THE SPECTRUM OF COMPOSITES:NEW TECHNIQUES AND MATERIALS

DANIEL FORTIN, D.M.D., M.S.; MARCOS A. VARGAS, D.D.S., M.S.

Background. During the past 25 years, advances in adhesive technology and composite-based resins have provided dentists and patients with new treatment options. This technology provides patients with more tooth-conserving and highly esthetic restorations.

Clinical Implications. This article reviews advances in composite-based resin materials. It discusses composition and classification of current resin-based composite. It also reviews techniques for successful placement of these materials and provides a discussion of current concepts of polymerization.

The introduction of composite-based resin technology to restorative dentistry was one of the most significant contributions to dentistry in the last century. The advantages of bonded restorations include conservation of sound tooth structure, reduction of microleakage, prevention of postoperative sensitivity, marginal staining and recurrent caries, transmission and distribution of functional stress across the bonding interface to the tooth. Bonded restorations also offer the potential for tooth reinforcement (deteriorated restorations can be repaired with minimal or no additional loss of tooth material), cosmetic restoration and recontouring of teeth with little or no preparation, and diminished need for use of liners and bases.1 Today, improvements in formulations, optimization of properties and the development of new techniques for placement have made the restoration of direct composite more reliable and predictable. This article discusses the range of new materials used in composite-based resins, as well as new techniques for using them.
ADHESION

Some adhesives combine the etching with the priming steps, resulting in the so-called selfetching primers, which simultaneously etch and infiltrate enamel and dentin. Other adhesives, single-bottle primer/adhesives, etch tooth structure followed by a combined priming and bonding step. Nevertheless, the long-term efficacy of these simplified systems needs to be proven.1
COMPOSITE-BASED RESINS

Conventional adhesives work in three steps etching, priming and bonding. In an effort to simplify bonding procedures, recently manufacturers have tried to eliminate or combine steps.
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By definition a composite is a material that consists of two or more components. Typically a dental resin composite contains an organic binder and an inorganic filler incorporated into a system that would induce polymerization. Usually the filler particles are coated with a coupling agent to bond to the resin matrix.2 Change of size and filler-loading has improved the wear resistance of the early composite resins. Modern composite systems contain filler such as quartz, colloidal silica, silica glass containing barium, strontium and others. This filler increases strength and modulus of elasticity and reduces the polymerization shrinkage, the coefficient of thermal expansion, and the water sorption.3 The generalized wear behavior of compositebased resins has become less and less important compared to other criteria. A major drawback of current composite-based resins is that they con-

JADA, Vol. 131, June 2000 Copyright 1998-2001 American Dental Association. All rights reserved.

tract or shrink during conversion from monomer to polymer. The resin matrix of all composite-based resin restorative materials shrinks volumetrically approximately 10 percent during polymerization.4 This polymerization stresses the adhesive between the tooth and the restorative material, frequently resulting in failure of this bond. This marginal breakdown results in marginal infiltration.5 Shrinkage is markedly reduced by the incorporation of filler particles and, therefore, the higher the filler loading, the less shrinkage should take place.
CLASSIFICATION OF COMPOSITE-BASED RESINS

Modern composite-based resins are composed of a resin or matrix, fillers, and interfacial phase to couple the filler with the matrix and initiators for polymerization. The matrix phase is com-

A number of commercially available compositebased resins lack the necessary radiopacity.

posed of organic difunctional monomers. Most commercially available composite-based resins contain bisphenol-A glycidyl methacrylate, urethane dimethacrylate or modified urethane dimethacrylate. Because these monomers are extremely viscous for their use in composed-based resins, triethylene glycol dimethacrylate is added

