POSTERIOR

COMPOSITERESINS

ACURRENTASSESSMENT

HISTORY
Theuseofposteriorcompositeresinshasbeenincreasingforsometimeduetopatientsexpectations
forestheticsandthelingeringconcernovermercurytoxicitydespitedecadesofformalproceedingson
thesafetyofdentalamalgamsthatproducednosoundscientificevidenceofchronictoxicityinhumans.

Thequestforcompositeresinswithsufficientstrengthand
durabilityforposteriorplacementactuallybegannearlyfour
decadesago,shortlyafterthisclassofmaterialswasintroducedto
thedentalprofessionasanextraordinarilysuccessfulalternativeto
silicatecementsanddirectfillingresins.1,2Earliermaterialsshowed
relativelyhighratesofwearandsecondarycariesafteracoupleof
years.3,4Figure1showsacastofanearliercompositeresinintooth

Figure1
number19aftertwoyears.Theocclusalwearalongthemarginsis
apparentandmeasuredapproximately400microns.

Forthemostpart,theseproblemshavebeenovercomeduetoevolutionaryadvancesincomposite
resintechnologythatincludedimprovedadhesiontodentinresultinginlessmicroleakageand
secondarycariesdevelopment,areductioninthesizeofinorganicfillerparticlesresultinginlesswear,
andvisiblelightcuringresultinginimprovedadaptationduetoanunlimitedworkingtimeaswellas
increasedphysicalpropertiesduetotheeliminationofvoidsincorporatedduringthemixingprocess.

ADVANTAGES
Theadvantagesposteriorcompositeresinrestorationsofferoverdentalamalgamaremany:
Esthetics
Mostmoderndaycompositesaremadeavailableinnumerousshadesandseveralvariationsinopacity
makingpossibleexcellentopticalmatchestotoothstructure.Thefiguresbelow(seriescourtesyDr.Jeff
Blank)showacommonlyusedcompositelayeringtechniquethatcanresultinahighlevelofesthetics
whenrestoringposteriorteeth.

Figure1.Cavitypreparation
Figure2.Flowablecompositelinerplaced

Figure3.BodylayerplaceduptoDEJ Figure4.Enamellayerplacedfinishedrestoration
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ConservativeCavityPreparations
Amajorbenefittousingcompositeresinsistheabilitytoprepareveryconservativecavitypreparations.
Whencoupledwiththestrongbondsthatcanbeformedwithenamelanddentin,theresultisless
weakeningoftoothstructure.Thereisusuallynoneedforundercutsorextendingcavitypreparations
intoselfcleansingareas.Lineanglesareroundedandocclusalbevelsareoftennotnecessary.Figures5
and6showanarrayofconservativecavitiespreparedtoreceivecompositeresinrestorations.

Figure5

Figure6

IncreasedWearResistance
AtarecentmeetingoftheInternationalAssociationofDentalResearch,datawerepresentedona
packableposteriorcompositeresin,SureFilHighDensityPosteriorRestorative,DENTSPLY/Caulk,
Milford,DE,showingmeanmarginalwearofonly142micronsaftertenyears.5Consideringthisisless
thanwearmeasurementsrecordedforposteriorenamelcusps,6,7itisapparentthatcontemporary
compositeresinsmatrerialscanwithstandthechallengesposedintheposteriorregionofthemouth.

Reparability
Ithasbeenshownthatcompositeresincanbondtopreviouslycuredmaterial,evenaftertheoxygen
inhibitionlayerisremoved,ifthecuredsurfaceisfirstetchedwithphosphoricacidandthencoatedwith
achemicallycompatiblebondingagent.8

LowerCoefficientofThermalConductivity
Teethoftenbecomemoresensitivetotemperaturefluctuationsfollowingoperativeprocedures,and
restorativematerialscapableofrapidlyconductingheatcanonlyaddtotheproblem.Dentalamalgamis
morethan30timesmoreconductivethandentinandgoldisapproximately500timesmore
conductive;9thereforeinsulatingbasesarerequiredwhenthesematerialsareusedindeeper
restorations.Whiletheminimalthicknessofaninsulatingmaterialhasnotbeenspecified,anythingless
than0.5mmwouldbeconsideredoflittlehelp.10Filledresinmaterialsarenotgoodconductorsofheat
andinfactoffergreaterinsulationthandentalenamel,11adesirablepropertythatobviatestheneedfor
insulatingbases.

