numerous increments of composite. Furthermore the risk of polymerization stress and shrinkage has long been a concern with risks of post-operative sensitivity, stress fractures at the cavosurface margins, marginal defects due to polymerization stress and shrinkage which can ultimately lead to microleakage and failure of a restoration. Depending on the size of the defect and the manufacturer’s material you can now utilize bulk fill composites to restore a cavity preparation of 4mm, or in some cases up to a depth, of 5mm with a single increment of composite.

The advent of the bulk fill composite restorative material is meant to provide the dentist with a simplified, faster application of materials when compared to traditional composite stratification of 2mm increments. Not only do the bulk fill composites offer a convenient time savings, they also boast a decrease in the polymerization stresses on the tooth structure due to modifications of the composition and type of monomers and polymers in the materials. There are two different and unique categories for the bulk fill composite market. Many dentists utilize traditional flowable composites for lining the proximal boxes and deeper areas of a preparation to achieve a better adaptation prior to placement of the more viscous final composite. To that end, many of the composite manufacturers have created a bulk fill flowable composite used for the sole purpose of replacing larger amounts of the dentin in a single increment. These materials allow for better adaptation with decreased polymerization stresses, thereby reducing the amount of microleakage while requiring minimal to no manipulation during placement. Significant reduction in cuspal deflection (C factor) has been reported when utilizing the dentin replacement bulk fill composite systems. The process works well and is far more convenient when compared to traditional composite stratification layering of 2mm increments. These bulk fill flowable composites materials are utilized as a dentin replacement up to 4mm in depth, but they require a final overlaying composite that has physical properties that are better able to withstand the forces of mastication. Bulk fill dentin replacements are excellent for large cavity preparations, where one layer can instantly replace 4mm of dentin followed by a final layer of traditional composite. The overlying composite placed onto the dentin replacement layer is meant to mimic enamel in appearance and physical properties.

However to simplify the process further many dental corporations like VOCO have offered yet another alternative to traditional incremental layering of composites. This second type of bulk fill material is more viscous and can be used to restore the entire cavity preparation from the pulpal floor to the occlusal and interproximal surfaces in a single increment. The advent of the standalone single layer bulk fill composite is a very convenient alternative because it replaces both dentin and enamel. X-tra fil is VOCO’s bulk fill composite material that can be placed and cured up to 4mm in depth. It could also be used as a final layer to cover their bulk fill flowable dentin replacement composite which is known as x-tra base. Utilizing a bulk fill material on top of a bulk fill flowable dentin replacement allows for only two increments of composite to be utilized on restorations up to 8mm deep. Both materials having the capabilities to be placed in 4mm increments can make traditionally diffi cult placement of restorations that would require lots of layers to be simplified down to only two layers. No matter what process is more appealing or easier to implement either treatment modality is substantially quicker and more convenient than traditional placement modalities.

The two cases that follow show the options of placing either a dentin replacement bulk fill material (VOCO x-tra base) with an overlying traditional composite (VOCO GrandioSO) or a bulk fill standalone composite material (VOCO x-tra fil) used to fill the entire defect to the cavosurface margin with one layer of material.

Case Presentation

In the first case the patient presented with the lower left first molar having a large failing amalgam (Fig. 1). The patient was anesthetized and the existing amalgam was removed with a 330 carbide bur (SS White) (Fig. 2). Recurrent decay and any other debris was removed with a polymer round bur (SS W hite). The preparation was then checked with a caries indicator to verify that all decay was removed. The preparation design was then measured for depth from the pulpal floor to the cavosurface margin to determine the amount of room available for proper placement of a bulk fill composite restoration (Fig. 3). Having between 3-4mms of depth was ideal for a single increment of VOCO’s bulk fill composite restorative material, x-tra fil.

