Eur J Oral Sci 2017; 125: 303309 2017 Eur J Oral Sci

DOI: 10.1111/eos.12351 European Journal of

Printed in Singapore. All rights reserved
Oral Sciences

Jan W. V. van Dijken1 ,

Bulk-filled posterior resin restorations Ulla Pallesen2
1
Dental School, Faculty of Medicine, Ume

a
based on stress-decreasing resin University, Ume

a, Sweden; 2Department of
Odontology, Faculty of Health and Medical
Sciences, University of Copenhagen,
technology: a randomized, controlled Copenhagen, Denmark

6-year evaluation
van Dijken JWV, Pallesen U. Bulk-filled posterior resin restorations based on stress-
decreasing resin technology: a randomized, controlled 6-year evaluation.
Eur J Oral Sci 2017; 125: 303309. 2017 Eur J Oral Sci
This randomized study evaluated a owable resin composite bulk-ll technique in
posterior restorations and compared it intraindividually with a conventional 2-mm
resin composite layering technique over a 6-yr follow-up period. Thirty-eight pairs
of Class II restorations and 15 pairs of Class I restorations were placed in 38 adults.
In all cavities a single-step self-etch adhesive (Xeno V) was applied. In the rst cav-
ity of each pair, the owable resin composite (SDR) was placed, in bulk increments
of up to 4 mm. The occlusal part was completed with a layer of nanohybrid resin
composite (Ceram X mono). In the second cavity of each pair, the hybrid resin
Jan W. V. van Dijken, Department of
composite was placed in 2-mm increments. The restorations were evaluated using Odontology, Dental School Ume
a, Ume

a
slightly modied US Public Health Service (USPHS) criteria at baseline and then University, 901 87 Ume
a, Sweden
annually for a time period of 6 yr. After 6 yr, 72 Class II restorations and 26 Class
E-mail: Jan.van.Dijken@odont.umu.se
I restorations could be evaluated. Six failed Class II molar restorations, three in
each group, were observed, resulting in a success rate of 93.9% for all restorations
and an annual failure rate (AFR) of 1.0% for both groups. The AFR for Class II Key words: bulk-fill; clinical; composite resin;
and Class I restorations in both groups was 1.4% and 0%, respectively. The main posterior; self-etch adhesive
reason for failure was resin composite fracture. Accepted for publication April 2017

