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Two Techniques for Posterior Composite

Restorations
Article January 2015

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1 author:
Ronaldo Hirata
New York University College of Dentistry
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4:01 pm, Feb 19, 2015

Traditional Layering vs.

Modified Bulk Filling
Two Techniques for Posterior Composite Restorations
AACD 2015San Francisco is offering a rapid-fire lecture series featuring The Next Generation. Dr. Hirata will present:
Low-Shrinkage Composites: Laboratorial Investigations and Clinical Approach. Please join us on Friday, May 2, 2015,
for this event by registering at: aacd.com/registration.

Ronaldo Hirata, DDS, MSc, PhD

William Kabbach DDS, MSc, PhD
Oswaldo Scopin de Andrade, DDS, MSc, PhD
Estevam A. Bonfante, DDS, MSc, PhD

CE

Abstract

CREDIT

After reading this article, the

participant should be able to:
1.

Compare two composite restorative techniques: the traditional layering technique; and
the modified technique using
low-shrinkage composites,
bulk flowable, and enamel
composite resin.

2. Describe the benefits of advances in polymer chemistry

engineering as they relate to
clinical techniques for placing
posterior composites.
3. Compare the step-by-step
techniques and advantages
unique to posterior composite
restorations completed with
new and traditional materials.

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Winter 2015 Volume 30 Number 4

The use of composite resin restorations in posterior teeth has become

routine in clinical practice because of certain advantages over traditional
amalgam restorations. Among several techniques described in the literature,
the layering technique commonly is claimed to reproduce the look of natural
dentition and allow control of the stress generated by polymerization
shrinkage. However, the layering technique involves detailed knowledge of
adhesive procedures, material handling, and dental anatomy, which makes
it complex and time-consuming. To overcome such drawbacks, advances
in polymer chemistry engineering, along with new layering techniques,
have been proposed. For instance, low-shrinkage composites have been
developed for bulk filling of cavities, eliminating the steps required in the
traditional layering techniques, which substantially simplifies composite
resin restoration procedures. Bulk filling allows the restoration to be built
in either one or two layers, according to the type and features of the bulkfill composite. This article describes two techniques: the traditional layering
technique of dentin, chromatic, and achromatic enamel; and the modified
technique, using low-shrinkage composites, bulk flowable, and enamel
composite resin. The step-by-step sequence for each technique is described,
along with benefits and drawbacks.
Key Words: composite resin, dental sculpture, bulk-fill
composite, low-shrinkage composite

Hirata/Kabbach/de Andrade/Bonfante

Journal of Cosmetic Dentistry

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Introduction
Composite resin restorations routinely have been used because of
greatly increasing patient demand
for esthetics and also because of
their high survival rates when
placed in large cavities.1 However,
there are still several concerns regarding the polymerization shrinkage generated by conventional
resin-based composites, which has
been an active research topic.2-6 Polymerization shrinkage may lead
to contraction of the total composite volume, by means of the crosslinking of the monomeric chains,
potentially resulting in marginal
opening, leakage, postoperative
sensitivity, and dental cracks.7
The United Nations Environment Programme has set a 2020
deadline to end commercial use of
mercury-based products in 170 nations.8 This decision has motivated
research toward improving minimally shrinking or nonshrinking
restorative composites as an alternative to replace amalgam.4 In
the past few years, low-shrinkage
composites have been presented
with the concept of bulk filling in a
flowable consistency for restricted
use as a cavity base or liner, leaving
only a thickness for a last layer of
conventional composite resin.
This article describes two different techniques for posterior composite restorations:
Layering technique, using
three layers of composites with
different levels of opacity and
translucency.
Bulk-fill technique, involving
the placement of a first layer
of bulk-fill composite and a
last layer of enamel composite
resin.
A step-by-step clinical sequence
is presented for each approach.

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Winter 2015 Volume 30 Number 4

Figure 1: Initial appearance of a wide occlusal cavity.

