Adaptation of bulk-fill composite resin was analysed by evaluating the void area at the cavity floor and the void volume in the bottom, middle, and top-third of the cavity using a non-destructive technique and micro-CT. The findings of the present study showed that void formation varied depending on layering methods at different resin thicknesses (incremental filling vs. bulk filling) and vibration application (no vibration vs. vibration), rejecting the null hypotheses.
Regardless of vibration application and resin thickness, voids were more frequently observed in the bottom part of the cavities compared with the middle and top parts. These findings were in agreement with those of previous studies15,17, confirming that the bottom part is most likely to be free of voids. In the present study, vibration resulted in significantly improved surface adaptation at the cavity floor and reduced void volumes, particularly in the bottom part, when composite resin was placed in two 2-mm-thick layers through incremental filling. A correlation between gap formation at the pulpal floor and post-operative sensitivity has long been established18; using a vibration device combined with incremental layering might help alleviate post-operative sensitivity. As the presence of an internal void within the composite resin reduced the durability and weakened the mechanical properties, possibly leading to fractures and failure of resin restoration19, the use of a vibration device in composite resin placement appears to be useful for increasing the strength and durability of resin restoration. Han et al. also studied the effect of the device used in the present study on resin adaptation15. The authors reported a tendency of FB to result in fewer gaps forming with vibration, although the difference was not statistically significant. The difference between the present and previous findings cannot be explained by variability in experimental features, such as number of samples, cavity geometry, design, and resin type (syringe vs. compule type).
Within the bottom part of the cavity, voids were more readily detected at the cavity floor, particularly around the line angle at the junction of the axial wall and cavity floor. This might be associated with cavity geometry; the cavity had a sharp line angle that represents the most challenging situation for intimate adaptation of composite resin to the line angle. In addition to superior distribution of shrinkage stress, rounded internal angles would be also favourable for resin adaptation. Flowable composite resins might allow for superior adaptation to cavity walls due to their lower viscosity20; applying flowable resin as a liner should therefore enhance adaptation and reduce microleakage21. Use of a flowable resin as a liner is also effective in reducing cusp deflection due to its low elastic modulus22. One other method of reducing the viscosity of composite resin is preheating before delivery23. As with vibration, preheating improves handling and increases adaptation, with none of the mechanical disadvantages. Although multiple studies have reported superior adaptation and decreased gap formation with preheated resin composite compared with resin at room temperature24–26, injecting heated resin into the cavity might not favour pulpal health27.
An SLDV is a non-invasive device for measuring the instantaneous velocity of vibrating objects using the Doppler shift of laser light16. SLDVs have replaced accelerometers and other surface-contacting sensors in the measurement of vibrating objects due to the non-contacting nature of the instrument. They have been used to measure the vibration patterns of dental devices, including an ultrasonic scaler28, high-speed handpiece29, endosonic file30, and powered tooth brush31. In the present study, the frequency and vertical and horizontal amplitudes of the COMO vibratory resin applicator measured by SLDV were approximately 149 Hz and 50.5 µm and 26.4 µm, respectively. For rheology tests, the complex viscosity of the bulk fill decreased significantly as the vibration frequency increased. This phenomenon is known as pseudoplasticity and is a common characteristic of composite resin caused by molecular repositioning and separation under shear stress32. As the frequency exceeded 100 Hz, complex viscosity converged to approximately 2,000 Pa·s, which means that the degree of viscosity reduction due to the vibrator might be similar or slightly lower if the vibration frequency is greater than 100 Hz. Although vibration effectively reduced void formation in the bottom part of the incremental filling, its effect was negligible in bulk filling. The 4-mm-thick resin in the bulk filling was too thick for the vibration energy to be delivered effectively to the resin, as evidenced by the colour map obtained by the SLDV, which showed a gradual reduction of the vibration effect as the distance from the applicator tip increased. The limited vibration effect beyond a depth of 2 mm accounts for the contrasting findings between incremental and bulk filling.
Previous studies of the use of vibration devices for composite resin restoration report conflicting outcomes. Most studies of the effect of vibration on resin restoration employed the SonicFill system. According to the manufacturer, the increased flowability due to vibration is intended to achieve more precise adaptation to cavity walls, but these results are controversial. One study that evaluated microleakage in class II restoration using dye penetration reported that a SonicFill had the lowest microleakage values among tested groups33. In contrast, studies of gap formation and microleakage reported that a SonicFill system produced no specific differences compared with other bulk-fill resins7,34 or conventional resins with incremental layering35. A study evaluating the internal adaptation and gap formation using several bulk-fill resins and a conventional resin as a control found that a SonicFill system produced significantly larger gaps and less adaptation to cavities compared with other tested resins36. Other studies reported that the sonic insertion method increased void formation during delivery of resin composites. Given that the SonicFill is a sonically activated resin-delivery system, no additional vibration can be applied to condensed resin after it is placed in the cavity. In contrast, the device used in this study was designed to provide vibration energy with a packing motion after the resin is placed in the cavity. Because the mode of vibration differs between the two devices, it is not appropriate to directly compare the results of the present study to those of studies using SonicFill.
The void volumes of all areas of interests were significantly greater in 4-mm bulk filling compared with those of 2-mm incremental filling, irrespective of vibration application. Although a greater reduction was seen with vibration, incremental filling of the bulk-fill resin using a conventional method also effectively reduced void formation. This can be explained by easier adaptation and relatively greater chances of void escape during placement of a relatively smaller amount of composite resin. In addition, a smaller amount of composite resin in each layer is associated with less shrinkage stress and exothermic heat generation during polymerization37. The placement of bulk-fill composite resins in incremental layers could be recommended over bulk filling to minimize void formation and possible thermal damage to the pulp while still ensuring a reliable interface between teeth and resin restoration. Some voids were found at the middle of the cavity in the incremental filling group, but these were assumed to be entrapped voids between the incremental layers. Meticulous placement of resin increments should eliminate potential discrepancy between layers.
The findings of this study should be interpreted with caution given certain limitations. Only a nano-hybrid resin, FB, was used, and the effect of vibration on different composite resins of various viscosity should be subjected to further study because the effect of vibration would not be identical in other composite resin with varying compositions. Standardized cylindrical class I cavities were prepared for restoration, but different cavity designs can affect vibration propagation and composite resin adaptation. We were unable to directly compare the effects of vibratory device–related variables, such as vibration frequency, amplitude, and applicator tip design (all of which can alter vibrational properties), because no other vibratory devices designed for resin placement were available. However, our findings suggest a potential application of vibration during composite resin placement in terms of reducing void formation at the interface between the cavity and resin and within composite resin. Further studies are needed to validate the effect of vibration in composite resin restoration.