Q U I N T E S S E N C E I N T E R N AT I O N A L
RESTORATIVE DENTISTRY
Evaluation of the efficacy of flowable composite as
lining material on microleakage of composite resin
restorations: A systematic review and meta-analysis
Alireza Boruziniat, DDS, MS1/Samineh Gharaee, DDS, MS2/Alireza Sarraf Shirazi, DDS, MS3/
Sara Majidinia, DDS, MS4/Mehdi Vatanpour, DDS, MS5
Objective: The ecacy of owable composite in improving
marginal adaptation or reducing microleakage is not fully under-
stood. The purpose of this study was to systematically evaluate
existing evidence to verify whether an application of owable
composite as a liner provided less microleakage in Class 2 com-
posite restorations. Method and Materials: PubMed, ISI (Web
of Science), and Scopus databases were searched according to
the selected keywords, up to 15 Feb 2015, without any restric-
tion on date or language. Full texts of published articles that
seemed to meet primary criteria for inclusion in this research
were obtained. Data of studies were extracted if they were
assessed as high or moderate level of evidence. Due to the
variation of methods used in dierent studies, they were divided
into ve groups: groups 1 and 2, studies that evaluated the eect
of owable composite as a liner on dentinal or enamel margins
Key words: composite restoration, owable composite, meta-analysis, microleakage, systematic review
1
Assistant Professor, Dental Research Center, Department of Operative Dentistry,
Mashhad Dental School, Mashhad University of Medical Sciences, Mashhad, Iran.
2
Postgraduate Student, Department of Operative Dentistry, Mashhad Dental
School, Mashhad University of Medical Sciences, Mashhad, Iran.
3 Associate Professor, Dental Research Center, Department of Pediatric Dentistry,
Mashhad Dental School, Mashhad University of Medical Sciences, Mashhad, Iran.
4 Assistant Professor, Dental Material Research Center, Department of Operative
Dentistry, Mashhad Dental School, Mashhad University of Medical Sciences,
Mashhad, Iran.
5
Assistant Professor, Department Of Endodontics, Tehran Dental School, Tehran
University Of Medical Sciences, Tehran, Iran.
Correspondence: Dr Sara Majidinia, Dental Material Research Center,
Department of Operative Dentistry, Mashhad Dental School, Mashhad
University of Medical Sciences, Vakilabad Blvd, Mashhad, Iran.
Email: majidinias@mums.ac.ir; Sara_majidinia@yahoo.com
VOLUME 47 NUMBER 2 FEBRUARY 2016
Alireza Boruziniat
and applied owable composite on all of the cavity wall mar-
gins; groups 3 and 4, studies that evaluated the eect of ow-
able composite as a liner on dentinal and enamel margins and
applied owable composite only on gingival margin; and group
5, clinical studies. Results: The initial search yielded 1,370 pub-
lications. After hand searching, six extra studies were included
in the review. The abstracts of all were read independently by
AB and SG. After methodologic assessment and evaluation of
the level of evidence, 18 studies were selected for this study.
The results of this study indicate that owable composite liners
have no signicant eect on microleakage of composite restor-
ations in all of ve groups. Conclusion: Application of owable
composite as a liner in composite restorations cannot reduce
microleakage or improve clinical performance. (Quintessence Int
2016;47:93101; doi: 10.3290/j.qi.a35260)
Composite resin materials and adhesive technology
have advanced rapidly; however, the polymerization
shrinkage of these materials is still a challenge for prac-
titioners. This shrinkage depends on the cavity size, C
factor, modulus of elasticity of composite materials,
and type of polymerization,1 which results in de-bond-
ing of restoration from tooth structure. Therefore, mar-
ginal adaptation and microleakage remain an unavoid-
able problem in composite restorations, especially at
the gingival oor without enamel margin,2 where they
may result in marginal staining, postoperative sensitiv-
ity, secondary caries, and restoration failure.3