Layering Technique
One of the objectives of the layering technique is to reproduce the optical
properties of the natural tooth9,10 by using the correct translucency and opacity for each layer.11 An important advantage of working in increments is the
possibility of simulating different opacities, shades, and translucency characteristics of enamel and dentin,12 which can be customized during buildup.13
The use of incremental layers helps to decrease the stress generated by
resin composite polymerization shrinkage because it reduces the configuration factor (the number of bonded walls divided by the number of free
surfaces).14,15 However, precision is needed for each clinical step and specific care must be given to materials that become highly sensitive during
handling; the final functional and esthetic result may be compromised if
the clinician does not control each layer. Therefore, the filling technique for
posterior teeth should guarantee a precise fit for the material, especially to
the margins of the cavity; proper anatomic reconstruction; and reduction
of the inherent shrinkage stress generated by polymerization contraction.16
In the presented layering technique, three different composite layers are
used.11 After the margin of the cavity is finished (Fig 1), a self-etching adhesive can be used due to the consistency of results on dentin, especially
those using 10-methacryloyloxydecl dihydrogen phosphate monomers.17 On
enamel, a selective enamel-etching approach is recommended before using
the self-etching adhesive system (Figs 2 & 3).18
The first layer applied has to be a composite resin of the correct dentin, opaque, or body shade. A high saturation A3.5 color also is necessary
to reproduce the natural look of dentin and to block potential stains from
previous amalgam fillings. There is no need for shade matching in posterior
teeth because the thickness and levels of opacity and translucency are more
important in this region. The key for matching the perfect shade in posterior
teeth is to combine dentin layering in its proper thickness, as well as the
enamel or translucent layer (Figs 4 & 5).

Hirata/Kabbach/de Andrade/Bonfante

Figure 2: Phosphoric acid 35% application on only the enamel

margins (selective etching).

Figure 3: Application of dental adhesive (Scotchbond Universal

Adhesive, 3M ESPE; St. Paul, MN) as a self-etching system.

Figure 4: The bottom layer was made in two stages. Initially, an

incremental layer was applied onto the bottom and buccal walls;
high chroma and opacity Filtek Z350 XT body shades (3M ESPE) were
used.

Figure 5: Another incremental layer of the same composite was used

to complete the first layer. A space of 2.5 mm was left for the next
two layers.

One of the objectives of the layering technique is to reproduce

the optical properties of the natural tooth by using the correct
translucency and opacity for each layer.

Journal of Cosmetic Dentistry

123

An ideal dentin thickness should provide

2.5 mm of space occlusally for the layering of
chromatic and achromatic enamel shades. A
practical reference that can be used to ensure
such clearance for the material is provided by
a burnisher, such as the titanium 26/30 burnisher (Cosmedent; Chicago, IL). This should
sit on top of the composite-built dentin layer,
leaving 2.5 mm occlusally for the enamel layer. After curing the layer first in the direction of
the palatal and lingual walls, and then in the
direction of the buccal walls, layering of the
restoration is continued.
A second layer of chromatic enamel
(meaning enamel composite with a specific
VITA shade [VITA Zahnfabrik; Bad Sckingen,
Germany]) is selected (Figs 6-9). Shade A2
enamel currently is the most frequently used
material for the chromatic enamel layer in
posterior restorations. After this layer, a space
of 1.2 mm should be left to achieve the perfect
thickness for the achromatic enamel (meaning enamel composite that does not have a
VITA shade; usually these have names such as
Pearl, Trans, and Enamel). The last layer
must be applied individually for each cusp to
control the final desired contour (Figs 10-13).
Common problems associated with the
shrinkage generated by the polymerization
process and cross-linking of the monomers
are leakage of the restoration, resulting in
marginal degradation; secondary or recurrent caries; enamel cracks; and postoperative
sensitivity.6 The continuous search for a lowshrinkage resin composite included alternative materials such as ormocers and siloranes.3
Their resulting shrinkage stress and volume
analysis showed promising results compared
to the results with regular methacrylate composites.3 However, the need for a specific
adhesive system for this kind of material, as
with the limitation of repair with bisphenol
A-glycidyl methacrylate materials, has limited
their widespread use. The difficulty of achieving optimal polymerization depth with the
siloranes was another drawback.19 Chemically
cured composites also were launched for use
as a base (e.g., BISFIL 2B, Bisco; Schaumburg,
IL) and were claimed to provide bulk filling
with a lower-stress shrinkage polymerization
process.20

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Winter 2015 Volume 30 Number 4