Next the tooth was selectively etched on the enamel only with Bisco’s HV etchant for 15 seconds, rinse and dried followed by the application of VOCO’s Futurabond U adhesive. (Fig. 4). After curing for 40 seconds with Valo (Ultradent) the tooth was ready to restore with the VOCO x-tra fil bulk fill composite. Placing the tip of the compule on the distobuccal gingival floor and under pressure from extrusion a homogeneous layer of material was applied across the pulpal floor finalizing the placement by using the mesial marginal ridge to cleave the material from the compule so as to not lift the already adapted material off of the pulpal floor. Next an egg burnisher (Hu-Friedy) was used to facilitate adaptation along the cavosurface margin and to create the primary anatomy. This was followed by the use of a PKT #5 (Hu-Friedy) to create additional anatomy. The material was then cured for 40 seconds using a Valo curing light (Ultradent). Occlusion was then adjusted using a 12 fluted football bur (HuFriedy). The restoration was then polished with Dimanto Polishers (VOCO). The tooth restored in one efficient increment of x-tra fil mimics the natural tooth structure very well (Fig. 5).

In the second case just like the previous restoration the existing amalgam in the lower left first molar was removed with a 330 bur (SS White) followed by the use of a slow speed polymer round bur (SS White) to remove decay (Fig. 6). A caries indicator was used to verify complete removal of decay (Fig. 7). The depth of the preparation was then measured with a periodontal probe to determine if a single increment of 4mm or less is possible (Fig. 8). A selective-etch was then performed on the enamel using Bisco’s HV etchant. The application of the Futurabond U adhesive (VOCO) was next followed by light curing with a Valo (Ultradent) curing light (Fig. 9). After light curing the adhesive, the VOCO x-tra base was then syringed into the cavity preparation to completely cover all of the exposed dentin (Fig. 10). The composite was then cured with the Valo (Ultradent) for 10 seconds compared to most brands that require 20 seconds. In my experience, x-tra base has higher compressive strengths, lower shrinkage, water absorption and shrinkage stresses compared to other flowable bulk fill dentin replacement materials.

After having replaced all of the absent dentin in the first increment, the final enamel layer was added utilizing the VOCO’s GrandioSO since it is an excellent enamel replacement material that offers good physical properties to withstand the pressure and wear in the posterior dentition. After placing a single increment of 2mm or less of the GrandioSO an egg burnisher is used to start shaping the occlusal morphology and seal the composite against the cavosurface margins. No condensing of the composite is necessary when the composite is placed under pressure from a compule delivery system properly. After the basic morphology is created additional anatomy can be created with various instruments such as a PKT #5 ( Fig. 11).

The two bulk fill composite technique options described are available for practitioners that want a more efficient technique to restore posterior teeth instead of the traditional time consuming incremental layering techniques. Little to no layering can also cut down on the risk of voids that would often occur from trying to obtain good adaptation of numerous layers. In addition the ability to place large increments of composites while at the same time being able to reduce the polymerization stresses on the tooth structure is very desirable.

Adaptation of materials is quickest with the dentin replacement variety but does require a second enamel layer to be placed. While the bulk fill universal composite requires a single increment with no additional layers it could take a little more effort for adaptation in smaller or more convoluted restorations. While the more viscous traditional type of composite can be placed in bulk it still must be compressed or delivered in a manner that allows for ideal adaptation. Smaller preparations as well as larger preparations that require fast adaptation is where a dentin replacement has an advantage over the more viscous variety. While a larger preparation where access and positioning are easily achieved the more viscous bulk fill material has a benefit in the amount of time required for placement.



Dr. Todd C. Snyder received his doctorate in dental surgery at the UCLA School of Dentistry. Furthermore he has trained at the prestigious F.A.C.E. institute for complex gnathological (functional) and temporomandibular joint disorders (TMD). He is an Accredited Member of the American Academy of Cosmetic Dentistry. Dr. Snyder has been on the faculty at U.C.L.A. and is currently on the faculty at Esthetic Professionals. He lectures both nationally and internationally on numerous aspects of dental materials, techniques, and equipment. Dr. Snyder also founded and is CEO of Miles To Smiles a non-profit mobile children’s charity that helps indigent and underprivileged children.
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September 2025
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