Light-cured resin composites have become increasingly
popular, allowing dental-restorative procedures to be
more dental hard-tissue preserving and restorations to
be more aesthetic (1). The degree of cure of the resin
composite is aected by many factors, including the
power density of the curing unit, the exposure time,
the resin shade, the ller size, and the loading level
(2). As light passes through the bulk of the restora-
tion its intensity becomes greatly reduced, thus
decreasing the curing ecacy and limiting the depth
of cure (3). To prevent clinical failures from a non-
optimally cured resin composite and to decrease the
elution of non-reacted monomers, the resin composite
restoration has to be cured in increments. The maxi-
mal incremental thickness, which provides adequate
light penetration and polymerization, has been gener-
ally dened as 2 mm (4, 5). The layering technique
makes the restorative procedure time consuming,
voids may be included, and the failure risk increases
(6). The conversion rate in resin composite restora-
tions will also decrease with increasing distance from
the curing light and by decreased radiant exposure (7,
8). The main concern regarding the application of
thicker increments is whether the resin composite
cures suciently in the deeper parts to obtain accept-
able properties. Inadequate cure of the restoration
bulk degrades the physical properties of the resin
composite restoration and leads to increased elution
of monomers (912).
During the early 2000s, a new approach was intro-
duced to the application of posterior resin composite
restorations in thicker layers, which involved the use of
a highly translucent resin composite (13). During the
following years, several so-called bulk-ll resin compos-
ites have been introduced. The rst marketed material,
SDR (DentsplySirona, Konstanz, Germany), was a
owable resin composite based on a stress-decreasing
resin technology to be used in 4-mm layers as open or
closed dentin replacement beneath a conventional resin
composite (14). The degree of cure and mechanical
properties of the resin composite were shown to be
constant within the 4-mm increment at a curing time of
20 s (15).
There is almost no clinical evidence for the group of
bulk-ll resin composites. For the rst marketed ow-
able bulk-ll resin composite, SDR, acceptable short-
time eectiveness was recently reported (1618). The
aim of the present randomized clinical study was to
304 van Dijken & Pallesen
report on a 6-yr follow-up study of the owable bulk-ll
resin composite SDR. In an intra-individual compar-
ison, the clinical eectiveness was compared with a resin
composite-only restoration placed with a 2-mm layering
technique. In both cavities, a one-step self-etching bond-
ing system was used. The hypothesis tested was that the
bulk-ll technique shows similar durability as the
restoration placed with conventional 2 mm layering.
Material and methods
During the period 5 May 2010 to 31 October 2010, all
adult patients attending the Public Dental Health Service
clinic at the Dental School Ume
a, who needed one or two
pairs of similar Class II or Class I restorations, were asked
to participate in the study. All invited patients participated
in the study and, in order to reect the whole patient pop-
ulation, no-one was excluded because of high caries activ-
ity, periodontal condition, or parafunctional habits. All
teeth were in occlusion and had at least one proximal con-
tact with an adjacent tooth.
All patients were informed about the background of
the study, which was approved by the Ethics Committee
of the University of Ume
a (Dnr 07-152M) (16). Reasons
for placement of the resin composite restorations were
carious lesions, fracture of old llings, and replacement
for aesthetic or other reasons. In order to make an intra-
individual comparison possible, each patient received two
or four restorations, which were pairwise similar in size
and location. The cavity pairs in each participant were
randomly allocated to be restored with either the experi-
mental or the control restoration before the operative
procedure started, according to a predetermined scheme
of randomization. The participants were not aware of
which cavity received the experimental restoration or the
control restoration. In the experimental cavity, an inter-
mediate layer of the SDR owable resin composite
(DentsplySirona, Konstanz, Germany; Table 1) was
Table 1
Resin composites and adhesive system used
Material Composition
SDR Filler: barium-alumino-uoro-borosilicate
glass, strontium alumino-uoro-silicate glass
Matrix: modied urethane dimethacrylate
resin, ethoxylated bisphenol-A dimethacrylate,
triethyleneglycol dimethacrylate, camphorquinone,
butylated hydroxyl toluene, UV stabilizer,
titanium oxide, iron oxide pigments
Ceram X Filler: barium-aluminium-borosilicate glass
mono (1.11.5 lm), methacrylate functionalized
silicone dioxide nanoller (10 nm)
Matrix: methacrylate modied polysiloxane,
dimethacrylate resin, uorescent pigment,
UV stabilizer, stabilizer, camphorquinone, ethyl-4
(dimethylamino) benzoate, titanium oxide pigments,
aluminium silicate pigments
Xeno V Bifunctional acryl resin with amide functions,
acryloylamino alkylsulfonic acid, inverse
functionalized phosphoric acid ester, acrylic
acid, camphorquinone, co-initiator, butylated
benzenediol, water, tert-butanol
placed in the dentinal part, followed by a covering layer
of the nanohybrid resin composite Ceram X mono
(DentsplySirona). The control restoration (resin compos-
ite-only restoration) was lled with Ceram X (Dentsply-
Sirona). Thirty-eight pairs of Class II restorations and 15
pairs of Class I restorations were placed in 38 (22 male
and 16 female) patients, with a mean age of 55.3 (range:
3287) yr, by one experienced operator (JvD). The distri-
bution of the experimental teeth and the size of the
restorations is shown in Table 2.
The theoretical sample size was set to 40 restorations
per group to determine signicant dierences in outcomes
at the 95% condence level, with an alpha value of 0.05
and 80% power. With this sample size, it has been possi-
ble to determine signicant dierences between groups
treated with dierent materials in similar intra-individual
comparison design evaluations (19, 20). The number of
participants was increased to safeguard against possible
dropouts.
Clinical procedure
The clinical procedure has been described in a previous
report on the study (16) and will therefore be described
only briey (16). The operative eld was carefully isolated
with cotton rolls and a suction device. In none of the cavi-
ties were calcium hydroxide [Ca(OH)2] or other base mate-
rials applied. Application of the one-step self etching
adhesive XenoV (DentsplySirona) in both cavities was per-
formed according to the manufacturers instructions
(Table 1). Curing of adhesive and resin composite was per-
formed with a well-controlled high-power curing unit
(950 mW cm
, Smartlite PS; DentsplySirona). In the SDR
restoration, the ow material was dispensed directly into
the cavity from the compula tip using low, steady pressure.
The material was available in one semi-transluscent univer-
sal shade. SDR was placed in bulk increments up to 4 mm
as needed to ll the cavity 2 mm short of the occlusal cavo-
surface. After curing of the ow increment(s) (20 s), the
occlusal part of the restoration was completed using the
Type Application steps Manufacturer
4-mm layers, light DentsplySirona,
cured for 20 s Konstanz,
The SDR ow base is Germany
covered with at least
2 mm of resin composite
Nanohybrid 2-mm layers, light DentsplySirona
76% (w/w) ller cured for 2030 s
57% (v/v) ller
average
size Nanollers
10 nm and
nanoparticles 2.3 nm
One-component, Apply primer for DentsplySirona
one-step 20 s, careful
self-etching air drying
adhesive for >5 s, light
cured for 10 s
 Durability of a bulk-fill resin composite 305

