UNIVERSIDADE ESTADUAL PAULISTA

“JÚLIO DE MESQUITA FILHO”

Instituto de Ciência e Tecnologia

Campus de São José dos Campos

ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2023.e3737

Braz Dent Sci 2023 July/Sept;26 (3): e3737

Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

Estudo clínico de diferentes sistemas de resina composta em cavidades de Classe I

(um ensaio clínico randomizado de 18 meses)

Hend Ali IBRAHIM1 , Ali Ibrahim ABDALLA1,2 , Hussein Yehia EL-SAYED1 

1 - Tanta University, Faculty of Dentistry, Restorative Dentistry. Tanta, Egypt.

2 - Saveetha University, Saveetha Dental College and Hospitals, Department of Orthodontics. Chennai, India.

How to cite: Ibrahim HA, Abdalla AI, El-Sayed HY. Clinical study of different composite resin systems in Class I cavities (an 18-month

randomized clinical trial). Braz Dent Sci. 2023;26(3):e3737. https://doi.org/10.4322/bds.2023.e3737

ABSTRACT

Objective: this double-blind randomized clinical trial evaluate the clinical performance of Thermo-Viscous

Bulk Fill composite, Self-Adhesive Flowable composite, and Filtek Bulk Fill Composites restorations in Class I

cavities over a period of 18 months. Material and Methods: twenty individuals between the ages of 30 and

45 participated in this research. Each patient should have at least three occlusal Class I carious lesions on their

molars. They were dispersed at random, with n=20 teeth representing each tested material. Group I (Futurabond

M+ and VisCalor Bulk Fill which heated in a viscolar dispenser at 68 °C for 30s and placed in a 4 mm thickness),

Group II (Fusio Liquid Dentin self-adhesive composite which put in a thin layer (1mm increment)), and Group

III (Single Bond Universal and Filtek Bulk Fill Posterior composite which applied in 4 mm thickness without

heating). Using (USPHS) criteria, all restorations were assessed clinically at baseline, 6 months, 12 months, and

18 months. Using an inverse replica, the marginal seal of the investigated restorations was further evaluated under

SEM. Statistical analysis was performed with Chi-square test for all USPH parameters. Results: the three tested

groups recorded a one hundred percent retention rate after 18 months follow up period. Concerning marginal

adaptation, marginal discoloration, anatomical form, surface texture, and color matching, there was a signicant

difference (p˂0.05) between the three tested groups after 12 & 18 months. After 12 & 18 months, SEM analysis

of the marginal seal revealed a statistically signicant difference between the three groups. Conclusion: Bulk

ll resin composite restorations showed satisfactory acceptable clinical performance after 18 months of clinical

service compared to self-adhesive owable composites, and Viscalor Bulk Fill composite demonstrated excellent

results with considerable changes in marginal integrity as a consequence of thermal viscous technology and

increased adaptability of restorations toward cavity walls and margins.

KEYWORDS

Bulk ll; Class I; Clinical; Scanning electron microscope; Viscalor.

RESUMO

Objetivo: este ensaio clínico randomizado duplo-cego avaliou o desempenho clínico de restaurações de resina

Bulk Fill Termo-Viscosa, resina autoadesiva Flowable e Filtek Bulk Fill Composites em cavidades Classe I durante

um período de 18 meses. Material e Métodos: 20 indivíduos com idade entre 30 e 45 anos participaram da

pesquisa. Cada paciente deveria ter pelo menos três lesões de cárie oclusais de Classe I nos molares. Eles foram

divididos aleatoriamente, com n=20 dentes representando cada material testado. Grupo I (Futurabond M+ e

VisCalor Bulk Fill aquecido em dispensador viscolar a 68 °C por 30s e colocado em uma espessura de 4 mm),

Grupo II (resina composta autoadesiva Fusio Liquid Dentin colocada em uma camada na (incremento de 1 mm))

e Grupo III (resina composta Single Bond Universal e Filtek Bulk Fill Posterior aplicado em espessura de 4 mm

Braz Dent Sci 2023 July/Sept;26 (3): e3737

Ibrahim HA et al.

Clinical study of different composite resin systems in Class I cavities (an 18-month randomized clinical trial)

Ibrahim HA et al. Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

INTRODUCTION

Composite resins are the material of choice

in restorative dentistry due to the growing need

for high-quality cosmetic results in daily practice.

They are commonly employed in the restoration

of posterior teeth due to the growing need for

esthetics and the signicant progress of newer

generations of adhesive methods and composite

resin formulations [1].

Despite the recent advancements in restorative

materials and procedures, postoperative sensitivity

with composite restorations remains a difculty

for clinicians [2]. One of the drawbacks of

composite resins is the polymerization shrinkage

that leads to contraction stresses that can cause

tension at the tooth-restoration interface,

and if the stresses exceed the bond strength,

microleakage occurs [3].