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The application of a liner such as a resin-modied
glass ionomer4-6 or a owable composite,7,8 which act as
a exible intermediate layer between restoration and
substrate, has been suggested as a method of relieving
the stress associated with polymerization shrinkage.
Van Meerbeek et al9 conrmed the eciency of this
technique in improving the marginal adaptation of
composite restorations. The rst generation of owable
composite was introduced in late 1996. Because of their
low ller loading, owable composites exhibited a
lower modulus of elasticity and more stress-buering
capacity than hybrid composite resins,10 and this leads
to the better marginal seal of owable composites.11-14
On the other hand, some studies demonstrated that
application of owable composite has no eect on mar-
ginal adaptation or microleakage and also its low vis-
cosity may lead to increased incidence of gingival mar-
gin overhangs. The owable composites have higher
polymerization shrinkage due to their lower ller con-
tent and this may disrupt the bond to cavity walls.15-17
However, use of a owable liner has been shown to
weaken the strength of the above polymerized restora-
tive composite.18 An additional concern with early gen-
eration owable composites pertains to their radiopa-
city, which has not met the standard of being at least as
radiopaque as enamel.
To the best of the authors knowledge, the ecacy
of the owable composite to improve the marginal
adaptation or to reduce the microleakage is uncertain.
The purpose of this study was to systematically evalu-
ate existing evidence to verify whether an application
of the owable composite as a liner provided less
microleakage in composite restorations. The null
hypothesis was that owable composite application
has no eect on enamel and dentin marginal leakage in
in-vivo and in-vitro situations.
METHOD AND MATERIALS
The guidelines developed and recommended by
PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) were employed in the
present systematic review.
94
Search strategy
A literature search was performed in the following
databases without any language or time limitation:
PubMed (to 15 Feb 2015)
ISI (Web of Science) to 15 Feb 2015
Scopus (to 15 Feb 2015).
The following key words were used (MeSH): (composite
AND (ow* OR (low-viscosity)) AND ((stress relieving
layer) OR (stress breaker) OR (stress relaxation) OR (stress
absorbing layer) OR (microleakage) OR (leakage) OR
(bacterial leakage) OR (marginal gap) OR (marginal adap-
tation) OR (marginal seal) OR (marginal integrity) OR
(gap formation) OR (interfacial gap) OR (interfacial adap-
tation) OR (interfacial seal) OR (interfacial integrity) OR
(polymerization shrinkage) OR (setting polymerization)).
A series of published studies that met the inclusion
criteria were selected. In order to identify additional
studies not included in the initial literature search, an
investigation was completed with an additional hand
search of the references of the selected articles.
Inclusion and exclusion criteria
Inclusion criteria were as follows:
The owable composite must be used as a lining
material in gingival oor or other cavity walls with a
maximum thickness of 1 mm.
The statistical data such as the sample size, mean,
and standard deviation were mentioned in articles.
The study should have a control group.
The owable composite should be cured before
insertion of conventional composites.
Human teeth samples were used.
For in-vivo studies:
Only randomized control trials (RCTs) were eligible
for the study.
Details of the study methods should be mentioned
including the follow-up period, allocation conceal-
ment and blinding, adhesives, and type of the com-
posite resins.
A clinical sign of microleakage should be reported
as outcomes including loss of retention, marginal
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Electronic searching
Hand searching
n = 1,370
n=6
ISI = 417, PubMed = 540, Scopus = 413