Ceram X resin composite material. In the control cavity, sessions, evaluators did not know which study or which
the resin composite Ceram X was applied in 2-mm layers, restorative material group the scoring concerned. As
if possible, using an oblique layering technique. After described earlier, the caries risk for each participant and
checking the occlusion/articulation and contouring with their parafunctional habits activity at baseline and during
nishing diamond burs, the nal polishing was performed the follow-up period were estimated by the treating clini-
with the Shofu polishing system (Brownie, Shofu, Kyoto, cian using clinical and sociodemographic information rou-
Japan) or the Enhance polishing system (DentsplySirona). tinely available at the annual clinical examinations (e.g. in
the form of incipient caries lesions and former caries his-
tory) (1618, 22, 23).
Evaluation
At baseline (after placement of the restorations), and Statistical analysis
yearly for 6 yr thereafter, the restorations were assessed
using slightly modied US Public Health Service (USPHS) The characteristics of the restorations are described by
criteria (Table 3) (21). The follow-up registrations were descriptive statistics using cumulative relative frequency
performed blind by the operator and at regular intervals distributions of the USPHS scores. The experimental and
by two calibrated evaluators. During the evaluation control restorative techniques were compared intra-indivi-
dually using the non-parametric Friedmans two-way ANOVA
(24).
Table 2
Distribution and size of the experimental restorations
Results
Mandible Maxilla
One molar resin composite-only tooth showed postop-
No. of surfaces Premolars Molars Premolars Molars Total
erative sensitivity during the rst 3 wk for temperature
One 3 8 2 17 30 changes and occlusal forces. One female and three male
Two 16 8 26 20 70 patients with four Class I restorations and four Class II
Three or more 3 3 6 molar restorations (7.6%) could not be evaluated for
Total 19 19 28 40 106 the entire 6-yr follow-up period as either they had

Table 3
Modified US Public Health Service (USPHS) criteria for direct clinical evaluation (21)

Score
Category Acceptable Unacceptable Criteria

Anatomical form 0 The restoration is contiguous with tooth anatomy

1 Slightly under- or over-contoured restoration; marginal ridges slightly
undercontoured; contact slightly open (may be self-correcting); occlusal
height reduced locally
2 Restoration is undercontoured, dentin or base exposed; contact is
faulty, not self-correcting; occlusal height reduced; occlusion aected
3 Restoration is missing partially or totally; fracture of tooth structure;
shows traumatic occlusion; restoration causes pain in tooth or adjacent
tissue
Marginal adaptation 0 Restoration is contiguous with existing anatomic form, explorer does
not catch
1 Explorer catches, no crevice is visible into which explorer will penetrate
2 Crevice at margin, enamel exposed
3 Obvious crevice at margin, dentin or base exposed
4 Restoration mobile, fractured or missing
Color match 0 Very good color match
1 Good color match
2 Slight mismatch in color, shade or translucency
3 Obvious mismatch, outside the normal range
4 Gross mismatch
Marginal 0 No discoloration evident
discoloration 1 Slight staining, can be polished away
2 Obvious staining cannot be polished away
3 Gross staining
Surface roughness 0 Smooth surface
1 Slightly rough or pitted
2 Rough, cannot be renished
3 Surface deeply pitted, irregular grooves
Caries 0 No evidence of caries contiguous with the margin of the restoration
1 Caries is evident contiguous with the margin of the restoration
306 van Dijken & Pallesen

