Restaurarea directă în masă („bulk fill”) cu răşini compozite în sarcină – prezentare de caz

 Bulk-fill direct composite restoration technique in pregnancy – case report

First published: 30 septembrie 2020

Editorial Group: MEDICHUB MEDIA

DOI: 10.26416/Gine.29.3.2020.4065


In pregnant women, the characteristics of dental treatment must meet few important aspects: a minimal operative stress and trauma, if possible one-session treatment, short wor­king time, and long-time results, meaning an increased sur­vi­val rate of the restoration. One of the most effective and successful techniques for direct resin composites resto­ra­tions is bulk-fill technique. The specific feature of this treat­ment method is the insertion of restorative material in one step, often a single layer. Due to the improved characteristics of the resin composites developed for this technique, all the aforementioned requirements are fulfilled, making this technique the first choice for direct resin composite resto­ra­tion during pregnancy.

pregnancy, resin composite restoration, bulk-fill technique


Tratamentele stomatologice la femeile gravide trebuie să în­de­pli­neas­că unele criterii importante: traumă operatorie mi­ni­mă, pe cât posibil o singură şedinţă de tratament, timp de lu­cru scurt şi rezultate bune pe termen lung, ceea ce înseamnă o rată crescută de suprevieţuire în timp a obturaţiei. Una din­tre cele mai eficiente şi de succes tehnici pentru restaurările di­rec­te cu materiale compozite este tehnica de restaurare „în ma­să” („bulk-fill”). Caracteristica specifică a acestei metode de tratament o reprezintă inserarea materialului de restaurare într-o singură etapă, de cele mai multe ori într-un singur strat. Datorită caracteristicilor îmbunătăţite ale compozitelor crea­te pentru această modalitate de tratament, toate cerinţele men­ţio­na­te anterior sunt îndeplinite, făcând din această teh­ni­că opţiunea de ales pentru restaurările directe cu răşini com­po­zi­te în timpul sarcinii.


In pregnant women, all dental treatments, which are absolutely required, are strictly related to the fact that the female patient is in a special physiological condition, which reflects on the physical and equally emotional responses of her body(1).

Odontal restoration of hard dental tissues loss, often accompanied by acute dental pain, is the most common reason for which the pregnant women present to dental practice.

The priority of dental treatments in pregnant woman is to cause as little trauma as possible, with no harm for her and for the fetus. Thus, the treatment must be conservative, preferably in one session, but the working time must be short, with frequent breaks to ensure the comfort for the patient, especially if she presents in the second or the third trimester of the pregnancy(2). On the other hand, dental treatments in pregnant women must meet the criteria of a long-time restoration, with no possibility for further complications such as pulpal inflammations, coronal and radicular fractures, or even tooth loss(3).

The dental treatment in pregnant women is sub­jec­ted to the specific conditions we usually confront with during this physiological period: pregnancy gin­gi­­vitis associated with gingival bleedings, intense acute responses to normal stimuli to which dental sur­faces come into contact, exacerbated dental hyper­sen­si­tivity and dental hyperesthesia, the limits and in­di­ca­tions for dental anesthesia, the need for dental chair specially positioned for the woman(4,5). Above all, the dentist must have an attitude of kindness, to­le­rance and understanding towards the special needs, both physical and emotional, for a woman during her preg­nancy.

A proper, correct and rigorous dental treatment in a pregnant woman significantly contributes to a har­monious course of pregnancy and to a healthy new­born.

Nowadays, resin composite materials are the first choice as restorative materials. In order to obtain proper results, many techniques for inserting composites into the cavities have been developed: centripetal technique, incremental techniques with different types of layers: horizontal/oblique/vertical layering technique, successive cusp build-up technique, bulk-fill technique(6). Associated with these, specific resin composites have been developed, to fulfill the necessities for a certain method.