Papers excluded
Abstract and titles screened against in/exclusion
n = 1,171

Potential includes full texts retrieved Papers not obtained (n = 4)

n = 205 Authors didnt respond to email for details

Full document screened second time against in/exclusion criteria Papers excluded
n = 76 n = 129

Assess study quality, Extract data analysis and synthesis

n = 18

Clinical study Flowable composite only in gin- Flowable composite in gingival

n=6 gival oor n = 8 and other oor n = 4

Enamel margin Dentin margin Enamel margin Dentin margin

n = 4* n = 7* n = 2* n = 3*

Fig 1 The ow diagram of the included and excluded studies indicates some studies were common to the two groups (*).

integrity, marginal discoloration, secondary caries, Data extraction and analysis

and postoperative sensitivity.
It should be mentioned that gray literature, case reports,
meeting abstracts, and case series were excluded.
Author contact process
The authors of the articles with insucient data were
contacted via email to retrieve missing data and infor-
mation. If no answer was received by 2 weeks after the
initial email, a second email was forwarded. One month
after the rst contact, if no or incomplete answers were
sent by the authors, then the article was excluded.
Quality assessment of selected studies
To select eligible articles, two reviewers (AB and SG)
independently screened the literature and assessed
their quality using a Consort checklist form. In case of
dierent opinions, the subject was resolved by discus-
sion with the third reviewer.
The following data were recorded for each included
study:
statistical data such as the sample size, mean, and
standard deviation
details of the restorative protocol such as type of
tooth preparation, adhesive system, owable and
conventional composite, gingival margin position,
location of owable application, and thermal or
mechanical cycling.
RESULTS
Study search
The process of demonstrating the articles is presented
in Fig 1. Databases and hand searching yielded a total
of 1,376 potentially eligible studies. An initial assess-
ment of the articles led to the exclusion of 1,171
records; hence 205 publications that met the inclusion
criteria were included for scientic and methodologic

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Boruziniat et al

Table 1 The summary of eligible in-vitro studies in this meta-analysis

Adhesive Composite Load- Thermo- Curing Flowable

Title Tooth preparation type type ing cycle unit Dye composite
Basavanna
Class 2 Dentin Gingival Etch & rinse Packable No Yes Unknown Basic fuchsin Filtek Z 350 Flow
et al19
Senawongse Dentin and Methylene Estelite LV,
Class 5 Gingival Self-etch Nanolled Yes No QTH
et al14 enamel blue Paque Estelite LV
Sadeghi and Packable, Flowable Filtek
Class 2 Dentin Gingival Etch & rinse No Yes QTH-LED Basic fuchsin
Lynch13 nanolled Supreme XT
Chuang Dentin and Hybrid, Flow-it, Tetric
Class 2 Gingival Etch & rinse No Yes QTH Basic fuchsin
et al20 enamel microhybrid Flow, Filtek Flow
Ziskind Methylene
Class 2 Dentin Gingival Etch & rinse Packable No Yes Unknown Aeliteo, Flow-it
et al21 blue
Moazzami Methylene
Class 2 Dentin Gingival Etch & rinse Packable No Yes QTH Tetric Flow
et al17 blue
Etch & rinse, Packable,
Unlu et al22 Class 2 Enamel Gingival No Yes Unknown Basic fuchsin Start Flow
self-etch hybrid
Kuramoto
Class 2 Enamel Gingival Etch & rinse Microhybrid No No QTH Silver nitrate Tetric Flow
et al23
Pongprueksa Dentin and 5% Methy-
Class 5 All walls Etch & rinse Microhybrid Yes No QTH Filtek Flow
et al24 enamel lene blue
Gueders Rectan- Etch & rinse,
dentin All walls Microhybrid No Yes QTH Silver nitrate Filtek Flow
et al25 gular self-etch
Simi and 5% Methy-
Class 2 Enamel All walls Etch & rinse Nanolled No Yes LED Filtek Z 350 Flow
Suprabha26 lene blue
Sawani Gingival
Class II Dentin Etch & rinse Nanolled No Yes LED Basic fuchsin Filtek 350 XT Flow
et al27 or all walls

accuracy. Finally, 18 articles were included for the nal
qualitative analysis that were categorized into ve
groups. Most studies employed an in-vitro design and
applied owable composite in gingival oor (n = 9) or
in gingival and other cavity walls (n = 4) (one study is
common to both groups), and a few studies employed
a clinical design. Some of the in-vitro studies evaluated
the microleakage in dentinal gingival margin and some
of them in the enamel margin and a few of them had
evaluated both enamel and dentinal margins.
A summary of included studies is presented in
Table 1. According to the I2 value of the heterogeneity
test (I2 > .05), the random eect model was used for all
groups in this meta-analysis. Funnel plot tests showed
no publication bias for all groups.
The results of each group were as follow:
Group 1: Analysis of the eect of owable compos-
ite as liner on dentinal margin and applied owable
composite on all of the cavity wall margins showed
no signicant dierence in the reduction of micro-
leakage (P = .657) (Appendix 1, available in the
online version at http://quintessenz.de)
Group 2: Analysis of the eect of owable compos-
ite as liner on dentinal margin and applied owable
composite on gingival margins showed no signi-
cant dierence in the reduction of microleakage
(P = .138) (Appendix 2)
Group 3: Analysis of the eect of owable compos-
ite as liner on enamel margin and applied owable
composite on all of the cavity wall margins showed
no signicant dierence in the reduction of micro-
leakage (P = .145) (Appendix 3)
Group 4: Analysis of the eect of owable compos-
ite as liner on enamel margins and applied owable
composite on gingival margins (Fig 2) showed no
signicant dierence in the reduction of microleak-
age (P = .623) (Appendix 4)