Self-adhesive owable composites (SAFC)

were introduced to the market to minimize

procedure steps a few years ago. Vertise Flow

and Fusio Liquid Dentine are now commercially

available [4]. SAFC combines the characteristics

of adhesive and restorative material technologies

in a single product, giving new possibilities

to restorative procedures, since it is a direct

restorative composite resin material that contains

both an adhesive resin and a owable composite

resin [5].

Currently, incremental layering method is

regarded as the gold standard for the placement

of light-curing composite materials [6]. In order

to shorten the duration of the method without

compromising the durability of the materials,

so-called “bulk-fill” composites were brought

to the market with the commercial advantage

of lowering polymerization shrinkage and

eliminating the incremental technique. Due to

their low polymerization stress and excellent

light-curing reactivity, these materials are suitable

for insertion in a 4 mm bulk placement [7].

However, the high viscosity and stickiness

of composites make them difcult to handle and

manipulate, resulting in inadequate marginal

adaptation to preparation walls [8]. A new

alternative invention involves preheating of

conventional composites in a chair-side warming

device prior to polymerization [9].

Pre-heating of high viscosity bulk-fill

composites might provide a transitory viscosity

decrease equivalent to that of a flowable

composite without compromising the better

mechanical properties associated with highly

lled resin composites [10].

The thermo-viscous bulk-fill composite

VisCalor bulk ll takes a recent technique. This

is a composite material with a high viscosity at

room and body temperature that is transformed

into a owable consistency by heating to 68 °C

in a particular dispenser with a heating function

(Thermo-Viscous-Technology). In a single

restorative composite material, it combines the

owability of a low-viscosity composite during

insertion with the sculpting ability of a high-

viscosity composite [6].

This study aims to assess the clinical

performance of Thermo-Viscous, Self-Adhesive

Flowable, and nano hybrid bulk-ll composite

restorations. The null hypothesis was that the

investigated materials would demonstrate

identical clinical performance in simple Class I

cavities.

sem aquecimento). Usando os critérios (USPHS), todas as restaurações foram avaliadas clinicamente no início, 6

meses, 12 meses e 18 meses. Usando uma réplica inversa, o selamento marginal das restaurações investigadas foi

avaliado em MEV. A análise estatística foi realizada com o teste qui-quadrado para todos os parâmetros USPH.

Resultados: os três grupos testados registraram uma taxa de retenção de cem por cento após um período de

acompanhamento de 18 meses. Em relação à adaptação marginal, descoloração marginal, forma anatômica,

textura da superfície e combinação de cores, houve uma diferença signicativa (p˂0,05) entre os três grupos

testados após 12 e 18 meses. Após 12 e 18 meses, a análise SEM do selamento marginal revelou uma diferença

estatisticamente signicativa entre os três grupos. Conclusão: as restaurações de resina composta Bulk Fill

apresentaram desempenho clínico aceitável satisfatório após 18 meses de atendimento clínico em comparação

com as resinas compostas uidas autoadesivas, e a resina composta Viscalor Bulk Fill demonstrou excelentes

resultados com mudanças consideráveis na integridade marginal, como consequência da tecnologia viscosa

térmica e maior adaptabilidade de restaurações nas paredes e margens da cavidade.

PALAVRAS-CHAVE

Bulk ll; Classe I; Clínico; Microscópio eletrônico de varredura; Viscalor.

Braz Dent Sci 2023 July/Sept;26 (3): e3737

Ibrahim HA et al.

Clinical study of different composite resin systems in Class I cavities (an 18-month randomized clinical trial)

Ibrahim HA et al. Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

MATERIAL AND METHODS

Trial design

This study was conducted as a double-blind

randomized clinical study.

Trial setting

This study was carried out at the clinic of

Department of Restorative Dentistry, Faculty of

Dentistry, Tanta University.

Sample size

The total sample size in this study was

60 cases divided into 3 groups at the signicance

level of 95% using a computer program G

power version 3. The cases were distributed on

20 patients. Each patient have three moderate

posterior occlusal carious lesions. This was

performed according to the equation:

( )

1ZP P

××−

(1)

Where:

Z = Z value (1.96 for 95% confidence level)

p = percentage picking a choice, expressed as decimal

c = condence interval, expressed as decimal.

Ethical considerations

All procedures and nature of the study

were explained to the patients and their written

informed consents was obtained according to the

guidelines on human research performed by the

Ethics Committee at Faculty of Dentistry, Tanta

University which approved the performance of

the partical part of this research after fullling

the necessary requirements of committee with

code #R-RD-5-20-2.