A more recent generation of resin composites with photoinitiators, such as

a urethane-based patented monomer, allows bulk filling of layers up to 4 mm
thick.21 This flowable composite was named SDR Smart Dentine Replacement
(DENTSPLY; York, PA). However, an overlying layer of regular composite for
completion was still necessary. Another commercial brand in this category
is Filtek Bulk Fill Flowable Composite (3M ESPE; St. Paul, MN); its benefits
in terms of reduced shrinkage stress are still controversial and not clear in
the literature. Micro-computed tomography reconstructions of Class I cavity preparations restored with bulk-fill flowable composites showed fewer
gaps on the cavity floor interface after polymerization than did a regular resin
composite (Vitalescence, Ultradent; Salt Lake City, UT) (Figs 14-17).
A modification of the concept of flowable bulk-fill composites has been
proposed by the industry, allowing the complete restoration of cavities with
no need of an overlying final layer for completion. As a result, 4-mm4,22 (or
5-mm, depending on the manufacturers directions) increments can be placed
directly without an incremental layering technique because of the presence
of stress relief monomers and specific photoinitiators.4,21,22 Composite resins,
such as Tetric EvoCeram Bulk Fill (Ivoclar Vivadent; Schaan, Liechtenstein),
Venus Bulk Fill (Heraeus Kulzer; Hanau, Germany), and SonicFill (Kerr; Orange, CA), are some examples of this new category of material. Another manufacturer offers a flowable bulk-fill composite applied as a base or liner and a
bulk-fill composite to complete the reconstruction (Beautifil-Bulk Flowable,
Shofu Dental; San Marcos, CA).

Figure 6: A second layer was made with a chromatic enamel of shade A2 (Filtek
Z350 XT). A space of 1.2 mm was left for the last layer.

Hirata/Kabbach/de Andrade/Bonfante

Figures 7 & 8: The design of the

central occlusal sulcus was made
with an explorer, which also was
used to design the center sculpting.
Note that it has to provide enough
depth for the stain application.

Figure 9: White, ochre, and

brown stains (Kolor + Plus,
Kerr) were applied.
Journal of Cosmetic Dentistry

125

Figures 10-13: An achromatic

enamel shade (Filtek Z350 XT
WE) was applied to the cavity
margins. The explorer helped to
sculpt the details cusp by cusp.
Final appearance.

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Hirata/Kabbach/de Andrade/Bonfante

Figures 14 & 15: Micro-computed tomography three-dimensional reconstructions of a regular composite, bonded with its proprietary
adhesive system in a Class I preparation, used as bulk filling. Gaps generated by the shrinkage are visible on the bottom of the cavity walls.

Figures 16 & 17: Micro-computed tomography three-dimensional reconstruction of bulk-fill low-shrinkage flowable composite used as a bulk
filling along with its proprietary adhesive system in a Class I preparation.

On enamel, a selective enamel-etching approach is

recommended before using the self-etching adhesive system.

Journal of Cosmetic Dentistry

127

Bulk-Fill Technique
The bulk-fill technique is simple when compared with the traditional incremental layering technique just described because specific
composites have been developed to simplify
the steps, thus avoiding having to place several layers of varied shades. A technique modification has been suggested in an attempt to
simplify the steps, based on the premise that
incremental layering may not always be necessary.12 The rationale behind this method is
that if the composite is placed in one shot,
then a sculpting process similar to that used
for amalgam can be used.
The adhesive system application is identical to what has been described previously. After photocuring of the dental adhesive, a layer
of flowable composite with a thickness of up
to 4 mm is applied on the bottom of the cavity
and cured for 20 seconds.23
Low-shrinkage bulk-fill composites can be
used safely to fill posterior cavities, as long
as the cavities are up to 4 to 5 mm deep; the
situation may vary, depending on the manufacturer, and it is important to check instructions. With these materials, a cavity can be
filled with fewer layers. Two consistencies are
available for the bulk-fill composites: flowable
consistency (used as a base or liner) and regular consistency (used to fill and restore in one
shot).
The bulk-fill technique presented here is
called a two-step amalgam-like sculpting
technique, referring to the use of a flowable bulk-fill composite to build the core in a
single layer of up to 4-mm thickness, leaving
1.3 mm of space occlusally from the margin
for the last layer. Then, a regular composite is
used to allow completion of the occlusal surface. A clinical sequence of this technique is
presented in Figures 18 through 25.

Figure 18: After all the same initial steps as were used in the first
technique, a flowable bulk filling (Filtek Bulk Fill) was applied to the
cavity.

Figures 19 & 20: The cavity was filled almost completely with bulkfill composite, leaving 1.2 mm for a final layer of a conventional
composite.

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Winter 2015 Volume 30 Number 4

Hirata/Kabbach/de Andrade/Bonfante

Figures 21 & 22: A full layer of nanocomposite (Filtek Z350 XT A1E) was pressed into the dental cavity.