96 VOLUME 47 NUMBER 2 FEBRUARY 2016

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Boruziniat et al

Fig 2a Without liner of owable composite on gingival margin. Fig 2b Flowable composite as liner on enamel margins on gin-
gival margins.

Table 2 Summary of clinical studies that evaluated the effect of flowable composite as a liner on gingival floor

Tooth Adhesive Follow- Flowable

Title preparation type Composite type up Composite placement Curing unit composite
Boeckler and Gernhardt28 Class 2, 1 Self-etch Nano hybrid 2 years Horizontal incremental QTH Tetric Flow
29
Efes et al Class 1 Etch & rinse Nanolled, Ormocer 2 years Oblique incremental QTH Filtek Flow
Reis and Loguercio30 Class 5 Etch & rinse Microhybrid 2 years Incremental QTH Filtek Flow
Filtek Flow
Stefanski31 Class 2 Etch & rinse Nanolled 2 years Oblique incremental QTH
Supreme XT
van Dijken and Pallesen32 Class 2 Etch & rinse Hybrid 7 years Incremental QTH Tetric Flow
33
Ernst et al Class 2 Etch & rinse Packable 2 years Horizontal incremental QTH Revolution

Group 5: All of the clinical studies included in this
research showed that the application of owable
composite as liner did not improve the clinical suc-
cess of restoration in comparison with the control
group (Table 2).
Generally, the results of this study showed that applica-
tion of owable composite has no signicant dierence
in the reduction of microleakage (P = .097) (Appendix 5).
All of the clinical studies used US Public Health Ser-
vice criteria for evaluating the restorations.
DISCUSSION
This systematic review showed that the application of
owable composite either on enamel or dentinal mar-
gins and in vitro or in vivo could not reduce the amount
of microleakage. Therefore, the null hypothesis of this
study was accepted.
The methodology and materials of studies that eval-
uated the eect of owable composite on microleak-
age are very dierent. For systematic review, the stud-
ies should have as many of the same variables and
methods as possible; therefore, the present study cat-
egorized the studies into ve separate groups based on
the factors that have a signicant eect on microleak-
age, including position of gingival margin (in dentin or
1 mm above the cementoenamel junction),11,34,35 appli-
cation of owable composite only on gingival margin
or on all of the cavity wall, and set-up of the study (in
vitro or in vivo). In the snow-plow technique, uncured
owable composite is applied under the restorative
composite and both composites are cured coinci-
dently.36 Because of the dierent eect of this tech-
nique on polymerization shrinkage and microleakage
in comparison with cured owable composite, studies
with snow-plow technique were excluded.