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LowerIncidenceofCuspFractures?
Numerousstatementsandimplicationshavebeenmadethatcompositeresinrestorationsinposterior
teetharelesslikelytobeassociatedwithfracturingofremainingcuspsbecausetheycanbebondedso
welltotoothstructure.Theargumentmakessensefromthestandpointofmaterialscience,however,it
isnotwellsupportedwithevidence.Onestudythatobserved10,869posteriorteethwithamalgamor
compositeresinrestorationsin1,902
patientsfoundnosignificantdifferenceintheprevalence
ofcuspfracturesbetweenthetworestorative
materials.12Therewasahigherprevalenceofcusp
fracturesinteethwithmorethanonesurfacerestored
andinolderindividualsbutthesewereindependentof
thespecificrestorativematerialused.

Figure7.FracturedDBcusp#3(CourtesyDr.JeffBlank)

DISADVANTAGES
Despitethemanyadvantagesofferedbycompositeresinsandthevastimprovementsthathavebeen
madeinthepropertiesofthesematerialsoverthepastthreeplusdecades,issuesremainwiththeiruse
intheposteriorregionofthemouth,particularlyforlargerrestorations.In1998theAmericanDental
Association(ADA)issuedapositionstatementonposteriorresinbasedcompositesthatingeneral
supportedtheiruse,butnotinteethwithheavyocclusalstress,insitesthatcannotbeisolatedorin
patientswhoareallergicorsensitivetoresinbasedcompositematerials.13Whileamorerecentposition
statementhasnotbeenpublished,theADAdidhostapaneldiscussiononposteriorcompositeresins,
theproceedingsofwhichappearedinthesummer,2006issueoftheADAProfessionalProducts
Review.14Thepanelistsnotedthatwhilethereportsontheperformanceofposteriorcompositeshave
generallybeenfavorable,concernremainsregardinguseofthematerialinlargerestorationsandthe
durabilityofthebondtotoothstructuresincebondshavebeenshowninthelaboratorytodeteriorate
overtime.Itwasfurthersuggestedinthepaneldiscussionthatposteriorcompositeresinsnotbeplaced
insituationswheregoodisolationisnotpossible,inpatientswithahighcariesrateand/orpoororal
hygieneorinpatientswhoclenchorbruxtheirteeth.

Somedisadvantagesassociatedwiththeplacementofcompositeresinrestorationsintheposterior
regionofthemouthareasfollows:
TechniqueSensitivity
Ithaslongbeenrecognizedthatplacingposteriorcompositesresinsisamoredemandingclinical
procedurecomparedtodentalamalgamandmayrequiretwicethetimeforcompletion,particularlyin
multisurfacerestorations.15Adequatelightcuringisessentialformaximalphysicalproperties,and
incrementalplacementisnecessaryduetopolymerizationshrinkagestressanddepthofcure
limitations.Obtainingproperanatomicformandmarginaladaptationismoredifficultwithcomposite
resinsduetotheirplasticconsistencycomparedtothecarvingcharacteristicsassociatedwithdental
amalgam.Isolationbecomesmorecriticalwhenusingcompositeresinsthanwithdentalamalgamsor
glassionomercementssincemoisturecontaminationduringthepolymerizationprocesscanresultin
reducedphysicalproperties.

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Obtainingproximalcontactisalsomoredifficultsinceeventheheaviestbodiedcompositeresin
formulationshavedifficultyholdinganextendedmatrixbandinposition,andspecializedmatrixsystems
arenormallyrequired(Figure8).
Perhapsthegreatestsourceoftechniquesensitivityin
usingcompositeresinsistheneedtobondtoenameland
dentin.Moderndayadhesivescanbondadequatelyto
bothhardtissueseventhoughtheyvaryconsiderablyin
thenumberofstepsinvolved,thetypeofsolventused
and,inthecaseofselfetchadhesives,thepHvaluewhich
cangreatlyinfluencethe

