Advances in Composite Restorative Materials Support Conservative

Dentistry
Rena Vakay, DDS
Composite restorations were introduced in the mid-1950s. 1 Their
evolution has primarily revolved around filler type and size. 2 While,
overall, composite material has good clinical performance, the potential
for failure certainly exists. Annual failure rates of composite in posterior
teeth are 1% to 3%, and in anterior teeth failure rates are 1% to
5%.3 Clinically, failure is defined mainly by recurrent caries or fracture of
the restoration.4 Causes of these failures are multifactorial. Volumetric
shrinkage and microleakage are inherent in the material itself, and lack of
structural strength may be an issue in larger restorations. Factors such
as the armamentarium used, operator training and technique, curing-light
ergonomics, patient habits and caries risk, location in the oral cavity, and
particle size are some of the variables that determine long-term success.
This article will explore contemporary ways to reduce these risks and
increase efficiency with composite restorations.

Composite Technique
The technique used to place a composite material is fundamentally
critical. Because each composite material possesses different physical
and chemical properties, it is important that clinicians adhere to the
manufacturer's recommendations. Staying within the same resin system
when placing restorations is also highly recommended as best practice.
To be mechanically retentive, traditional cavity preparations require
increased sacrifice of tooth structure. Composite preparation lends itself
toward more conservative, minimally invasive preparations and the use
of additive techniques. Conventional bonding technique has entailed
placement of composite in incremental layers, which is time- and labor-
intensive. The layering of composite is vulnerable to the creation of
voids, seams, volumetric shrinkage, and cuspal flexure. These issues
can contribute to failure of the restoration.
To reduce failures caused by the layering of composite, the bulk-fill
technique was introduced and recently has become more dominant in
private practice,5 for good reason. Efficiency is increased with the ability
to place composite in 4 mm to 5 mm depths.6 Bulk-fill composite has
shown equal or improved qualities in comparison to conventional
technique, including less shrinkage, cusp deflection, polymerization
stress, and marginal gap, increased degree of conversion, and improved
flexural and fracture strength.7
One of the most recent significant alterations in technique is the
preheating of composite prior to placement. Preheating the material may
increase the degree of monomer conversion and reduce polymerization
shrinkage force.7 This creates a stronger composite and results in less
polymerization stress. Preheating allows for a more intimate adaptation
of the composite into the preparation and allows easier restoration of
interproximal areas, which are traditionally difficult to properly restore.
Many excellent bulk-fill composites have been studied in the literature
and are available on the market. Some of these include Tetric
EvoCeram® Bulk Fill (Ivoclar Vivadent, ivoclarvivadent.com),
SonicFill™ (Kerr, kerrdental.com), and Filtek™ Universal (3M Oral Care,
3m.com). Recently a technique has been refined that incorporates bulk-
fill composite placement with a preheating technique to increase quality
and efficiency.8 This approach solves the ledging problem that can occur
in interproximal areas and decreases time of placement of the
composite.
Other advances aimed at simplifying the direct restorative process have
involved composite technology that allows the clinician to limit color
choices without compromising esthetics (eg, Omnichroma, Tokuyama,
tokuyama-us.com; Beautifil II Enamel Shades, Shofu, shofu.com; Admira
Fusion x-tra, Voco, vocoamerica.com). Universal composites that are
designed to match virtually any tooth shade can reduce chairside time for
shade selection and also help dental practices reduce inventory and thus
overhead costs, because fewer color shades of composite need to be
stocked.9