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The ability of owable materials to improve the
marginal seal may be due to their low elastic modulus,
stress-buering capacity,12,19,37,38 the better wettability
of this material,15 and the reduction of the volume of
the restorative material.39 Therefore, reduction of the
polymerization shrinkage, with a coecient thermal
expansion close to the tooth structure, leads to
increased marginal adaptation during thermal
cycling.40-42
There is a relationship among the elastic modulus,
polymerization shrinkage, and contraction stress of
composite materials.43,44 Higher elastic modulus and
polymerization shrinkage induce more shrinkage stress.
In owable composites, in spite of low elastic modulus,
they have high contraction stress because of a higher
volumetric shrinkage (up to 6%). This low elastic mod-
ulus, however, relieves some of the contraction stress.45
The elastic moduli of dierent owable composites
vary between 6.5 and 12.5 GPa. The ller content and
degree of conversion of composite may have an inu-
ence on elastic modulus.46 This variation may be an
explanation for contradictory results of studies that
employed owable composite as a liner.45
The eects of various parameters of owable com-
posite application in marginal sealing are discussed
below.
The monomers of the flowable composite
In addition to above-mentioned factors, the type of
monomer in a composite material can aect its volu-
metric shrinkage. Stavridakis et al47 showed that com-
posites containing ethoxylated bisphenol-A dimethac-
rylate (bis-EMA; eg, Filtek supreme , 3M ESPE), which
have a high viscosity and low elasticity in comparison
with bisphenol glycidyl methacrylate (bis-GMA), have
more interfacial stress during polymerization. Also,
some studies demonstrated more polymerization
shrinkage in composites with a higher content of dilut-
ing monomer triethylene glycol dimethacrylate (TEG-
DMA).48,49 Castaneda-Espinosa et al50 showed that ow-
able composite continues to generate contraction
stress for at least 2 minutes after the light curing. The
remaining polymerization shrinkage stress hides the
98
favorable eect of low elastic modulus in owable
composite. If the remaining polymerization shrinkage
stress has not been eliminated, no dierence in the
microleakage of composite restorations with or without
a liner of owable composite would be anticipated.
The thickness of the flowable composite
Another important factor is the thickness of the exible
liner. Chuang et al51 concluded that owable composite
was better to apply in a thin layer. The mass of a thicker
owable composite lining layer develops more poly-
merization shrinkage and marginal gaps. Furthermore,
Ozgunaltay and Gorucu52 demonstrated that increasing
the thickness of the base materials can reduce fracture
resistance of restoration. On the other hand, Malm-
strom et al53 showed that a thick owable composite
(2 mm), compared with one with a lower thickness (0.5
to 1 mm), reduced the microleakage, which may be due
to the better ability of thick owable composite in
reducing the interfacial stress. A nite element study
stated that a rapid decrease in stress is observed if the
thickness of the resin liner increased up to 10% of the
thickness of the sample.54 The proportion of the elastic
modulus of the owable liner to composite resin also
has a great impact on interfacial stress. If this ratio
reaches one to six and the thickness of a owable liner
is 10% of total restoration thickness, the stress of
mechanical loading decreased to 32%.54 Kemp-Scholte
and Davidson55 reported that if the intermediate layer
thickness of unlled resin or other liner materials is 150
m, which is 3% of restoration thickness; the polymer-
ization shrinkage stress is reduced from 50% to 18%. It
should be noted that the thickness of owable com-
posite in all studies in this meta-analysis was 1 mm.
Thermocycling
Amaral et al56 demonstrated that thermocycling can
aect durability of composite restorations when the
number of cycles was more than 30,000. Those articles
that have been evaluated in this study did not use a
large number of thermal cycles. In addition to the num-
ber of cycles, type of restorative material, and cavity
size and type, direction and magnitude of force can
VOLUME 47 NUMBER 2 FEBRUARY 2016