One of the most successful techniques used today for direct restorations is the “bulk-fill”. This means the placement of a large quantity of resin composite into the cavity, often a single layer, to a depth of 4-5 mm(7). Among the new materials specially designed for this technique there are: Filtek Bulk Fill®, 3M ESPE; Tetric N-Flow Bulk Fill®, Ivoclar Vivadent; Filtek®One Bulk Fill Restorative, 3M ESPE. They exhibit special features which allow to obtain the requirements of lower shrinkage, lower polymerization stress, better light transmission in depth, thus a smaller numbers of layers and, as a result, less time consuming, with a very good result of the restoration(8). The bulk-fill technique, as other adhesive methods, permits a very conservative approach in dental treatment and prevents the postoperative sensitivity. The reduced shrinkage stress on the enamel and dentin walls means a very good marginal sealing, preventing nano- and microleakage, thus providing a long-time re­s­toration.

Case report

A 28-year-old female patient presented to dental practice for the restoration of a carious lesion in tooth 35 (Figure 1). The patient was in her 21st week of pregnancy, and the reason for asking for dental treatment was the acute pain at different stimuli like sweet or cold located at her tooth. The clinical exam we performed revealed the loss of hard dental tissues as a result of dental caries, in the occlusal pits and groove. The exacerbated sensitivity at both phy­sical and chemical stimuli is related to the special physiological period in which the patient has presented to us. The specific hormonal changes make the patient to consider the pain less acceptable or bearable than before pregnancy. Taking also into consideration that the carious lesion must be restored before further evolution, and the next stages of the pregnancy, followed by the postnatal and breastfeeding periods, we decided to use a direct technique of odontal restoration in one stage(9). The bulk-fill technique was chosen because it has a number of certain advantages, as follows: it is a simple method of treatment, it is a very rapid technique in which the hard tissue loss is restored using a specific flow resin composite, and the result is predictable, offering a long-time success restoration(10).

Figure 1. Carious lesion on occlusal surface  in tooth 35
Figure 1. Carious lesion on occlusal surface in tooth 35

As for every dental treatment, we started with removing the dental plaque by professional brushing, and the next stage was to start excavate and completely remove the altered tissues presented inside dental caries. A class I cavity for adhesive materials was obtained, by using for treatment only spherical burs, which provide a smooth internal surface and no sharp walls or angles (Figure 2).

Figure 2. Occlusal cavity for adhesive dental materials in tooth 35
Figure 2. Occlusal cavity for adhesive dental materials in tooth 35

For this case, the restorative specific resin com­po­site for bulk technique was Filtek® One Bulk Fill Restorative, 3M ESPE. This product provides a proper light curing of the entire inserted material in one step, for a thickness up to 5 mm.

Also, the maneuver of placing the material inside the cavity is extremely easy, and its viscosity – higher than of other flowable restorative resin composites (such as SDR [Smart Dentin Replacement], Dentsply® or Filtek Bulk Fill®, 3M ESPE) – permits a slightly condensation to increase adaptation to cavity walls. Thus, it offers excellent adaptation and handling advantages(11). The physical properties of this material – such as its flexural properties, excellent strength and low tooth wear – make it a good choice for posterior restoration when an easy technique with predictable and long-term success of restoration is needed, as in pregnant patients(12).

The next step of the dental treatment was to in­sert the resin composite into the cavity. The pro­to­col started with the adhesion stage, in which we used first etching with 32% orthophosphoric acid (Scotch­bond Universal Etchant[R], 3M ESPE), for 20 seconds, both on enamel and dentin (Figure 3). Fol­lowing the removal and thoroughly cleaning of the acid and slightly drying the cavity, the adhesive system was applied (Adper™ Single Bond 2, 3M ESPE). The adhesive layer was light-cured for 20 seconds.

Figure 3. Total etch adhesive technique for occlusal cavity in tooth 35
Figure 3. Total etch adhesive technique for occlusal cavity in tooth 35

Next, the resin composite material was inserted into cavity. Using the composite placement and modeling instrument called Compothixo®, Kerr, the adaptation of the resin composites to cavity walls and the marginal adaptation were easily achieved, and also the morphological aspect of the occlusal surface. The material was light-cured for 20 seconds (Figure 4).

Figure 4. Insertion and occlusal modeling of resin composite material in tooth 35
Figure 4. Insertion and occlusal modeling of resin composite material in tooth 35

The last step of any dental treatment is represented by the occlusal adaptation of the direct restoration, using diamond burs, followed by polishing with polishing gums and cups in the slow-speed handpiece (Figure 5).