− Patient Selection - Twenty individuals

between the ages of 30 and 45 participated

in this research. Each patient should have

at least three occlusal Class I carious lesions

on their molars (Figure 1). Patients were

chosen from the clinic of the Department of

Restorative Dentistry, Faculty of Dentistry,

Tanta University, based on inclusion and

exclusion criteria. Before procedures of

treatment, all patients were given oral

hygiene instructions, and when necessary,

they were sent to the periodontology

department for scaling and polishing [11].

Inclusion criteria

− Good oral hygiene.

− Patient should have normal occlusion.

− Accessible isolation with rubber dam.

− Good periodontal health.

− Availability for follow up recalls.

Exclusion criteria

− Patients with bad oral hygiene.

− Abnormal occlusion.

− Patients with compromised medical history.

− Sever or chronic periodontitis.

− Non-vital or endodontically treated teeth.

− Pregnancy.

Randomization and allocation concealment

These randomization sketches were

performed utilizing tools available on the

website www.sealedenvelope.com. A researcher

not involved in the research plan performed the

Figure 1 - Preoperative image of patient having three molars with simple Class I carious lesions.

Figure 1

Figure 2

Figure 1

Figure 2

Braz Dent Sci 2023 July/Sept;26 (3): e3737

Ibrahim HA et al.

Clinical study of different composite resin systems in Class I cavities (an 18-month randomized clinical trial)

Ibrahim HA et al. Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

randomization process. Each participant was

randomized 30 min before starting the procedures

with help of researcher. The randomization

sketch of the patient was sent to operator just

before starting the dental procedures to avoid

bias.

Blinding

The evaluators who were not included

in the restorative procedures, were blinded to

investigated groups. The patient was also consider

blinded to tested groups, but the operator wasn’t

blinded to these groups as result of the signicant

difference between the tested materials, this is

what describe the double-blind study.

Materials

The materials used in this study are three types

of composites (Self-Adhesive Flowable composite,

Thermo-Viscous composite and Filtek Bulk Fill

Composites with their two recommended types

of adhesives (Futura bond M+ and Single Bond

Universal adhesives respectively). The chemical

composition, manufacturer and web site of each

material are provided in (Table I).

Restorative procedures

To minimize salivary contamination and

to ease the restorative treatments, the eld was

isolated by a rubber dam. The cavity of occlusal

Class I was prepared in accordance with the

extension of caries. Cavity preparation was

restricted to the removal of carious lesions up

to 4 mm in depth (Figure 2). Using a graded

periodontal probe, the cavity’s depth was

measured [12].

All cavities were prepared using straight

carbide ssure burs number 57 (Dentsply, United

Kingdom) held in a high-speed handpiece with

a water-cooling system. In cases of deep caries,

a thin coating of calcium hydroxide (Dycal

chemically cured Calcium Hydroxide, Dentsply

Sirona, United Kingdom) was applied, followed

by a layer of glass ionomer cement base (Ionoseal

Resin modified Glass Ionomer Cement Base,

Voco, Germany).

Three groups were evaluated based on the

materials utilized for restoration (Figure 3).

These materials were randomly divided in

each patient having 3 different carious molars

either upper or lower teeth. Restorations were

randomly distributed intra-orally to eliminate

variables such as tooth type and position as

shown in (Table II). In accordance with the

manufacturer’s instructions, the cavities were

restored with the appropriate adhesive system

and composites.

•

Group (I): cavities were restored with

VisCalor Bulk Fill using the corresponding

adhesive system Futurabond M+

•

Group (II): cavities were restored with Fusio

Liquid Dentin self-adhesive composite

Table I - Chemical composition, manufacturer and web site of tested materials in this study

Material Composition Manufacturer Web Site

VisCalor Bulk Fill

(Thermoviscous, Nano hybrid

bulk-ﬁll composite compules)

Matrix: BIS-GMA (10-25%), aliphatic

dimethacrylate(2.5-5%) Inorganic Filler: nano-

scale ﬁller(83% by wt)

VOCO GmbH

www.voco.comshade A2 Cuxhaven, Germany

Futurabond M+ (one-step self-

etch adhesive, PH=2)

BIS-GMA, 2-Hydroxy ethyl methacrylate

(HEMA), ethanol, adhesive momomer, catalyst

and Urethanedimethacrylate (UDMA)

Fusio liquid Dentin (Self-

Adhesive Flowable Composite) Matrix: 4MET, HEMA, UDMA, TEGDMA, Fillers:

Nano-sized amorphous silica and barium glass

(65% by wt)

Pentron Clinical,

Orange, CA, USA www. Pentron. com

shade A2

Filtek Bulk Fill Posterior

Restorative (Nanohybrid bulk-

ﬁll composite)