also inuence the eect of load cycling on marginal
microleakage. Moreover, Wibowo and Stockton57
showed that thermocycling has no eect on the micro-
leakage of restorations.
Adhesive system
The type of adhesive system is one of the most import-
ant factors for marginal sealing. Deliperi et al58 showed
that a perfect hybrid layer formation is the most
important factor in the performance of a composite
restoration. Therefore, the dierence in microleakage at
the enamel and dentinal margins may be due to the
quality of current adhesive systems. Kasraei et al59
showed that total-etch and self-etch adhesive systems
have no eect on the microleakage of owable com-
posite in dentinal margin. Swift et al60 and Kubo et al61
believed that the microleakage of owable composite
depends on the thickness of the adhesive layer. Thick
adhesives (such as lled adhesives) can act as a
stress-absorbing layer, but adhesives with little thick-
ness, such as all-in-one adhesives with low viscosity, did
not succeed in this manner. Another factor that needs
to be considered is the bond strength of adhesive sys-
tems. Kubo et al61 believed that adhesives which cre-
ated a high bond strength to enamel and dentin, even
without the application of a owable liner, are also able
to create and maintain long-lasting and high-quality
marginal integrity.
Gueders et al25 and Pamir et al62 showed that the
type of adhesive system (self-etch/total-etch) has no
eect on the microleakage of the owable composite
except for strong self-etch adhesive (eg, Prompt L-Pop,
3M Espe). This may be explained by the adequate bond
strength of these adhesives to enamel and dentin that
can compensate the polymerization shrinkage stress. It
should be considered that the strong self-etch adhesive
creates a weak bond to dentin; therefore, application of
owable composite can improve the marginal seal and
reduce the microleakage.
Restorative composite
Many studies noted that application of the owable
composite under packable and nanolled composite
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Boruziniat et al
reduced the microleakage.13,63,64 According to the study
by Neme et al,65 this nding may be attributed to the
similarity of the thermal expansion coecient of some
packable composites and owable composites to tooth
structure, which can be a factor in the increase of
microleakage, especially in thermal cycles. On the other
hand, adaptation of highly viscous composite with the
cavity wall is more dicult,37 and therefore application
of owable composite as a liner under the packable
composite enhances the adaptation and reduces the
microleakage. Another study by Chuang et al66 demon-
strated that packable composite has signicantly
higher stress than non-packable composite, because of
the large ller particles of these composites, which
increase the elastic modulus and result in higher
remaining contraction stress.
Type of the light-curing unit
Intensity, duration, and type of the light-curing unit can
alter the polymerization process and stress. In the cur-
rent study, all the eligible studies have a standard cav-
ity preparation that makes it possible for a suitable
amount of light intensity to reach the bottom of prep-
arations.13 It should be noted, however, that some
studies have shown that the type of the light-curing
unit can aect the microleakage.48,67 It seems that the
light intensity of the curing unit was more important
than the type of curing unit. Deliperi et al58 showed that
microhybrid owable composite could reduce the
microleakage only when soft-start or pulse curing
mode were applied for ploymerization. In none of the
eligible studies for the present systematic review, was
the owable composite cured in soft-start or pulse cur-
ing mode.
Systematic evaluation of the clinical studies
Unfortunately, direct evaluation of the microleakage in
clinical situations is impossible; therefore, in this study
those investigations which evaluated factors such as
marginal adaptation, recurrent caries, marginal discol-
oration, and hypersensitivity have been considered.
In all of the eligible clinical studies, the application
of owable composite as an intermediate layer has not
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Boruziniat et al
improved the performance of the composite restor-
ation. While checking for the present systematic review,
no research was found that restored teeth with/without
owable composite intraorally and then extracted
them for evaluation of microleakage. The exception is
the study by Lindberg et al,68 which restored Class 2
lesions in premolars with/without owable composite
and after 1 month extracted them and evaluated the
interfacial adaptation. They concluded that owable
composite has no eect on the marginal adaptation.
The results of the present study showed that the
application of owable composite as an intermediate
layer has neither improved the performance of the
composite restoration nor reduced its performance. In
problematic situations in which access to all the cavity
walls, especially the gingival oor, was dicult (for
example, endodontically treated teeth), application of
owable composite as a liner can enhance the adapta-
tion of the composite restoration.
A few valuable studies may have been missed in
this meta-analysis with the described search strategy. It
was intended to reduce this bias by duplicating the
search and by contacting authors to obtain necessary
information. In addition, it should be recognized that
the selection and qualitative synthesis of eligible stud-
ies is ultimately a subjective process. However, having
two reviewers conduct the screening procedure inde-
pendently, using a standardized form to extract the
data, and assessing methodologic quality using a vali-
dated checklist, helped to ensure a level of objectivity
in the search strategy.
CONCLUSION
This meta-analysis showed that the application of the
owable composite as a lining material in the gingival
oor or cavity walls did not signicantly reduce micro-
leakage of composite restorations in dentinal or
enamel margins.
In clinical studies, it was shown that the application
of the owable liner under composite restorations will
not improve their clinical performance.
100
ACKNOWLEDGMENT
This study was supported by a grant from Mashhad University
Research Council. The results of the present study have been taken
from a student thesis, Mashhad University, no. 494.
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