Table 4
Distribution of unacceptable restorations according to reasons for failure during the 6-yr follow-up period

Year of follow-up
1 2 3 4 5 6
Reason for failure SDR RC SDR RC SDR RC SDR RC SDR RC SDR RC

Fracture resin composite 1M 1P 1M 1M

Caries 1M
Cusp fracture 1M
Cumulative absolute frequency 0 1 0 2 0 2 0 2 1 3 3 3
Cumulative relative frequency (%) 0 2.0 0 3.9 0 3.9 0 4.0 2.0 6.0 6.1 6.1

M, molar; P, premolar; RC, Ceram X-only restoration; SDR, SDR/Ceram X.

Table 5
moved away (two patients) or died (two patients). After
6 yr, 49 pairs of restorations, including 26 Class I Per cent distribution of US Public Health Service (USPHS)
restorations and 72 Class II restorations, were evalu- scores for the posterior restorations evaluated at baseline
ated with a success frequency of 93.9%. Six Class II (106), and at 3 (104) and 6 (98) years follow-up for the two
types of restorations, SDR/Ceram X (SDR) and Ceram X only
molar restorations (three in each group) failed, which (RC)
resulted in annual failure rates (AFRs) of 1.0% for
both groups. All failures but one occurred in two-sur- Type of USPHS score
face molar tooth restorations. The AFR at 6 yr was restoration and
0% for Class I restorations and 1.4% for Class II Time of
Criterion assessment 0 1 2 3 4
restorations. The cumulative failure frequencies during
the follow-up period, the time of failure, and the rea- Anatomical SDR baseline 96.2 3.8
sons for failure are shown in Table 4. The main reason form RC baseline 100 0
for failure was fractures of the resin composite, which SDR 3 yr 92.3 7.7
were observed as partial fractures, except for one total RC 3 yr 94.3 1.9 1.9 1.9
fracture of a two-surface premolar restoration. The SDR 6 yr 87.8 8.2 4.0
RC 6 yr 85.8 8.2 2.0 2.0
overall dierence between the two restoration groups
Marginal SDR baseline 100
for the variables evaluated in both cavity classes was adaptation RC baseline 100
not signicant. The scores at baseline, 3 yr, and 6 yr SDR 3 yr 96.2 3.8
for the restorations evaluated are given as relative RC 3 yr 88.5 5.8 1.9 1.9 1.9
frequencies in Table 5. The colour match deteriorated SDR 6 yr 79.6 12.4 2.0 2.0 4.0
signicantly during the 6-yr follow-up period RC 6 yr 73.6 16.4 4.0 2.0 4.0
Color match SDR baseline 26.9 71.2 1.9
(P < 0.05). Ten participants were estimated as having
RC baseline 25.0 75.0 0
high caries risk, and 11 participants showed mild-to- SDR 3 yr 5.8 80.8 13.4
severe parafunctional habits during the observation RC 3 yr 6.0 86.0 8.0
period. All fractures occured in active bruxing partici- SDR 6 yr 4.4 71.7 23.9
pants. One secondary caries lesion was observed in a RC 6 yr 13.0 69.6 17.4
caries-risk participant. Four of the failures occurred in Marginal SDR baseline 100
male participants and two occurred in female partici- discoloration RC baseline 100
SDR 3 yr 100
pants. Two Class II restorations with small occlusal RC 3 yr 100
marginal defects, not scored as failures, were observed SDR 6 yr 89.2 6.5 4.3
at the last evaluation. RC 6 yr 93.4 4.4 2.2
Surface SDR baseline 100
roughness RC baseline 100
SDR 3 yr 100
Discussion RC 3 yr 100
SDR 6 yr 91.4 8.6
The bulk-ll technique investigated in the present study RC 6 yr 93.5 6.5
represents one of the attempts during recent years to Caries SDR baseline 100
simplify the placement of resin composites. Most of RC baseline 100
these simplications have concerned a reduction in the SDR 3 yr 100
number of steps and the use of self-etching adhesive RC 3 yr 100
SDR 6 yr 98.0 2.0
systems. The traditional 2-mm incremental placement
RC 6 yr 100
technique of traditional resin composite materials was
necessary to obtain adequate light penetration and has
been suggested to reduce shrinkage stress. However, calculations have shown that an oblique layering tech-
the stress-reducing eect of the incremental lling tech- nique produced more stress concentration at the inter-
niques has been questioned and nite element face compared with a horizontal lling technique (25,
 Durability of a bulk-fill resin composite 307