AUDMA, UDMA, ﬁllers are a combination of

non-agglomerated /non-aggregated 20 nm

silica ﬁller, a non-agglomerated/non-aggregated

4 to 11 nm zirconia ﬁller, an aggregated

zirconia/silica cluster ﬁller and a ytterbium

triﬂuoride ﬁller (76.5% by wt)

3M ESPE, St. paul, MN,

USA www.3M ESPE.comshade A2

Single Bond Universal (one-

step self-etch adhesive, PH=2.7)

10-MDP phosphate monomer, Di methacrylate

Resin ﬁller, BISGMA, Vitrebond copolymer,

HEMA, saline, water

Braz Dent Sci 2023 July/Sept;26 (3): e3737

Ibrahim HA et al.

Clinical study of different composite resin systems in Class I cavities (an 18-month randomized clinical trial)

Ibrahim HA et al. Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

•

Group (III): cavities were restored with

Filtek Bulk Fill Posterior composite using the

corresponding adhesive system Single Bond

Universal (Control group)

Group (I): the following Prior to the application

of VisCalor Bulk ll composite, Futurabond M+

adhesive (one-step self-etch adhesive) was

applied by micro-brush and light cured using LED

curing light device for 10s in accordance with

the manufacturer’s instructions. VisCalor Bulk ll

was heated in a viscolar dispenser at 68 °C for

30s and placed in a 4 mm thickness as a single

piece; then the unpolymerized and still plastic

composite was adapted with a Teflon-coated

condenser and light-cured using LED curing light

device with an intensity >850mW/cm2 max reach

1200 mW/cm2 for 20s following manufacturer’s

instructions

Group (II): Fusio Liquid Dentin self-adhesive

composite resin was put in a thin layer (1mm

increment) and agitated with a needle tip for

20s, followed by 10s of light curing. Then, when

required, additional layers were applied in

increments of 2mm and light-cured for 10s per

the manufacturer’s recommendations.

Group (III): Prior the application of Filtek

Bulk Fill restorative material, the suggested

Single Bond Universal adhesive (one-step self-

etch adhesive) was applied by micro-brush

and light cured for 10s per manufacturer’s

recommendations. This restorative material was

placed in a 4 mm thickness, tted with a Teon-

coated condenser, and light-cured for 10s per the

manufacturer’s instructions.

Restorations were nished using a composite

finishing kit (Enhance Finishing & Polishing

System, Dentsply) and then polished using

aluminium oxide extra thin polishing disks (Sof-

Lex XT, 3M Espe, Germany) according to the

manufacturer’s instructions [11,13].

Table II - Intra- oral random distribution of restorations

Type of restoration Lower

teeth

Upper

teeth

Total

number

Group (I) VisCalor Bulk Fill 18 molar 2 molar 20 molar

Group (II) Fusio Liquid Dentin 13 molar 7 molar 20 molar

Group (III) Filtek Bulk Fill 16 molar 4 molar 20 molar

Figure 2 - An image of patient showing Class I cavity preparation of three molars.

Figure 3 - An image showing ﬁnal restoration of group I with preheated Viscalor Bulk Fill composite (a), group II with self-adhesive composite

Fusio Liquid Dentin (b) and group III with Filtek Bulk Fill composite resin (c).

Figure 1

Figure 2

Figure 3

Base line After 18 months

Figure 4

Braz Dent Sci 2023 July/Sept;26 (3): e3737

Ibrahim HA et al.

Clinical study of different composite resin systems in Class I cavities (an 18-month randomized clinical trial)

Ibrahim HA et al. Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

Clinical evaluation

Each restoration was clinically assessed at

baseline, 6 months, 12 months, and 18 months

by two calibrated investigators not including

the dentist who restored the lesions, utilizing an

intraoral camera, at-surfaced mouth mirrors,

and a dental explorer in accordance with modied

United States Public Health Service (USPHS)

criteria [14]. Included in these parameters are

retention rate, marginal adaption, postoperative

sensitivity, marginal discoloration, secondary

caries, anatomical form, surface texture, and

color matching. If disagreement was occurred

between the examiners, a third equally calibrated

expert was asked for evaluation.

SEM evaluation

In addition, for evaluation of marginal

integrity, impressions of the restored teeth

were made using a silicone impression material

(Aquasil Ultra XLV, Dentsply, United Kingdom),

and an inverse replica of the restored teeth

was prepared along evaluation periods and

gold sputtered to be examined under scanning

electron microscopy (SEM) with magnication

x200 to study the restoration-tooth interface [15].

The resultant micrographs were be scanned on

monitor screen, then they were transferred onto

Orion 6.60.6 software program and these images

were appeared on the computer to determine

marginal integrity.