in various concentrations to dilute them. Multiple fillers are used in compositebased resins. The first composite-based dental resins were based on pure silica; because of the hardness of this material, it was difficult to pro- Figure 1. Scanning electron micrograph of a hybrid duce small par- resin-based composite (Esthet-X, Dentsply Caulk). Numerous resin-based composites are now availticles and the able with smaller and more polishable distribution final polymerof particles (magnification 10,000). ized composite was difficult to finish and polthe filler percentage increases. ish. To circumvent the hardness Reducing the size of the filler problem, aluminum and lithium particle also enhances the polare used; barium, zinc, boron ishability of the composite. and yttrium are used to impart Particle size has been continradiolucency. Ytterbium fluouously reduced since the advent ride is also incorporated to renof composite-based resin. der fluoride-releasing composEarlier dental composite-based ites; however, fluoride is resins used the average particle released in small amounts. The size of about 20 micrometers. silica glasses are covered with Modern composite-based resins silane coupling agents, difuncuse particles averaging from tional molecules, which bond less than 1 to 0.1 m in combiwith the silicas hydroxyl nation with fumed silica partigroups in one end and with the cles of 0.04 m, as in hybrid double bond of the monomer composite-based resins, or matrix in the other end. The fumed silica alone, as in comfiller is the portion of the composite-based microfill resins. posite-based resin that primariThe filler, the resin, the polyly affects its properties. The merization process and water size has a direct effect on sursorption also influences the face roughness and in the optical properties of the final amount of filler capable of being composite.6 incorporated. Use of small parComposite-based resins can ticles results in an increase in be classified according to their surface area, which impedes particle size7: higher loading. The amount of dmacrofilledmore than 10 filler affects the physical propm up to 100 m; erties, and as a general rule the dmidsize filledless than 10 higher the loading, the higher and more than 1 m; the strength of the final comdminifilledless than 1 and posite-based resin restoration. more than 0.1 m; Viscosity is also increased as dmicrofilledless than 0.1 m.
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JADA, Vol. 131, June 2000 Copyright 1998-2001 American Dental Association. All rights reserved.

FLOWABLES

Figure 2. Abfraction lesion, commonly caused by tooth flexure during mastication.

Commonly, composite-based resins are referred as hybrids or microfills. A hybrid resin is a composite in which at least seven to 15+ percent microfiller of fumed silica has been added 8 to the mixture (Figure 1). A composite-based microfill resin is exclusively composed of microfill particles. Hybrids incorporate fumed silica to help with the handling properties. Due to the increase in surface area when incorporating microfill particles, heavy loading is impossible. To circumvent the problem and increase the filler percentage, fumed silica is incorporated in a variety of manners, prepolymerized fillers, agglomerated and sintered agglomerated particles.9 Composite-based resins should have a range of translucency and opacity that reflects that of enamel and dentin. Translucency and opacity have been reported in the literature for commercially available composite-based resins.10 Another important characteristic that should be considered
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Figure 3. Canine restored with a flowable resin-based composite. A resin-based composite with a lower elastic modulus is recommended for the restoration of abfraction lesions.

is the radiopacity of the composite-based resin. The type of filler directly influences radiopacity. Radiopacity is attained through the incorporation of elements with high atomic number into the inorganic filler phase. Optimal radiopacity should be greater than enamel. However, a number of commercially available composite-based resins lack the necessary radiopacity.11-16 Barium is the element most commonly incorporated into composite-based resins to increase radiopacity. Excessive incorporation of radiopaque glasses results in a reduction in the translucency of these materials. Recently, manufacturers have been paying attention to the polishing of resin composites. Proper polishing reduces wear and better simulates the appearance of enamel. A number of hybrid composite-based resins are now available with smaller and more polishable distribution of particles.

Introduction of flowable composite-based resins is a recent event.15 An example of an advantage is that flowable composite-based resins possess the potential for flowing into a small undercut. Because of the materials flexibility, it can be used for restoration of abfraction lesions (Figures 2 and 3). The relative ease of flow allows these materials to be used in difficult-to-access areas and repairs of amalgam, crown, porcelain or composite restorations.16 The application of a flowable as a liner in difficultto-access areas is becoming popular; however, long-term clinical studies are not yet available to support the use of a flowable composite as a liner at this time. A recently published article observed that placement of flowable composite-based resins into the proximal box of a Class II restoration in permanent teeth may contribute to reduction in microleakage at the cavosurface margin when compared to the placement of an injectable glass ionomer.17 Another recent publication reported reduction in microleakage on Class I restorations when using flowable composite-based resins.18 A thick adhesive layer or a composite-based resin showing greater toughness similar to the flowable may be sufficiently energy-absorbing,16 may compensate for the polymerization stress due to elastic properties and may reduce gap formation.19 Clinicians should be careful in selecting flowable compositebased resins as many of them on the market do not exhibit a radiopacity equal to or greater

JADA, Vol. 131, June 2000 Copyright 1998-2001 American Dental Association. All rights reserved.

than that of enamel. A low radiodensity flowable should be avoided in Class II restorations to prevent confusion in determination of recurrent caries.20
PACKABLE COMPOSITE-BASED RESINS

