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Case Reports in Dentistry

Volume 2017, Article ID 9408591, 5 pages
https://doi.org/10.1155/2017/9408591

Case Report
A Novel Technique for Bulk-Fill Resin-Based Restorations:
Achieving Function and Esthetics in Posterior Teeth

Gerardo Durán Ojeda,1 Ismael Henrı́quez Gutiérrez,1 José Pablo Tisi,1

and Abelardo Báez Rosales2
1
Facultad de Ciencias de la Salud, Universidad Arturo Prat, Iquique, Chile
2
Restorative Dentistry Department, University Andrés Bello, Viña del Mar, Chile

Correspondence should be addressed to Gerardo Durán Ojeda; gerardo.duran.ojeda@gmail.com

Received 21 July 2017; Accepted 22 October 2017; Published 26 November 2017

Academic Editor: Michelle A. Chinelatti

Copyright © 2017 Gerardo Durán Ojeda et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Advances in the mechanical properties of composite resins have allowed for their use in posterior teeth. Conventional resins have
several problems associated with polymerization shrinkage stress. The development of “bulk-fill” resins has allowed for their use in
single increments up to depths of 4 mm, with very low polymerization shrinkage stress. Nevertheless, differences in anatomy and
the desire for optimal esthetics present unique difficulties. This article describes a step-by-step technique using flowable bulk-fill
resin as a substitute for dentin in a single increment, together with a high-reflective-index resin to restore enamel and decrease
clinical time, obtaining anatomically and esthetically acceptable results without detriment to the mechanical properties required to
restore the functionality of the posterior teeth.

1. Introduction single-increment applications up to 4–5 mm [13]. These resins

initially had a flowable consistency for use as base materials or
Posterior teeth represent a scenario of variable complexity liners, which are then complemented with a final layer of
when clinicians are performing a direct or indirect resto- a conventional composite resin. The first of these materials
ration using adhesive-resin-based materials. The application was SureFil® SDR® flow (DENTSPLY, Konstanz, Germany),
of conventional resins using the stratification technique is which used “stress decreasing resin” (SDR) technology and
associated with the risk of incorporating bubbles and im- provided greater flexibility, allowing for dissipation of stress
purities, longer clinical time, and polymerization shrinkage during the polymerization reaction [14].
stress [1–3]. Additionally, subsequent problems arising from The present case report details a step-by-step procedure
polymerization shrinkage stress can occur, such as micro- to restore two molars with old failed amalgam restorations
leakage at the margins [1], cuspal deflection and enamel classified as “Charlie” according to the Modified United
cracks [4–6], an increased predisposition to the formation of States Public Health Service (USPHS) Ryge Criteria for
secondary caries, and postoperative sensitivity [7, 8]. Direct Clinical Evaluation of Restoration, which presented
Despite issues with the stratification technique in the color mismatch, marginal discoloration, loss of restorative
posterior teeth, the longevity of these restorations has been substance in the anatomic contour, microleakage, and
examined in previous reports with high rates of clinical secondary caries. This led to the decision to restore with
success based on randomized and retrospective longitudi- a new restoration instead to repair both amalgams and the
nal studies, with results showing survival times of up to remaining tooth structure. The technique of choice in this
18–20 years [9–12]. case includes a mix of a flowable bulk-fill resin, with the
Given the problems associated with polymerization anatomical completion of the enamel using a conventional
shrinkage stress, new composite resins, termed “bulk-fill” restorative resin. An 18-month follow-up allowed for
resins, are now available on the dental market for use in evaluation of the results.
2 Case Reports in Dentistry

base surface of both tooth preparations in single-layer in-

crements until the dentin was completely full, leaving suf-
ficient space (approximately 1 mm) to apply an enamel resin
material (Figure 4). Once this layer was placed, it was po-
lymerized for 20 sec.
To complete the occlusal morphology of both teeth,
a conventional stratification resin was selected (UE1, ENA
HRi, Micerium S.P.A., Avegno, GE, Italy) that was applied in
single-layer increments to complete the final anatomy of the
lost enamel, after which it was light-cured for 40 sec (Figures 5
and 6). To characterize these teeth, flowable resin pigmen-
Figure 1: Failed OV amalgam filling in tooth 36 and an old occlusal
tations were applied (Brown2, Micerium S.P.A., Avegno, GE,
amalgam restoration in tooth 37.
Italy) (Figure 7). A final polymerization through a layer of
glycerin was performed for 40 sec for each tooth to eliminate
the polymerization inhibition layer.
Finally, finishing and polishing were performed. In this
case, the procedure started with Enhance diamond points
(Enhance®, DENTSPLY, Konstanz, Germany) for prepo-
lishing, together with diamond polishing pastes (Shiny A
and Shiny B, Micerium S.P.A., Avegno, GE, Italy) and a final
aluminum oxide paste (Shiny C, Micerium S.P.A., Avegno,
GE, Italy). An immediate control image is shown in Figure 8
and 18-month follow-up in Figure 9.