Statistical analysis

The collected data along the evaluation

periods were tabulated and statistically analyzed

using Statistical Package for Social Sciences

(SPSS) version 25 computer program. The three

tested groups statistically evaluated by Chi-

Square test, was used to examine the statistical

relationship between clinical evaluation periods

and scores in the same group, also used to shows

the signicant difference between groups in the

same duration for primary outcome (retention)

and secondary outcomes (marginal adaptation,

marginal discoloration, surface roughness, color

match, anatomical form and postoperative

sensitivity)

RESULTS

A total of 60 cases (were distributed on

20 patients) were selected and recalled all over

18 months of follow-up. Regarding the retention

rate of the composite restorations that were

evaluated. After 18 months of follow-up, the Chi-

Square test indicated that all tested groups had a

hundred percent (100%) retention rate.

Regarding marginal adaptation, marginal

discoloration, anatomic form, surface texture

and color matching, the Chi-Square test revealed

a statistically signicant difference between the

three examined groups after 12 and 18 months of

follow-up (p˂0.05). Chi-square test demonstrated

a statistically significant difference between

follow-up periods in group II, as group II Fusio

Liquid Dentin self-adhesive composite scored

the greatest rate of deterioration of these clinical

criteria (Table III), (Figures 4, 5, 6, 7).

In the current investigation, marginal

adaptation of group II (Fusio Liquid Dentin)

recorded 50 percent Alfa scores and 50 percent

Bravo scores throughout the duration of the

study, as group II Fusio Liquid Dentin self-

adhesive composite scored the greatest rate

of marginal breakdown. These clinical results

were comparable to those observed by SEM

examination of the inverse replica, which revealed

a signicant difference between the three groups

after 12 & 18 months (p= 0.033, 0.016) as group

II Fusio Liquid Dentin self-adhesive composite

had the highest rate of marginal seal deterioration

(Figures 8, 9). In addition, there was a statistically

signicant difference (p = 0.014) in the clinical

follow-up times in group II.

Group I recorded an Alfa rating during all

evaluation periods, with the exception of surface

roughness and color matching (5 percent bravo

score after 18 months follow up). During the

clinical assessment period, none of the tested

restorations exhibit secondary caries; all tested

materials achieved a perfect Alfa score.

In terms of post-operative hypersensitivity,

in the present investigation, sensitivity was

identied in only 5% and 10% of patients restored

with Viscalor and Filtek Bulk Fill composite

restorations (groups I and III respectively) at

baseline, and it dissipated within a few days.

At the baseline, the Chi-Square test indicated no

signicant difference between the three examined

groups (p = 0.349). In group II, which utilized

the self-adhesive composite Fusio Liquid Dentin,

no post-operative sensitivity was identified

throughout any of the assessment periods.

Braz Dent Sci 2023 July/Sept;26 (3): e3737

Ibrahim HA et al.

Clinical study of different composite resin systems in Class I cavities (an 18-month randomized clinical trial)

Ibrahim HA et al. Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

Table III - Number and percentage of restorations that scored Alfa at baseline (BL), 6, 12 and 18 months for each parameter

Viscalor Bulk Fill Fusio Liquid Dentin Filtek Bulk Fill

BL 6M 12M 18M BL 6M 12M 18M BL 6M 12M 18M

Retention 20

(100%)

Marginal

adaptation

(100%)

(95%)

(70%)

(50%)

(100%)

(95%)

(80%)

Hyper

sensitivity

(95%)

(100%)

Marginal

discoloration

(100%)

(90%)

(70%)

(55%)

(100%)

(95%)

(85%)

secondary

caries

(100%)

Anatomic

form

(100%)

(90%)

(75%)

(60%)

(100%)

(95%)

surface

texture

(100%)

(95%)

(100%)

(85%)

(650%)

(55%)

(100%)

(95%)

(85%)

color match 20

(100%)

(95%)

(100%)

(85%)

(650%)

(55%)

(100%)

(95%)

(85%)

Figure 4 - Clinical photo represents Alfa score of marginal adaptation of

Viscalor Bulk Fill

(a)

and Filtek Bulk

(

b) at base line

(a) & Bravo score

of marginal adaptation

Filtek Bulk Fill only

(b) after 18 months follow up period.

