Earn

4 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.
Go Green, Go Online to take your course
This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
Composite Restoration
Esthetics
A Peer-Reviewed Publication
Written by Robert C. Margeas, DDS, FAGD
PennWell is an ADA CERP recognized provider
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying
quality providers of continuing dental education. ADA CERP does not approve or endorse individual
courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
Concerns of complaints about a CE provider may be directed to the provider or to ADA CERP at
www.ada.org/goto/cerp.
2 www.ineedce.com
Educational Objectives
Overall goal: The purpose of this article is to provide dental pro-
fessionals with information about the esthetic considerations and
strength of direct composites. Upon completion of this course, the
clinician will be able to do the following:
1. Know the categories of composite resin restorative materials
available and their characteristics and indications for use.
2. Know the modes of failure for composite resin restorative
materials.
3. Know the shade considerations involved in the attainment
of esthetics in composite resin restorations and the use of
different shading and layering techniques.
4. Know the relevance of a smooth surface and gloss as well as
polishability, and factors infuencing these.
Abstract
The increased use of direct composite restorations can be mainly
attributed to patient demand for esthetic restorations and the
availability of composites with high strength and excellent esthet-
ics. While early composites were weak and suitable only for ante-
rior restorations, current composites are highly esthetic and offer
high strength for their intended purposes. Techniques have also
evolved, with sophisticated bonding techniques and single-shade,
dual-shade, and multilayering techniques to optimize esthetics.
It is important to consider not only the individual case, relative
strength, and esthetics of different types of composites but also the
technique to be used when selecting a restorative material.
Introduction
Direct composite restorative materials offer esthetic solutions for
clinicians and patients. Esthetic solutions must be achieved in
tandem with the functional requirements of strength, volumetric
and morphologic stability, physical compatibility with the sur-
rounding tooth structure, biocompatibility, and the ability either
to self-adhere to the tooth surface or to adhere with an adhesive
system for a durable bond at the tooth-restoration interface. Ad-
ditional desirable properties include the ability to inhibit bioflm
formation, thereby reducing the load of acidogenic and periodontal
bacteria; stain resistance; and user-friendliness. Ideally, a restor-
ative material will meet all these requirements, allowing it to be
used for both anterior and posterior restorations. While amalgam
fulflls the physical requirements for direct restorations,
1
is quicker
and easier to place than are esthetic restorative materials, is more
tolerant of moisture, and can now be hybrid-bonded with the use
of amalgam bonding techniques (which has reduced the need for
classical amalgam preparations, although results have been found
to be variable),
2,3
its lack of esthetic results means it is suitable
only for posterior restorations. Its use for posterior restorations
has also gradually declined
4
as patients have become increasingly
aware of esthetics and want the improved posterior esthetic ma-
terials that have become available in response to these demands.
Clinicians demand esthetic materials with improved physical and
handling properties. Physical requirements differ for anterior
and posterior restorations. Anterior restorations, especially those
involving incisal edges, require high strength as well as high es-
thetics. Posterior restorations have the added requirement of low
wear. Esthetic restorative materials must offer adequate shade
availability, suitable chroma and values, translucency, opacity,
opalescence, fuorescence, a smooth and glossy surface, and stain
and wear resistance.
Development of Composite Resins
When frst introduced in the 1970s, composite resins were utilized
only for anterior restorations.
5
These early variants were typi-
cally quartz-flled; did not meet the compressive and tensile force
requirements for posterior restorations; and had relatively high
surface roughness, low polishability, poor resistance to staining,
and poor bonding at the tooth-restoration interface, which, in
combination with polymerization shrinkage, resulted in margin
degradation and postoperative sensitivity. The choice of shades
was limited, and the materials, other than being tooth-colored,
offered poor esthetics with little or no differentiation of shading by
fuorescence, translucency, or intended location (such as cervical
shades for cervical restorations). In addition to these disadvantag-
es, early resin composites were diffcult to handle, required manual
mixing of the resin paste (A) and the catalyst (B), were available
only in tubs or syringes of pastes (A and B separately), and were
always self-cured with a limited working time. Over time, the
strength characteristics of composite resins were improved and
the resins were introduced for use in posterior restorations. These
materials were still unsuitable for posterior restorations in which
high compressive strength was required to resist occlusal and
masticatory forces. Wear resistance was also low. Bonding systems
were still primitive in the 1980s, with limited choice in technique.