Table 6
Published annual failure rates for restorative systems in Class II cavities as observed in studies, of at least 6 yr duration, carried out
in Umea or Copenhagen

Year of Failures
Restorative system publication rates at 6 yr
Classication (total follow-up time) (reference no.) (%) AFR (%) Manufacturer

Resin composite system low els/cmf 2017 (34) 11.4 1.9 Saremco AG, Rebstein,
shrinkage, HEMA/TEGDMA els/AdheSE (6 yr) 20.0 3.3 Switzerland
free Ivoclar/Vivadent, Schaan,
Liechtenstein
Resin composite, low shrinkage InTen-S/Excite 2015 (35) 12.8 2.1 Ivoclar/Vivadent, Schaan,
Resin composite, microhybrid Point 4/Optibond 14.3 2.4 Liechtenstein
Solo Plus (15 yr) Kerr, Orange, CA, USA
Resin composite, nanolled Ceram X/Xeno III 2015 (36) 10.1 1.7 DeTrey/Dentsply, Konstanz,
Ceram X/Excite 5.8 1.0 Germany
(8 yr)
Resin composite, nanolled, Tetric Evo Ceram 2014 (37) 13.6 2.3 Ivoclar/Vivadent, Schaan,
highly lled hybrid Tetric Ceram 10.2 1.7 Liechtenstein
(10 yr)
Resin composite, hybrid Spectrum TPH/ 2014 (38) 15.0 2.5 Dentsply DeTrey, Konstanz
Prime&Bond
(8 yr)
Resin composite, hybrid Gradia Direct 2013 (39) 8.5 1.4 GC, Tokyo, Japan
Resin composite, Giomer Posterior/G-Bond 17.7 3.0 Shofu, Kyoto, Japan
Beautil/FLbond
(6 yr)
Resin composite, highly Tetric Ceram/Excite 2011 (40) 14.0 2.3 Ivoclar/Vivadent, Schaan
lled hybrid Tetric Ceram/ 12.3 2.1
small-particle Tetric ow/Excite
(7 yr)

AFR, annual failure rate; cmf, no information; els, extra low shrinkage; HEMA, 2-hydroxyethyl methacrylate; TEGDMA, triethyleneglycol
dimethacrylate.