Figure 23: With the explorer, the final anatomic reconstruction can
Figure 24: Stains can be used inside the central sulcus traversing
be achieved, which also divides the cusps and controls the shrinkage the occlusal surface. To protect against abrasion, a sealant layer
stress.
(OptiGuard, Kerr) is applied.

The bulk-fill technique is simple

when compared with the traditional
incremental layering technique
because specific composites have
been developed to simplify the
steps, thus avoiding having to place
several layers of varied shades.
Figure 25: Final appearance.

Journal of Cosmetic Dentistry

129

Summary
This article described two techniques for posterior Class I composite restorations: traditional
incremental layering and a bulk-fill technique.
The decision as to which to use depends on
the desired esthetic outcome (although results
seem highly acceptable for both techniques),
the time available for the operative steps, and
the clinicians familiarity with the techniques
and materials. Although both techniques are
supported by scientific evidence, there seems to
be a trend toward simplification of steps, benefits being less treatment time and reduced polymerization contraction stress in bulk-fill composites. Long-term clinical implications have
yet to be confirmed.

6. El-Damanhoury H, Platt J. Polymerization shrinkage stress kinetics and

related properties of bulk-fill resin composites. Oper Dent. 2014 JulAug;39(4):374-82.
7. Roulet JF, Salchow B, Wald M. Margin analysis of posterior composites
in vivo. Dent Mater. 1991 Jan;7(1):44-9.
8. Rekow ED, Fox CH, Petersen PE, Watson T. Innovations in materials for
direct restorations: Why do we need innovations? Why is it so hard to
capitalize on them? J Dent Res. 2013 Nov;92(11):945-7.
9. Fahl N Jr. A polychromatic composite layering approach for solving
a complex Class IV/direct veneer-diastema combination: part I. Pract
Proced Aesthet Dent. 2006 Nov-Dec;18(10):641-5.
10. Fahl N Jr. A polychromatic composite layering approach for solving a
complex Class IV/direct veneer/diastema combination: part II. Pract

References

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MC. 12-year survival of composite vs. amalgam restora-

Mdicas; 2010. [Hirata R. Tips in cosmetic dentistry. So Paulo (Brazil):

tions. J Dent Res. 2010 Oct;89(10):1063-7.

Medical Arts; 2010.]

2. Hirata RC, Clozza E, Giannini M, Farrokhomanesh E,

Janal M, Tovar N, Bonfante EA, Coelho PG. Micro-com-

12. Jackson RD, Morgan M. The new posterior resins and a simplified
placement technique. J Am Dent Assoc. 2000 Mar;131(3):375-83.

puted tomography evaluation of volume changes in regular versus low shrinkage composites in Class I prepara-

13. Kwon Y, Ferracane J, Lee IB. Effect of layering methods, composite

tions. J Biomed Mater Res B Appl Biomater. Forthcoming

type, and flowable liner on the polymerization shrinkage stress of light

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cured composites. Dent Mater. 2012 Jul;28(7):801-9.

3. Arrais CA, Oliveira MT, Mettenburg D, Rueggeberg FA,

14. Lutz E, Krejci I, Oldenburg TR. Elimination of polymerization stresses

Giannini M. Silorane- and high filled-based low-shrink-

at the margins of posterior composite resin restorations: a new restor-

age resin composites: shrinkage, flexural strength and

ative technique. Quintessence Int. 1986 Dec;17(12):777-84.

modulus. Braz Oral Res. 2013 Mar-Apr;27(2):97-102.

15. Braga RR, Ballester RY, Ferracane JL. Factors involved in the develop4. Eick JD, Robinson SJ, Byerley TJ, Chappelow CC. Adhesives and nonshrinking dental resins of the future. Quin-

ment of polymerization shrinkage stress in resin-composites: a systematic review. Dent Mater. 2005 Oct;21(10):962-70.

tessence Int. 1993 Sep;24(9):632-40.

16. Park J, Chang J, Ferracane J, Lee IB. How should composite be layered
5. Eick JD, Kotha SP, Chappelow CC, Kilway KV, Giese GJ,
Glaros AG, Pinzino CS. Properties of silorane-based den-

to reduce shrinkage stress: incremental or bulk filling? Dent Mater.

2008 Nov;24(11):1501-5.

tal resins and composites containing a stress-reducing

monomer. Dent Mater. 2007 Aug;23(8):1011-7.

17. Muoz M, Luque-Martinez I, Malaquias P, Hass V, Reis A, Campanha

N, Loguercio A. In vitro longevity of bonding properties of universal
adhesives to dentin. Oper Dent. 2014 Nov 18. Epub ahead of print.