Figure 3

Base line After 18 months

Figure 4

Figure 3

Base line After 18 months

Figure 4

Figure 3

Base line After 18 months

Figure 4

Figure 5 – (A) Clinical photo represents Bravo score of marginal adaptation and discolration of

Fusio Liquid Dentin

. (B) Clinical photo represents

Bravo score of of marginal adaptation and marginal discoloration

Fusio Liquid Dentin

After 6months After 18 months

Base line After 18 months

Figure 5

After 6 month After 18 months

Figure 6

After 6months After 18 months

Base line After 18 months

Figure 5

After 6 month After 18 months

Figure 6

After 6 month After 18 months

Figure 7

After 6 month After 18 months

Figure 7

After 6 month After 18 months

Figure 7

Figure 3

Base line After 18 months

Figure 4

Braz Dent Sci 2023 July/Sept;26 (3): e3737

Ibrahim HA et al.

Clinical study of different composite resin systems in Class I cavities (an 18-month randomized clinical trial)

Ibrahim HA et al. Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

DISCUSSION

The present participants were chosen based

on specic inclusion and exclusion criteria, and

the majority of them had good dental hygiene

and periodontal health. To get tested restorations,

these patients must have had at least three simple

occlusal carious posterior teeth. To prevent the

high pulp horns, huge pulp chambers, and hidden

microscopic pulpal exposures that are always

linked with young age patients [16], the age

range of the selected patients was (30-45) years.

Class I cavity design was chosen for the

current investigation because it resembled

complex cavity preparation and restoration

clinically. The large configuration factor of

Figure 8 - SEM image of VisCalor Bulk Fill at base line showing

sealed marginal interface between composite (C) and tooth (T)

without micro-gaps (arrow). Figure 9 - SEM image of Fusio liquid

Dentin

after 18 months follow

up showing diﬀerent measurements of micro-gaps at interface

between composite (C) and tooth (T) (arrow).

Figure 7 - Clinical photo represents Bravo score of anatomic form of Fusio Liquid Dentin (b), Filtek Bulk Fill (c) after 6 and 18 months follow up.

After 6 month After 18 months

Figure 7

After 6 month After 18 months

Figure 7

After 6 month After 18 months

Figure 7

Figure 6 - Clinical photo represents Bravo score of color match of Fusio Liquid Dentin after 6 and 18 months follow up.

After 6months After 18 months

Base line After 18 months

Figure 5

After 6 month After 18 months

Figure 6

After 6 month After 18 months

Figure 7

After 6 month After 18 months

Figure 7

Braz Dent Sci 2023 July/Sept;26 (3): e3737

Ibrahim HA et al.

Clinical study of different composite resin systems in Class I cavities (an 18-month randomized clinical trial)

Ibrahim HA et al. Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

these cavities limits composite resin flow

during polymerization shrinkage, hence raising

contraction stresses at the bonding contact and

the likelihood of microleakage [17].

Today, bulk-fill composite resins are the

preferred material for direct dental restorations.

They exhibit less post-gel shrinkage and more

reactivity to light polymerization than the

majority of traditional composites due to their

improved translucency, which increases light

penetration and cure depth [18].

When the composite resin was heated, its

viscosity reduced, which improved its adaptability

to the walls of the cavity preparation, as well

as several physical properties, such as a better

degree of conversion and less polymerization

shrinkage [19]. Typically, the temperature utilized

to enhance these properties ranges between 54°C

and 68°C, depending on the available device.

There are new resins on the market, such as

Viscalor [20], created specically for preheating

with enhanced manipulation capabilities.

Concerning the retention rate, the current

results recorded a 100 percent retention rate

after 18 months of follow-up in all three tested

groups. This can be attributed to the effect of

preheating and increasing the owability of the

materials, as well as increasing the bond strength

at the tooth/restoration interface and utilizing

the specic adhesive system recommended by

the manufacturers. The high retention rate of

Viscalor Bulk Fill restorations in the current

investigation was conrmed by Abdalla [21] and

Favoreto et al. [22], which stated that there was

no retention loss of Viscalor Bulk Fill restorations

during the trial.

In addition, Shaalan et al. [23] ,

AlHumaid et al. [14], and Shaalan & Abou-Auf [24]

conrmed the current ndings for Fusio Liquid

Dentin restorations. In basic occlusal cavity

preparations, even in conservative designs, the

inuence of macro-mechanical ways of retention

might have enhanced the overall performance of

SAFCs, according to their results.

On the other hand, Çelik et al. [11] disagreed

with the current results, who evaluated Fusio

Liquid Dentin (SAFC) in non-carious cervical

lesions; they reported that success rate of Fusio

Liquid Dentin was recorded 33% after six months

and concluded that, the poor performance of

the material may be attributed to lack of macro-

mechanical retention and weak bonding due to

hydrolytic instability of the functional monomer

(4-MET) and the lower etching ability of self-

adhesive composite it-self.