26). VERSLUIS et al. showed that additional increments
increased the cuspal deformation of the weakened cusps
(25). Despite its owability, SDR showed the lowest
shrinkage stress and shrinkage rate compared with reg-
ular methacrylate resin composites (27). Cuspal deec-
tions were signicantly reduced when a single
increment of the owable resin composite was used as
dentin replacement base to restore Class II cavities
(28). Application of the bulk-ll technique showed
good interfacial adaptation and satisfactory microten-
sile bond strength to cavity-bottom dentin in high
C-factor cavities (29, 30).
The present prospective study is the longest clinical
evaluation of restoration made using the bulk-ll tech-
nique. The durability of the posterior restorations,
expressed as AFR, showed that the novel 4-mm layer-
ing technique produced results that were similar to
those obtained using the traditional 2-mm layering
technique. The null hypothesis of no dierence was
therefore accepted. No Class I restoration failed during
the follow-up period, conrming the high durability of
occlusal restorations, despite the high C-factor of the
cavity (1618, 31). For the Class II restorations in the
present study a 1.4% AFR was observed, which is simi-
lar to the AFR found in a recently published 5-yr fol-
low-up study of the same bulk-ll resin composite
placed with a modication of the self-etch adhesive
used in the present study (18).
Over the years, rather large dierences in the longev-
ity for Class II restorations have been reported in the
literature. The design of published studies have been
rather dierent and several involve a high degree of
selection of participants by excluding risk patients, such
as caries-risk patients and/or bruxing participants. A
high frequency of failures can be expected in these risk
participants (32, 33). To avoid selection bias, the pre-
sent study employed the rule that all participants
attending the Public Dental Health Service clinic, who
were in need of Class I and/or II restorations, were eli-
gible for participation. The success rate of the bulk-ll
resin composite should therefore be compared with
resin composite systems investigated in prospective
studies with the same study design and patient selection
as the present study. Table 6 presents an overview of
the posterior resin composite studies performed by
research groups in Ume
a and Copenhagen and recently
published in international peer-reviewed dental journals
(3440). Studies investigating Class II restorations and
reporting 6-yr failure rates and annual failure rates are
shown. Compared with the AFRs reported in the pre-
sent study for the bulk-ll technique, previous studies
have reported either slightly or signicantly higher
AFRs (1.73.3%; Table 6) for restorations placed using
the traditional 2-mm layering technique. In one of these
studies, the nanolled resin composite, which was used
in the present study in combination with the successor
308 van Dijken & Pallesen
of the present self-etch adhesive, showed a 1.7% AFR
at 6 yr (36). Even if real long-term results are still miss-
ing, it can be assumed, on the basis of the results of
the present study, that the new owable bulk-ll tech-
nique can be used in Class I and Class II cavities with
the same durability as the traditional 2-mm layering
technique. As a result of dierent ways to obtain a dee-
per cure and the large dierences in mechanical and
physical properties found within the so-called bulk-ll
resin composites, no overall conclusions for the whole
group can be made. A higher transluscency in the SDR
material and incorporation of a photoactive group in
the methacrylate resin enables the resin composite to be
cured in 4-mm layers (DentsplySirona technical infor-
mation, http://www.dentsply.de/bausteine.net/f/8883/
SCSDRDeTrey110815E.pdf?fd=2) while maintaining
the mechanical properties (15, 27, 29). However, as
indicated by the manufacturer, ILIE et al. showed that
addition of the occlusal capping layer made of a regu-
lar resin composite is a necessity (41). The modulus of
elasticity and and hardness of the owable material
was considerably below the mean values of regular
nanohybrid and microhybrid resin composites. The
main reason for failure was material fracture, all of
which occurred in bruxing-risk participants, thereby
conrming the results of earlier Class II studies (32,
33). Only one secondary caries lesion was observed in a
caries-risk participant. It can be concluded that the
bulk-lling technique based on SDR technology
showed highly acceptable clinical results that were com-
parable with the conventional 2-mm incremental tech-
nique in this 6-yr follow-up study.
Acknowledgements This study was partly sponsored by the
County Council of Vasterbotten and DentsplySirona.
Conflicts of interest The authors do not have any nancial inter-
est in the company whose materials are studied.
References