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18. Frankenberger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching reconsidered: better than etchand-rinse and self-etch? J Adhes Dent. 2008 Oct;10(5):339-44.
19. Goracci C, Cadenaro M, Fontanive L, Giangrosso G, Juloski
J, Vichi A, Ferrari M. Polymerization efficiency and flexural
strength of low-stress restorative composites. Dent Mater. 2014
Jun;30(6):688-94.

Low-shrinkage bulk-fill composites

can be used safely to fill posterior
cavities, as long as the cavities are
up to 4 to 5 mm deep

20. Peutzfeldt A, Asmussen E. Composite restorations: influence of

flowable and self-curing resin composite linings on microleakage
in vitro. Oper Dent. 2002 Nov-Dec;27(6):569-75.
21. Ilie N, Hickel R. Investigations on a methacrylate-based flowable composite based on the SDR technology. Dent Mater. 2011
Apr;27(4):348-55.
22. Moszner N, Fischer UK, Ganster B, Liska R, Rheinberger V. Benzoyl germanium derivatives as novel visible light photoinitiators
for dental materials. Dent Mater. 2008 Jul;24(7):901-7.

Dr. Hirata is an assistant professor of biomaterials and

biomimetics at New York University and a professor of
postgraduate restorative dentistry at Centro de Estudos
Treinamento e Aperfeioamento Em Odontologia (CETAO)
in So Paulo, Brazil.

23. Alshali RZ, Silikas N, Satterthwaite JD. Degree of conversion of

bulk-fill compared to conventional resin-composites at two time
intervals. Dent Mater. 2013 Sep;29(9):e213-7 jCD.

Dr. Kabbach is a professor of postgraduate restorative

dentistry at CETAO.

Dr. Scopin de Andrade is a professor of postgraduate restorative dentistry at CETAO and director of the Advanced
Program in Esthetic and Implant Dentistry at SENACSo
Paulo, Brazil.

Dr. Bonfante is an assistant professor of prosthodontics,

University of So PauloBauru School of Dentistry.

Disclosure: The authors did not report any disclosures.

Journal of Cosmetic Dentistry

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Winter 2015 Volume 30 Number 4

(CE) Exercise No. jCD18

Esthetic/Cosmetic Dentistry

AGD Subject Code: 255

The 10 multiple-choice questions for this Continuing Education (CE) self-instruction exam are based on the article, Traditional
Layering vs. Modified Bulk Filling, by Dr. Ronaldo Hirata, Dr. William Kabbach, Dr. Oswaldo Scopin de Andrade, and Dr. Estevam
Bonfante. This article appears on pages xx-xxx.
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1. What is unique about the layering technique used for composite

resin restorations?
a. Layering techniques are claimed to replicate tooth structure but
may increase the stress generated by polymerization shrinkage.
b. Layering techniques are advantageous for their time and cost
savings.
c. Advances in polymer chemistry engineering have allowed less
complex layering techniques.
d. Low-shrinkage composites should not be used with layering of
composite resin restorations.
2. Which of the following is an advantage of using a layering technique compared to a bulk-fill technique?
a. The layering technique presented will have considerably less
polymerization shrinkage.
b. A dentist can reproduce the optical properties of the natural
tooth with the layering technique.
c. The layering technique requires considerably less time.
d. By increasing the configuration factor, the layering technique
eliminates postoperative sensitivity.

4. In the modified layering technique proposed, the correct initial

layer should be which of the following?
a. The first layer applied has to be a composite resin of the correct
dentin, opaque, or body shade.
b. The first layer applied should be a low-shrinkage translucent
layer to allow the dentin shade to show through.
c. The first layer should be a thick layer of an opaque flowable
resin.
d. The first layer should be a low saturation, translucent A3.5
shade.
5. The author states that in posterior teeth there is no need for
shade matching for what reason?
a. Patients are less sensitive to the esthetics of posterior restorations.
b. It is more economical to stock one shade of low-shrinkage composite.
c. The levels of opacity and translucency are more important in
this region.
d. Shade matching cannot be achieved by combining dentin layering as well as the enamel or translucent layer.

3. In the layering technique presented, what is an essential first

step?
a. Application of a self-etching adhesive to the enamel margins of
the restoration.
b. Shaping the cavity margins with hand instruments.
c. Treatment of the exposed dentin with a desensitizing agent.
d. Etching of the enamel cavosurface margins prior to use of a selfetching adhesive.

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Journal of Cosmetic Dentistry

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