Concerning the clinical evaluation of

marginal adaptation, the marginal adaptation

of Viscalor Bulk Fill restorations (group I)

maintained alfa scores of one hundred percent

throughout the clinical research periods. This

is consistent with ndings of numerous other

researchers [21,25] who reported that Viscalor

Bulk Fill demonstrates excellent results due to its

thermo-viscous technology and excellent physical

properties, such as a reduction of polymerization

shrinkage accompanied by low shrinkage stresses.

Also, Demirel et al. [26] agree with the

current results concerning Viscalor Bulk Fill

material based on their in vitro ndings revealing

that the best internal adaptation was observed in

sonically inserted SF2 and preheated Viscalor bulk

ll, which were the manufacturers’ recommended

insertion techniques.

Favoreto et al. [22] who evaluated the clinical

performance of a new preheating thermoviscous

composite compared to a non-heating composite

resin in restorations of non-carious cervical

lesions over a period of 6-month, disagree

with current outcomes concerning Viscalor

Bulk Fill. It reported that 24% Viscalor Bulk

Fill group showed small defects related to the

marginal adaptation. This attributing to several

methodological differences (including cavity

type, adhesive type used and lower retention rate

of adhesive restorations in NCCLs) between both

studies explaining these differences.

Due to the material’s viscoelastic properties,

Alomairy et al. [27] explained and conrmed

the present outcomes of Filtek Bulk Fill

restoration. The tensions created during the

setting and polymerization process, which may

be compensated by the ow of the material and

have no effect on the restoration’s quality.

Throughout the current investigation,

marginal adaptation of group II received 50

percent Alfa scores and 50 percent Bravo

scores. This was consistent with the ndings of

Sabbagh et al. [4] who reported that Alfa scores

were obtained after 1 and 2 years (58.8% and

50%) respectively. This is due to the inclusion

of an adhesive component in the formulation

of self-adhesive composites, which may have

Braz Dent Sci 2023 July/Sept;26 (3): e3737

Ibrahim HA et al.

Clinical study of different composite resin systems in Class I cavities (an 18-month randomized clinical trial)

Ibrahim HA et al. Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

deleterious impacts on the composite’s physical

characteristics. Due to the addition of hydrophilic

monomers, the self-adhesive composite exhibited

the least dimensional stability [28].

An example of improper sealing of SAFCS

could be attributed to the fact that the acidity

of the monomers in the self-adhesive materials

is not low enough to promote extensive resin

penetration through smear-covered surfaces or

into aprismatic enamel and that the viscosity of

owable materials is not low enough to achieve

good adaptation to the cavity wall [29]. Only

after typical etch-and-rinse treatments with

strong phosphoric acid is their bond strength

improved [30].

Alomairy et al. [27] confirmed the

existing results of Filtek Bulk Fill restoration in

connection to Postoperative hypersensitivity.

They hypothesized that the use of a calcium

hydroxide-based liner over deep restorations

topped with a glass ionomer cement foundation

might reduce postoperative sensitivity.

Regarding Fusio Liquid Dentin restorations,

no hypersensitivity was reported throughout the

follow-up periods. This was consistent with the

findings of Shaalan et al. [23] and Shaalan &

Abou-Auf [24] and can be attributed to the fact

that the self-adhesive owable composite material

dissolved the smear layer but did not remove it.

Concerning the clinical evaluation of

marginal discoloration, the outstanding ndings

of group I (Viscalor Bulk Fill) supported by

Abdalla [21] who recorded 100 percent alfa

scores throughout the trial and attributed this

to Viscalor Bulk Fill, demonstrate exceptional

marginal adaption outcomes.

Favoreto et al. [22] and Elkaffas et al. [31]

supported the current results of Viscalor Bulk

Fill. Elkaffas et al. [31] reported that only a

few favorable results for resin restorations

with preheated composites after 3 years of

clinical evaluation, with less marginal staining

in the preheating composite than non-heating

composite resin restorations.

In addition, the current ndings on Filtek Bulk

Fill were supported by other researches [27,32].

This is because nanofillers allow for great

polishability, which minimizes surface roughness

and discoloration.

Elbaz et al. [33] attributed their results to

the aging of materials and the change in their

marginal integrity over time, which resulted in

an increase in marginal discoloration.

Secondary caries were not observed in any

restorations made using the tested materials

during the research period (Alfa score of 100

percent); this might be ascribed to the inclusion

of only people with good oral hygiene and/or the

short clinical time of assessment. In addition, the

present ndings on Fusio Liquid Dentin concurred

with those of others [12,14,32]. Elbaz et al. [33]

demonstrated that Fusio Liquid Dentin undergoes

hygroscopic expansion over time; this may have

contributed to enhanced marginal adaption by

compensating for resin polymerization shrinkage.