Figure8.Sectionalmatrixinplace(CourtesyDr.Mark
Latta)
aggressivenessoftheetchingpattern.Mostofthedocumentedclinicaltrialsonadhesiveshavebeenin
noncariouscervicalerosionlesionssincetheirnonretentivenaturepresentsaformidableclinical
challengetothestrengthanddurabilityofanadhesivebond.Thesetrialshaveshowngoodresultswith
bothetchandrinseandselfetchadhesives,butthemostconsistentresultsseemtobeassociatedwith
thethreestepetchandrinsesystemsandthetwostepselfadhesivesytems.16

Nonantimicrobial
Unlikedentalamalgam,compositeresinsareunabletoarrestthegrowthofmicroorganisms,which
couldresultinamorerapidprogressionofrecurrentorsecondarycaries.15,20

PolymerizationShrinkageStress
Theresinmatrixofcompositeresinmaterialsiscomposedofmonomermoleculesthatupon
polymerizationconverttoapolymernetworkwhereinmoleculesarepackedcloserthanintheirfree
stateleadingtobulkcontraction.17Iftheresultingstressisgreaterthanthebondstrengthtotooth
structure,debondingcouldoccurleadingtomarginalgapformationandirritationofthepulpdueto
microbialcolonization.18Theextentofshrinkageandtheresultingstresswilldependuponthedynamics
ofthepolymerizationreactionandthelevelofinorganicfillerloading.Attheclinicallevel,thedegreeof
stressplacedonrestorativemarginsismostinfluencedbythebulkofmaterialbeingcuredandthe
configurationofthecavityintowhichthematerialisplaced.Thepotentialforagivencavity
configurationtocausestressatthemarginsofarestorationisknownastheCfactorandiscalculated
verysimplybydividingthenumberofbondedinternalcavitysurfacesbythenumberofnonbonded
surfaces.BelowareshowntheCfactorsforthevariouscavityclasses(CourtesyDr.JeffBlank).

ClassIVC=0.5
ClassIVC=0.5

ClassIIIC=1.0
ClassIIIC=1.0

ClassIC=5.0
ClassIC=5.0
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ClassIIC=2.0
ClassIIC=2.0

Littleclinicalevidenceexiststosupportarelationshipbetweennegativeoutcomesandpolymerization
shrinkagestress;however,directeffectsrelativetobondstabilitycanbeshowninthelaboratory.Itis
thereforeprudenttoatleastbearinmindthatshrinkagestressislikelyanundesirablepropertyfora
restorativematerialandpracticalstepsthatcouldminimizeshrinkagestressshouldbeconsidered.Such
stepsincludeverticalratherthanhorizontallayeringofcompositeresinsandavoidingtheplacementof
bulkamountsofthematerialpriortolightcuring.

POSTERIORRESINCOMPOSITEFAILUREANDCAUSES
Sincecompositeresinswerefirstconsideredasapotentialreplacementfordentalamalgam,questions
havebeenraisedastotheirsuitabilityforsuchacriticalroleindentistry.Therearemanyreports
comparingthesuccessratesofthetwomaterials,andbyandlargecompositeresinshaveshown
acceptableperformanceevenifnotquitetothelevelofdentalamalgam.Matchingtheefficiencyof
dentalamalgamasapublichealthmeasureisindeedbeyondthereachofmostrestorativematerials.
Table1showstheresultsofonecomprehensivestudythatfollowedover1700posteriorrestorationsfor
asevenyearperiod.Halfofthepatientsreceivedcompositeresinrestorationswhiletheotherhalf
receivedamalgam.