Recently, packable compositebased resins have been introduced in an attempt to address certain issues such as shrinkage, wear and handling. They have been mistakenly called condensable composites, but they do not condense. They offer higher viscosity trying to mimic amalgam placement techniques. They offer the potential to obtain a better proximal contact when packing them against a matrix band. To obtain such a characteristic, manufacturers use a higher percentage of irregular (mixture of different size particles or glass rods) or porous filler (packables are generally loaded in excess of 80 percent, and traditional hybrids are generally loaded less than 80 percent) to reduce the amount of resin, increasing the viscosity and creating this particular handling property. Unlike conventional hybrids, this category of composite-based resins is relatively resistant to displacement during insertion (packing). Early clinical results are encouraging; in recent clinical trials on SureFil (Dentsply Caulk), the one-year recall showed restorations with no open contacts, acceptable clinical wear and amalgamlike handling properties21 (Figure 4).
TECHNIQUE FOR PLACEMENT

Placement procedures for composite-based resin restorations

are very techniquesensitive.22 The operating field must be kept absolutely clean and dry during the insertion of the compositebased resins. Inability to achieve moisture control Figure 4. One year recall of a restored premolar will lead to clin- with a packable posterior resin-based composite (SureFil, Dentsply Caulk). ical problems; therefore, placement of a rubber dam is highly proximal surface being recommended, if not essential. restored. Prewedging of the Water, moisture or saliva are tooth will protect the intersepcontaminants. tal dam and soft tissue, prevent Good marginal adaptation damage during tooth prepararequires adequate physical and tion and create a rapid tooth mechanical properties of the separation to compensate for filling material and its careful the matrix band. It is therefore manipulation. The use of comeasier to achieve adequate conposite resin for direct restoratact with the adjacent tooth foltions demands careful and lowing removal of the matrix thoughtful clinical application. once the resin is inserted. Incremental layering techUsing finite element analysis niques have been recognized as on Class V restorations, it was the technique of choice to minisuggested that bulk filling of mize stresses from polymerizalight-cured composite-based tion shrinkage.13,23 Gaps may resins should be used in restorations that are sufficientdevelop when the bonding capacity of the adhesive system ly shallow to be cured to their is insufficient to resist the full depth.26 A previous study forces of polymerization shrinkreported similar results conage of the composite.24,25 cluding that none of the placeAlthough the universal ment techniques (incremental matrix band is a versatile or bulk) improved the adaptainstrument, it does not meet all tion at the gingival margin. criteria with respect to contour They did demonstrate, however, and form. Two major disadvanthat the incremental techniques tages of the universal matrix ensured the complete polymerare that it allows curing only ization of the composite-based from the occlusal aspect and is resin.27 not anatomically shaped for POLYMERIZATION OF contour. Precontour bands RESIN-BASED COMPOSITES requiring little or no adjustment are desirable. The matrix will provide axial confinement Polymerization of resin-based of the resin and convexity to the composites has received consid29S

JADA, Vol. 131, June 2000 Copyright 1998-2001 American Dental Association. All rights reserved.

erable attention owing to the introduction of high-intensity energy output light sources and other methods of light exposure. During polymerization, the monomer is converted to polymer. This results in shrinkage of the resin, causing stress at bonded interface and adjacent tooth structure.28 Polymerization stress initially is relieved by composite flow until it reaches the so-called gel point. Before this point, the resin-based composite is flexible and accommodates to relieve stress. After this gel point is reached, the composite changes to an unyielding state in which the shrinkage stress is transmitted to the tooth structure. It has been observed that the longer the pre-gel point time, the less the stress in the post-gel phase.29 High-intensity energy output light sources, such as plasma arc curing lights or laser curing lights, allow a reduction in polymerization time by increasing the polymerization rate. This results in a decrease of the pre-gel point time and may increase the shrinkage stress. Another concern is that some of these light sources present a narrow band of light emission that may not correspond to the absorption band of the photo initiators, resulting in an incompletely cured resin. Many researchers are evaluating other factors that influence polymerization. The dental practitioner should be cautious when using these alternate sources of light to polymerize resin-based composite.