Therefore, in the current study regarding

the clinical assessment of anatomic form, the

excellent results of group I (Viscalor Bulk Fill)

are supported by others [21,34] who recorded

excellent anatomic form (100 percent alfa scores)

throughout the study and stated that Preheating

of bulk ll composite results in increased micro-

hardness and, therefore, the composite exhibits

greater wear resistance.

Currently, Filtek Bulk Fill restorations

have achieved favorable outcomes, consistent

with the ndings of earlier studies [27,31,35].

Alomairy et al. [27] interpreted their ndings

as a result of the incorporation of a unique nano

ller size and technology of bulk-lled materials;

exhibiting superior anatomic shape and good

wear resistance.

Shaalan & Abou-Auf [24] veried the existing

results of Fusio Liquid Dentin restorations,

attributing this to the lower ller loading and

weaker mechanical characteristics of self-

adhesive owable composites, which diminish

the wear resistance of such restorations.

In terms of surface texture, the current

results of Viscalor Bulk Fill concur with those of

Attia [36] who found no statistically signicant

difference between warmed and non-heated

incremental nano hybrid composite over any

follow-up period. These results demonstrated that

preheating did not increase surface roughness

over the duration of the trial.

Currently, Filtek Bulk Fill restorations

have documented favorable surface texture

outcomes; our results concur with those of earlier

studies [31,35]. This may be the result of the

incorporation of nanoller size and technology

into bulk-lled materials; these materials may

Braz Dent Sci 2023 July/Sept;26 (3): e3737

Ibrahim HA et al.

Clinical study of different composite resin systems in Class I cavities (an 18-month randomized clinical trial)

Ibrahim HA et al. Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

exhibit great polishability, hence reducing any

surface roughness.

Shaalan & Abou-Auf [24] corroborate

the current finding for Fusio Liquid Dentin

restorations, attributing this to the surface wear

of Fusio Liquid Dentin restorations over time. In

contrast, AlHamid et al. [14] and Elbaz et al. [33]

found that the addition of nano-sized amorphous

silica and glass ller in a self-adhesive owable

composite produces a material with a smoother

surface and a superior nish after polishing.

Regarding the clinical assessment of color

match, the results of Viscalor Bulk Fill, supported

by Abdalla [21] and Elkaffas et al. [31] who

reported that these restorations showed superior

color stability and clinical performance after 12

and 36 months clinical follow up respectively.

Concerning color match, Fusio Liquid Dentin

results were conrmed by Çelik et al. [11] who

showed a signicant difference in color stability

between Fusio Liquid Dentin and traditional

composite due to the increased solubility of Fusio

Liquid Dentin. According to some experts, the

amount of ller inside composites may inuence

color variations. It is assumed that composites

having more than 70 percent by weight of ller

are dened by high color stability; nevertheless,

Fusio Liquid Dentin, which has 65 percent by

weight of ller, demonstrates exceptional color

mismatch [37].

CONCLUSION

It was concluded that Bulk ll resin composite

restorations showed satisfactory acceptable clinical

performance after 18 months of clinical service

compared to self-adhesive owable composites,

and Viscalor Bulk Fill composite displayed

excellent results with considerable changes in

marginal integrity as a result of thermal viscous

technology and enhancing cavity wall and margin

adaptability. Regarding SEM investigation, the

time had a detrimental effect on the marginal seal

of self-adhesive owable composite restorations,

which degraded at the conclusion of an 18-month

clinical assessment period.

Author’s Contributions

AB, CDE, FG: Conceptualization. HI, JKF:

Methodology. LMN, OP: Software. CDE, FG:

Validation. CDE, FG: Formal Analysis. RTY:

Investigation. LMN, OP: Data Curation. AB, CDE,

FG: Writing – Original Draft Preparation. HI, JKF:

Writing – Review & Editing.CDE, FG: Supervision.

CDE, FG, RTY, UIH: Project Administration.

Conict of Interest

No conicts of interest declared concerning

the publication of this article.

Funding

The authors declare that no nancial support

was received.

Regulatory Statement

This study was conducted in accordance with

all the provisions of the local human subjects

oversight committee guidelines and policies

of faculty of dentistry, Tanta university. The

approval code for this study is: #R-RD-5-20-2.

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Braz Dent Sci 2023 July/Sept;26 (3): e3737

Ibrahim HA et al.

Clinical study of different composite resin systems in Class I cavities (an 18-month randomized clinical trial)

Ibrahim HA et al. Clinical study of diﬀerent composite resin systems in Class I

cavities (an 18-month randomized clinical trial)

Hussein Yehia El-Sayed

(Corresponding address)

Tanta University, Faculty of Dentistry, Restorative Dentistry, Tanta, Egypt.

Email: dr-hussein-yehia@hotmail.com Date submitted: 2022 Dec 12

Accept submission: 2023 Mar 19