TABLE1
MEANANNUALSURVIVALRATESOFCOMPOSITESANDAMALGAMS
AFTERSEVENYEARS(%)
CHARACTERISTIC

AMALGAM

TOOTHTYPE
Premolar
Molar

RESTOREDSURFACES
1
2
3
4ormore

COMPOSITE

94.5
94.4

85.7
85.5

98.8
90.5
88.5
81.8

93.6
80.6
66.2
50.0

SIZE
Small
Medium
Large

98.9
93.3
89.5

93.6
84.9
74.3

ALL

94.4

85.5

AdaptedfromBernardoMetal19

Asevidentfromthetable,amalgamrestorationsdiddemonstratefewerfailuresthancompositeresins
overthesevenyearperiod,particularlyinrestorationswiththreeormoresurfaceswherecomposite
resinsexperienceda50%failurerateinthelargestrestorations.Thisstudyalsoreportedthatthemain
reasonforrestorationfailuresinbothgroupswassecondarycaries.However,theproportionoffailures
duetosecondarycarieswashigherinthecompositeresingroup(88%)comparedwiththe
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amalgamgroup(66%).Ithasbeenreportedthatthemostfrequentsitesforsecondarycariesarethe
gingivalmarginsofallclassesofrestorations.20Thisisnotterriblysurprisinggiventhedifficultaccess
manyoftheseareaspresentaswellasthechallengesposedbybondingtodentinandcementumas
comparedwithenamel.

Whilethemaincauseforfailureofposteriorcompositeresinrestorationsappearstobesecondary
cariesintheareaofthegingivalmargin,thespecificreasonsforcariesdevelopmentarefarlessclear.
Certainlyalowleveloforalhygieneisconsideredbymanyascausative,yettheevidenceisscant.Itis
knownthatthereplacementrateforposteriorcompositeresinsishigherinadolescentscomparedwith
adults,perhapsowingtopooreroralhygieneandhighersugarintakeintheyoungercohort.The
techniquesensitivityofcompositeresinplacementandassociatedbondingprocedureshavebeen
thoughttocontributetoareducedsurvivalratecomparedwithamalgam,butevidencehereisalso
lacking.OnestudyhadClassIIrestorationsplacedinteethdestinedforextraction,followingwhichthe
restorationswereobservedonradiographsandunderscanningelectronmicroscopy.21Itwasreported
thatonly27%ofgingivalmarginswerefreeofdefects,afindingthatwouldsupportthetechnique
sensitivityinvolvedwithplacingcompositeresinsinposteriorteethandperhapsalsothehigherrisk
theseareasfacewithrespecttosecondarycaries.Surprisingly,thestudyalsofoundthatnoneofthe
followingvariableshadaneffectonthequalityofgingivalmargins:
Experienceleveloftheoperator
Horizontalversusverticallayeringofrestorations
Typeofadhesive;onestepetchandrinse,twostepetchandrinseortwostepselfetch
Whilethisstudyhighlightedthegingivalmarginasanareathatshouldreceivefocusedattention,itdid
notsuggestthatexperience,layeringtechniqueoradhesiveselectionwouldhelpremedytheobserved
defects.Anotherstudythatevaluatedthelongevityofposteriorresincompositerestorationscasta
shadowofdoubtovertheinsistenceonthepartofsomethatrubberdamisolationisessentialfora
successfulrestorationsinceitdidnotresultinsignificantlyhighersurvivalratesthanisolationbycotton
rolls.22

LINERS
Somecommentsregardingtheuseoflinersandflowablecompositesinparticularbeneathposterior
compositeresinrestorationsareinordersincearecentsurvey23indicatedthat90%ofdentistshave
usedaflowablecompositeinthepasttwelvemonths,andthat82%offlowableusersapplythemas
liners.Theuseofflowablecompositelinershasbeenclaimedtoincreasemarginaladaptationinthe
gingivalmarginalareaofClassIIrestorationstherebyreducingmicroleakage.Ithasalsobeenclaimedto
mollifypolymerizationshrinkagestressonthepartofthecompositeresinduethemoremoreelastic
natureofflowablecompositeresins.Recentworkhasshownthattheuseofaflowablelinershowed
fewervoidsattheinterfaceoftherestorationandtoothstructureinthecervicalareaofClassII
restorationswhencomparedwithbondingagentandresincompositealone.24Thestudyalsoshowed
thatthicker(2mm)flowableprecuredlinersshowedmoremarginalleakagewhencomparedwith
thinner(0.51mm)liners.Thisfindingwouldobviouslyrefutethenotionthatflowablelinerscould
counteracttheeffectsofpolymerizationshrinkagestressfromthecompositeresin.Finally,thisstudy
showedthataliningtechniqueoriginallypresentedbyJacksonandMorgan25involvingplacementofa
packablecompositeoverathinuncuredflowablelinerresultedinthebestmarginalsealingofallgroups
tested.

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