Figure 5. Final aspect of direct resin composite restora­tion of occlusal dental caries in tooth 35, using bulk-fill tech­nique
Figure 5. Final aspect of direct resin composite restora­tion of occlusal dental caries in tooth 35, using bulk-fill tech­nique

Bulk-fill technique for direct restoration provides a simple, rapid and facile method of restoring loss of hard dental tissue, no matter its etiology. The resin composite is placed in a unique layer, a single layer, up to 4-5 mm. Despite the great quantity of resin placed and light-cured in one step, the shrinkage stress and  the cusp deflection are low. The clinical expression of these features of newly developed bulk-fill resin composites means a high quality restoration, with a good marginal sealing, good abrasion resistance, proper resistant to fractures and tooth wear, therefore a long-term success(13).


In pregnant women, the characteristics of dental treatment must meet few important aspects: a minimal operative stress and trauma, one-session treatment, short working time and long-term results, meaning an increased survival rate of the restoration, which has a prophylactic and preventive role for the entire oral cavity. In this respect, bulk-fill technique represents one of the first treatment method op­tions, because it fulfills all the aforementioned re­quirements. 


  1. Giglio JA, Lanni SM, Laskin DM, Giglio NW. Oral health care for the pregnant patient. J Can Dent Assoc. 2009;75(1):43-8. 

  2. Naseem M, Khurshid Z, AliKhan H, Niazi F, Zohaib S, Zafar MS. Oral health challenges in pregnant women: Recommendations for dental care professionals. Saudi J Dent Res. 2016;7(2):138-46.

  3. Baskaradoss JK, Geevarghese A. Utilization of dental services among low and middle income pregnant, post-partum and six-month post-partum women. BMC Oral Health. 2020;20(1):120.

  4. Gheorghiu IM, Mitran M, Mitran L, Pană DP, Mironiuc-Cureu M. Gingivita de sarcină. 2012;14(1):42-3.

  5. Patil S, Thakur R, Madhu K, Paul ST, Gadicherla P. Oral health coalition: knowledge, attitude, practice behaviours among gynaecologists and dental practitioners. J Int Oral Health. 2013;5(1):8-15.

  6. Haak R, Näke T, Park KJ, Ziebolz D, Krause F, Schneider H. Internal and marginal adaptation of high-viscosity bulk-fill composites in class II cavities placed with different adhesive strategies. Odontology. 2019;107(3):374-82.

  7. Zorzin J, Maier E, Harre S, Fey T, Belli R, Lohbauer U, Petschelt A, Taschner M. Bulk-fill resin composites: polymerization properties and extended light curing. Dent Mater. 2015;31(3):293-301.

  8. Băluţă I, Gheorghiu IM, Perlea P, Temelcea AN, Scărlătescu S. Tehnica de restaurare odontală directă în masă („bulk fill”) cu răşini compozite în zona laterală – prezentare de caz. Rom J Stom. 2019;LXV(1):71-4.

  9. Nguyen JG, Nanayakkara S, Holden ACL. Knowledge, attitudes and practice behaviour of midwives concerning periodontal health of pregnant patients. Int J Environ Res Public Health. 2020;27;17(7):2246.

  10. Fahmi MK, Ashour AA, Arora V. Effect of multilayering incremental technique on the microleakage of high-viscosity bulk-fill composite restorations in endodontically treated teeth. J Contemp Dent Pract. 2019;20(7):822-7.

  11. Owens BM, Johnson WW. Effect of insertion technique and adhesive system on microleakage of Class V resin composite restorations. J Adhes Dent. 2005;7(4):303-8.

  12. Keirse MJ, Plutzer K. Women’s attitudes to and perceptions of oral health and dental care during pregnancy. J Perinat Med. 2010;38(1):3–8.

  13. Veloso SRM, Lemos CAA, de Moraes SLD, do Egito Vasconcelos BC, Pellizzer EP, de Melo Monteiro GQ. Clinical performance of bulk-fill and conventional resin composite restorations in posterior teeth: a systematic review and meta-analysis. Clin Oral Investig. 2019;23(1):221-33.

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