3. Discussion
Figure 2: Elimination of the failed 36 OV amalgam and the oc-
This article describes a reduced-step approach for ex-
clusal amalgam in tooth 37 under rubber dam isolation.
changing amalgam restorations with composite resins using
a base of flowable bulk-fill resin as a dentin substitute in
2. Case Report combination with a final layer of conventional composite
resin to replace the enamel and achieve anatomically and
A 52-year-old female patient presented to the private esthetically acceptable results.
practice of one of the authors with a main complaint of two Dental amalgam is commonly used as a restorative
old failed amalgam restorations in teeth 36 (OV) and 37 (O), material to restore posterior teeth. At this time, its use
requesting that these restorations be replaced with new is limited for various reasons, namely, it has been associ-
composite resins. After a complete clinical examination, it ated with cracked tooth syndrome [15–17], its physical-
was determined that both teeth were vital (Figure 1). mechanical properties differ from those of natural dental
Under rubber dam isolation, the elimination of the old structures, the esthetics are poor, less conservative tooth
amalgams was performed with carbide burs (H4MCL.314.012, preparations may be needed due to their lack of adhe-
Komet, Gebr. Brasseler GmbH & Co., Germany), attempting siveness [18], and there is a potential release of mercury,
to spare a healthier dental structure (Figure 2). Once the tooth which can be toxic [19, 20].
preparations were completed, the adhesive technique was Owing to these disadvantages and advances in the
performed on both teeth in the same manner. Initially, the mechanical properties of composite resins, novel restor-
enamel was etched with 37.5% phosphoric acid (Gel Etchant, ative materials have been optimized for restoration of the
Kerr, Orange, CA, USA) for 15 sec, after which the dentin was posterior region. The first materials used for the posterior
etched for 15 sec. The acid was then rinsed off with an region included conventional composite resins, whose
air/water spray for 30 sec and air-dried, taking care not to volumetric shrinkage after polymerization ranges between
desiccate the dentin. After the tooth surface had been treated, 1.35% and 7.1% [21], which generated cuspal deflection
a first layer of primer was applied to the dentin and rubbed [4, 6, 22, 23], thereby increasing the probability of enamel
using a microbrush for 20 sec (Primer, OptiBond FL, Kerr, microcrack formation, showing unavoidable adhesive
Orange, CA, USA). For the enamel, primer was applied gently failure of the tooth-restoration interface [24], and leading
without rubbing. An air jet allowed for primer runoff and to microleakage formation [25].
solvent volatilization, after which a thin layer of bonding was Flowable bulk-fill resins decrease polymerization shrink-
applied and light-cured for 20 sec (Bonding, OptiBond FL, age stress and have a better degree of conversion than re-
Kerr, Orange, CA, USA) with a light-emitting diode (LED) storative bulk-fill resins at depths of 4 mm [26]. The flowable
curing light unit (Coltolux® LED, Coltene/Whaledent Inc., bulk-fill material used in this case (SureFil SDR flow,
OH, USA) (Figure 3). DENTSPLY, Konstanz, Germany) showed greater depth of
A layer of flowable bulk-fill resin (SureFil SDR flow, cure and a higher degree of conversion than similar flowable
DENTSPLY, Konstanz, Germany) was then applied at the resins, conventional flowable composites, and restorative
Case Reports in Dentistry 3

(a) (b)

(c) (d)

Figure 3: Adhesive procedure. (a) Application of 37.5% phosphoric acid for 15 sec in enamel. (b) The dentin is now being etched for 15 sec.
(c) A thin layer of primer is being applied. (d) Glossy aspect of the bonding layer once the technique is finished.

Figure 4: Flowable bulk-fill resin has been applied (SureFil SDR Figure 6: The complete enamel has been restored with a con-
flow, DENTSPLY, Konstanz, Germany). ventional composite resin. Notice the correct anatomy achieved in
both teeth.

Figure 5: Vestibular wall of tooth 36 has been restored with a layer

of conventional high-refractive-index resin (UE1, Micerium S.P.A., Figure 7: Resin pigments were used to characterize the depths of
Avegno, GE, Italy). pits and fissures.

bulk-fill composites [27]. This resin has superior mechanical conventional restorative resins, justifying its incorporation
properties compared to conventional flowable composites into the final layer of incremental technique resins to protect
because of lack of the mechanical properties of high-density the fluid material from potential wear [28, 29].
4 Case Reports in Dentistry

Conflicts of Interest
The authors declare that they have no conflicts of interest.

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