SUMMARY

This article discussed a range of new materials and placement techniques for resin-based composite restorations. Even though the resin-based composite restorative materials of today are a vast improvement over what was previously offered, the placement of composite-based resin restorations remains technique-sensitive and complex. However, these materials provide patients with the esthetically acceptable restorations they seek. s
Dr. Fortin is associate professor, Department of Operative Dentistry, Universit de Montral, Facult de Mdecine Dentaire, douard Montpetit, Montral, Qubec, Canada H3T 1J4. Address reprint requests to Dr. Fortin. Dr. Vargas is an associate professor, Department of Operative Dentistry, The University of Iowa, Iowa City, Iowa. 1. Van Meerbeek B, Perdigao J, Lambrechts P, Vanherle G. The clinical performance of adhesives. J Dent 1998;26(1):1-20. 2. Phillips RW. Science of dental materials. 8th ed. Philadelphia: Saunders; 1982:224. 3. Dogon IL. Present and future value of dental composite materials and sealants. Int J Technol Assess Health Care 1990;6:369-77. 4. Glen JF. Composition and properties of unfilled and composite resin restorative materials. In: Smith DC, Williams DF. Biocompatibility of dental materials. Boca Raton, Fla.: CRC Press; 1982:98-130. 5. Browne RM, Tobias RS. Microbial microleakage and pulpal inflammation: a review. Endod Dent Traumatol 1986;2:177-83. 6. Johnston WM, Reisbick MH. Color and translucency changes during and after curing of esthetic restorative materials. Dent Mater 1997;13(2):89-97. 7. Sturdevant CM. The art and science of operative dentistry. 3rd ed. St. Louis: Mosby;1995:256. 8. Albers HF. Tooth-colored restoratives. 8th ed. Santa Rosa, Calif.: Alto Books; 1996. 9. Willems G, Lambrechts P, Braem M, Celis J, Vanherle G. A classification of dental composites according to their morphological and mechanical characteristics. Dent Mater 1992;8:310-9. 10. Vargas MA, Bouschlicher M. Translucency/opacity of proprietary composite resins (abstract 1384). J Dent Res 1995;74:184.

11. Bouschlicher MR, Cobb DS, Boyer DB. Radiopacity of compomers, flowable and conventional resin composites for posterior restorations. Oper Dent 1999;24(1):20-5. 12. Leinfelder KF. Restoration of abfracted lesions. Compend Contin Educ Dent 1994;15(11):1396-400. 13. Baratieri LN, Ritter A, Perdigao J, Felippe LA. Direct posterior composite resin restorations: current concepts for the technique. Pract Periodontics Aesthet Dent 1998;10(7):875-86. 14. Watts D. The structural scope of biomaterials as amalgam alternatives. Trans Acad Dent Mater 1996;9:51-67. 15. Flowable resinsstatus report no. 1. Clin Res Associates Newsletter 1997;21(2):1. 16. Bayne SC, Thompson JY, Swift EJ Jr., Stamatiades P, Wilkerson M. A characterization of first-generation flowable composites. JADA 1998;129(5):567-77. 17. Payne JH IV. The marginal seal of Class II restorations: flowable composite resin compared to injectable glass ionomer. J Clin Pediatr Dent 1999;23(2):123-30. 18. Ferdianakis K. Microleakage reduction from newer esthetic restorative materials in permanent molars. J Clin Pediatr Dent 1998;23(3):221-9. 19. Kemp-Scholte CM, Davidson CL. Marginal integrity related to bond strength and strain of composite resin restorative systems. J Prosthet Dent 1990;64:658-64. 20. Murchison DF, Charlton DG, Moore WS. Comparative radiopacity of flowable resin composites. Quintessence Int 1999;30:179-84. 21. Perry R, Kugel G, Leinfelder K. Oneyear clinical evaluation of SureFil packable composite. Compend Contin Educ Dent 1999;20(6):544-53. 22. Crim GA, Chapman KW. Reducing microleakage in Class II restorations: an in vitro study. Quintessence Int 1994;25:781-5. 23. Jordan RE, Suzuki M. Posterior composite restorations: where and how they work best. JADA 1991;122(12):30-7. 24. Opdam NJ, Roeters FM, Feilzer AJ, Verdonschot EH. Marginal integrity and post-operative sensitivity in Class 2 resin composite restorations in vivo. J Dent 1998;26:555-62. 25. Prati C, Tao L, Simpson M, Pashley DH. Permeability and microleakage of Class II resin composite restorations. J Dent 1994;22(1):49-56. 26. Winkler MM, Katonas TR, Paydar NH. Finite element stress analysis of three filling techniques for class V light-cured composite restorations. J Dent Res 1996;75(7):1477-83. 27. Tjan AH, Bergh BH, Lidner C. Effect of various incremental techniques on the marginal adaptation of Class II composite resin restorations. J Prosthet Dent 1992;67:62-6. 28. Davidson CL, DeGee AJ, Feilzer A. The competition between the composite dentin bond strength and the polymerization contraction stress. J Dent Res 1984;63:1396-9. 29. Versluis A, Tantbiron D, Douglas WH. Do dental composites always shrink toward the light? J Dent Res 1998;77:1435-45.

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JADA, Vol. 131, June 2000 Copyright 1998-2001 American Dental Association. All rights reserved.