Matrix Systems
When attempting to re-establish tooth form, a clinician is heavily reliant
on an effective matrix system. The Tofflemire matrix system was
introduced in 1946 and has been a popular system for both amalgam
and composite restorations for many years.10 This system employs a
screw-type retainer and thin stainless-steel bands that are used with
various sized wedges to separate teeth interproximally. This method
allows for a tight contact area in the finished restoration.
Assorted matrices subsequently have evolved that offer easier
placement of the matrix, better light-curing ergonomics, decreased
chairtime, and the ability to create enhanced contours of the restoration.
Three types of matrices may be used: a matrix for interproximal surfaces,
an occlusal surface matrix, and a cervical matrix.
Posterior interproximal matrix systemsare moving away from the
traditional stainless-steel Tofflemire-style bands and retainers. The
newer posterior retainers are clamp-like and can support either a clear or
a very thin metal band. Palodent® BiTine ring (Dentsply Sirona,
dentsplysirona.com) was one of the first of this kind, featuring a spring
action that gently separates teeth to provide the space needed to
achieve proper contours. Garrison Dental Solutions (garrisondental.com)
was soon to follow with the Composi-Tight® sectional matrix system that
comprises a naturally contoured band and operator-friendly retaining
system. The company now offers several ring systems and sectional
matrices. A more recent entry, the Waterpik® ClearView (Water Pik, Inc.,
waterpik.com), features an hourglass matrix system designed to increase
visibility and access.
One of the newest matrix systems has clear interproximal matrices for
both anterior and posterior restorations (Bioclear, bioclearmatrix.com).
The anterior matrices are ideal for closing "black triangles" that may
manifest after orthodontic treatment or certain periodontal surgeries.
Along with the preheating of both flowable and paste composite, these
matrices use injection molding to prevent interproximal ledges that can
occur with the use of straight mylar strips.11
An occlusal matrix or stamp made from clear polyvinyl can serve to
record the occlusal surface of the tooth prior to preparation. 12This matrix
is used near the end of completion of a bulk-fill restoration to help
decrease procedure time and increase efficiency. A cervical matrix could
be constructed in the same fashion and used to restore the cervical
portion of the tooth.

Curing
Perhaps the most crucial step in the long-term success of a composite
restoration-and maybe the one that clinicians most take for granted-is
proper polymerization. Just as it is crucial to follow the manufacturer's
instructions with the handling of the composite, so it is with respect to
light curing.
Five-time winner of the Cellerant’s Technology Award, the EyeSpecial C-
III camera from SHOFU enables staff to take impressive images for case
documentation, diagnosis and treatment planning, and patient
communication and education. This digital dental camera has eight pre-
programmed shooting modes
The characteristics of the composite material affect the time needed for
complete cure. Particle size, opacity due to color, photoinitiators, and
depth of preparation all influence the rate of cure. The performance of
the light also is dependent on the maintenance of the light. The light tip
must be kept clean of debris, and the clinician should routinely validate
the performance of the light. One study found that when both the
performance of the curing light and the effects of operator technique
were considered, 30% of the curing light/composite combinations could
not deliver even half of the energy dose required by the resin
composite.13
To ensure that the light is in proper working order, it must be evaluated
periodically. Curing lights cannot be accurately measured by
radiometers, as radiometers provide only relative information. 14 A
spectrometer is the recommended instrument to precisely measure the
output of a light source.15 This instrument can be quite expensive, and a
cost-effective alternative for clinicians is to use a device such as a
checkUP™ (BlueLight Analytics, bluelightanalytics.com). Via an app and
a small device connected to a smartphone, a report is constructed with
information about light intensity and the specific materials being used. 16
Proper ergonomics are needed to thoroughly cure the composite. The
restoration must directly receive the light emission for the correct amount
of time based on the manufacturer's recommendation.

Conclusion
Clinicians can take simple steps to increase the success of composite
restorations, such as knowing and following the manufacturer's
recommendations for the composite material and making the right light
selection and proper choice of matrix. Perhaps most important is
ensuring that the curing light is properly maintained and calibrated for the
appropriate output. These newer techniques and products highlighted in
this article are compatible with the goals of conserving tooth structure,
increasing efficiency, and delivering superior results to patients.

About the Author

Rena Vakay, DDS
Clinical Instructor, Kois Center, Seattle, Washington; Member, American
Academy of Restorative Dentistry; Accredited Member, American
Academy of Cosmetic Dentistry; Section Editor, Restorative,
Compendium of Continuing Education in Dentistry; Private Practice,
Centreville, Virginia

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