1. SUNNEGARDH
-GRONBERG K, VAN DIJKEN JWV, FUNEGARDH U,
LINDBERG A, NILSSON M. Selection of dental materials and
longevity of replaced restorations in Public Dental Health
clinics in northern Sweden. J Dent 2009; 37: 673678.
2. RUEGGEBERG FA, CAUGHMAN WF, CURTIS JW, DAVIS HC.
Factors aecting cure at depths within light-activated resin
composites. Am J Dent 1993; 6: 9195.
3. RUYTER IE, O YSAED H. Conversion in dierent depth of ultra-
violet and visible light activated composite materials. Acta
Odontol Scand 1982; 40: 179192.
4. PILO R, OELGIESSER D, CARDASH HS. A survey of output
intensity and potential for depth of cure among light-curing
units in clinical use. J Dent 1999; 27: 235241.
5. FLURY S, HAYOZ S, PEUTZFELDT A, HUSLER J, LUSSI A. Depth
of cure of resin composites. Is the ISO 4049 method suitable
for bulk-ll materials? Dent Mater 2012; 28: 521528.
6. EL-SAFTY S, SILIKAS N, WATTS DC. Creep deformation of
restorative resin-composites intended for bulk-ll placement.
Dent Mater 2012; 28: 928935.
7. LINDBERG A, PEUTZFELDT A, VAN DIJKEN JWV. Eect of
power density of curing unit, exposure duration, and light
guide distance on composite depth of cure. Clin Oral Investig
2005; 9: 7176.
8. LINDBERG A, ENAMI N, VAN DIJKEN JWV. A Fourier Trans-
form Raman spectroscopy analysis of the degree of conversion
of a universal hybrid resin composite cured with light-emitting
diode curing units. Swed Dent J 2005; 29: 105112.
9. CAUGHMAN WF, CAUGHMAN GB, SHIFLETT RA, RUEGGEBERG
F, SCHUSTER GS. Correlation of cytotoxicity, ller loading
and curing time of dental composites. Biomaterials 1991; 12:
737740.
10. DAVIDSON CL, FEILZER AJ. Polymerization shrinkage and
polymerization shrinkage stress in polymer-based restoratives.
J Dent 1997; 25: 435440.
11. VENHOVEN BAM, DE GEE AJ, DAVIDSON CL. Polymerization
contraction and conversion of light-curing BisGMA-based
methacrylate resins. Biomaterials 1993; 14: 871875.
12. MICHELSEN VB, KOPPERUD HB, LYGRE GB, BJORKMAN L, JEN-
SEN E, KLEVER IS, SVAHN J, LYGRE H. Detection and quanti-
cation of monomers in unstimulated whole saliva after
treatment with resin-based composite llings in vivo. Eur J
Oral Sci 2012; 120: 8995.
13. MANHART J, CHEN H-Y, HICKEL R. Clinical evaluation of the
posterior composite QuiXl in class I and II cavities: 4-year
follow-up of a randomized controlled trial. J Adhes Dent
2009; 12: 17.
14. JIN X, BERTRAND S, HAMMESFAHR PD. New radically poly-
merizable resins with remarkably low curing stress. J Dent
Res 2009; 88(Spec IssueA): 1651.
15. CZASCH P, ILIE N. In vitro comparison of mechanical proper-
ties and degree of cure of bulk-ll composites. Clin Oral
Investig 2012; 17: 227235.
16. VAN DIJKEN JWV, PALLESEN U. A randomized controlled
three year evaluation of bulk-lled posterior resin restora-
tions based on stress decreasing resin technology. Dent Mater
2014; 30: e229e237.
17. VAN DIJKEN JWV, PALLESEN U. Randomized 3 year clinical
evaluation of Class I and Class II posterior resin restorations
placed with a bulk-lled resin composite and a 1-step self-etch
adhesive. J Adhes Dent 2015; 17: 8188.
18. VAN DIJKEN JWV, LINDBERG A. Clinical eectiveness of a low
shrinkage resin composite. A ve-year study. J Adhes Dent
2009; 11: 143148.
19. VAN DIJKEN JWV, SUNNEGARDH

-GRONBERG K. A two-year
clinical evaluation of a new calcium aluminate cement in
Class II cavities. Acta Odontol Scand 2003; 61: 235240.
20. VAN DIJKEN JWV, SUNNEGARDH

-GRONBERG K. A three-year
clinical evaluation of a new calcium aluminate cement in
Class V cavities. Swed Dent J 2004; 28: 111118.
21. VAN DIJKEN JWV. A clincial evaluation of anterior conven-
tional, microller and hybrid composite resin llings. A six
year follow up study. Acta Odontol Scand 1986; 44: 357367.
22. ISOKANGAS P, ALANEN P, TIEKSO J. The clinician0 s ability to
identify caries risk subjects without saliva tests - a pilot study.
Community Dent Oral Epidemiol 1993; 21: 810.
23. SEPPA L, HAUSEN H, POLL
ANEN L, HELASHARJU K, KARKKAI-
NEN S. Past caries recording made in Public Dental Clinics as
predictors of caries prevalence in early adolescence. Commu-
nity Dent Oral Epidemiol 1989; 17: 277281.
24. SIEGEL S. Nonparametric statistics. New York: McGraw-Hill,
1956; 166172.
25. VERSLUIS A, DOUGLAS WH, CROSS M, SAKAGUCHI RL. Does
an incremental lling technique reduce polymerization shrink-
age stresses? J Dent Res 1996; 75: 871878.
26. ABBAS G, FLEMING GJ, HARRINGTON E, SHORTALL AC, BURKE
FJ. Cuspal movement and microleakage in premolar teeth
restored with a packable composite cured in bulk or incre-
ments. J Dent 2003; 31: 437444.
27. ILIE N, HICKEL R. Investigations on a methacrylate-based
owable composite based on the SDRTM technology. Dent
Mater 2011; 27: 348355.
28. MOORTHY A, HOGG CH, DOWLING AH, GRUFFERTY BF, BENE-
TTI AR, FLEMING GJP. Cuspal deection and microleakage in
premolar teeth restored with bulk-ll owable resin-based
composite base materials. J Dent 2012; 40: 500505.
29. VAN ENDE A, DE MUNCK J, VAN LANDUYT KL, POITEVIN A,
PEUMANS M, VAN MEERBEEK B. Bulk-lling of high C-factor

posterior cavities: eect on adhesion to cavity-bottom dentin.
Dent Mater 2012; 29: 269277.
30. ROGGENDORF MJ, KRAMER N, APPELT A, NAUMANN M,
FRANKENBERGER R. Marginal quality of owable 4-mm base
vs.conventionally layered resin composite. J Dent 2011; 39:
643647.
31. VAN DIJKEN JWV. Durability of resin composite restorations
in high C-factor cavities. A 12-year follow-up. J Dent 2010;
38: 469474.
32. A STVALDSDOTTIR
 A, DAGERHAMN J, VAN DIJKEN JWV, NAIMI-
AKBAR A, SANDBORGH-ENGLUND G, TRANUS S, NILSSON M.
Longevity of posterior resin composite restorations in adults.
A systematic review. J Dent 2015; 43: 934954.
33. OPDAM NJM, VAN DE SANDE FH, BRONKHORST E, CENCI MS,
BOTTENBERG P, PALLESEN U, GAENGLER P, LINDBERG A, HUYS-
MANS MCDNJM, VAN DIJKEN JWV. Longevity of posterior
composite restorations: a systematic review and meta-analysis.
J Dent Res 2014; 93: 943949.
34. VAN DIJKEN JWV, PALLESEN U. Durability of a low shrinkage
TEGDMA/HEMA-free resin composite system in Class II
restorations. A 6-year follow up. Dent Mater 2017; doi:10.
1016/j.dental.2017.04.021.
35. VAN DIJKEN JWV, LINDBERG A. A 15-year randomized con-
trolled study of a reduced shrinkage stress resin composite in
Class II cavities. Dent Mater 2015; 31: 11501158.
Durability of a bulk-fill resin composite 309
36. VAN DIJKEN JWV, PALLESEN U. Eight-year randomized clinical
evaluation of Class II nano-hybrid resin composite restora-
tions bonded with a one-step self-etch or a two-step etch-and-
rinse adhesive. Clin Oral Investig 2015; 19: 13711379.
37. VAN DIJKEN JWV, PALLESEN U. A randomized 10-year
prospective follow up of Class II nano-hybrid and conven-
tional hybrid resin composite restorations. J Adhes Dent
2014; 16: 585592.
38. PALLESEN U, VAN DIJKEN JWV, HALLONSTEN A-L, HALKEN J,
HOIGAARD R. A prospective 8-year follow-up of posterior
resin composite restorations in permanent teeth of children
and adolescents in Public Dental Health Service: reasons for
replacement. Clin Oral Investig 2014; 18: 819829.
39. VAN DIJKEN JWV. A 6-year prospective evaluation of a one-
step HEMA-free self etching adhesive in Class II restorations.
Dent Mater 2013; 29: 11161122.
40. VAN DIJKEN JWV, PALLESEN U. Clinical performance of a
hybrid resin composite with and without an intermediate
layer of owable resin composite: a 7-year evaluation. Dent
Mater 2011; 27: 150156.
41. ILIE N, BUCUTA S, DRAENERT M. Bulk-ll resin-based com-
posites: an in vitro assessment of their mechanical perfor-
mance. Oper Dent 2013; 38: 618625.