Self-adhesive systems were not available and there was little choice
in terms of etching methods. The focus was still on enamel etch-
ing and bonding, and early attempts at dentin bonding resulted in
weak bonding to the smear layer and a rapidly degrading bond.
6
It
was also recommended that, after curing of the resin, the enamel-
restoration interface be re-etched and an unflled resin be placed
over this surface to seal it and help inhibit microleakage and
wear.
7,8
By the 1990s, posterior composite restorations were avail-
able that were better-suited to Class I and Class II restorations.
9

These enabled a more conservative approach during preparation
than amalgam did, and they were used with improved bonding
systems for improved marginal integrity at the tooth-restoration
interface.
Current composite materials (and bonding systems) are vastly
superior to earlier versions. Current materials are available with
several types of fllers, advanced enamel and dentin adhesive sys-
tems, and they offer strength, lower polymerization shrinkage and
stress, wear resistance, and excellent esthetics.
Current Composite Restorative Materials
Composite resin materials are currently available as microflled,
(micro)hybrid, and nanoflled composites. Their chemistry is
typically based on bisphenol-a-glycidyl dimethacrylate (Bis-
GMA); however, additive chemistry has been used to reduce
www.ineedce.com 3
polymerization shrinkage or stress, and the addition of various
sizes and types of fllers has altered physical and esthetic proper-
ties. Pre-polymerized clusters and increased fller load help reduce
polymerization shrinkage and stress, and increasing flled load also
results in a higher viscosity composite. Each composite type offers
advantages specifc to its chemistry. An understanding of these is
necessary to select an appropriate material for clinical procedures.
Microfilled Composite Resins
Microflled composite resins contain crushed particles ranging in
size from 0.04 to 1 micron. The fller particles are typically prepo-
lymerized particles comprised of resin and fumed silica. Filler load
is lower in microflled composite resins, and internal bonding be-
tween the matrix resin and the prepolymerized fller resin is weak,
resulting in lower strength. This is an important consideration in
stress-bearing areas. The very small particle sizes in microflled
resins, however, offer excellent esthetics with high polishability
and a long-lasting surface gloss.
Microhybrid/Hybrid Composite Resins
Microhybrid composite resins contain silicon dioxide fller with
particles ranging in size from approximately 0.04 up to 0.1 mi-
cron, and glass particle fllers typically range in size from 0.4 to 0.6
micron (400 to 600 nm). These resins lose their high polish over
time with the development of a rougher surface, reducing their
suitability for esthetically demanding cases. They do, however,
offer strong physical properties and are suitable for stress-bearing
restorations. Hybrid resins have slightly larger fller sizes than do
microhybrid resins and essentially behave in the same manner.
Nanofilled Composite Resins
Nanoflled composite resins have a high fller load in order to
obtain strength and wear resistance similar to that of micro-
hybrid composite resins. Nanoflled composite resins contain
smaller particles of fller in the range of 0.02 to 0.1 microns.
One nanoflled composite (Filtek Supreme Plus) contains
nanofller particles that are approximately 0.02 microns in
diameter, sintered into nanoclusters of 0.6 to 1.4 microns that
contain zirconia/silica particles, in order to improve physical
characteristics.
Table 1. Indications for composite resins
High-esthetic restorations Stress-bearing restorations
Microfilled X
Microhybrid X
Nanofilled X X
Flowable and Packable Composites
Another method of categorizing composite resin restorative
materials is by fow characteristics. Flowable composite resins
have a lower fller load and a low viscosity, enabling them to be
syringed directly into preparations, where they fow and conform
to the preparation margins. The fowable composites are used
extensively as a liner under posterior restorations and are also
used as an initial bulk layer for the sandwich technique, similar
to glass ionomer cements, that is then covered with a microflled
or nanoflled composite. They are also used in clinical situations
in which heavy stress-bearing is not a requirement. Packable
(universal) composites are denser and can be condensed using
plastic instruments during placement, prior to curing. One
study comparing a nanoflled composite resin with and without
an underlying layer of fowable composite after use of a two-step
(total etch) or single-step bonding technique found no statistical
differences in secondary caries, postoperative sensitivity, mar-
ginal discoloration or adaptation, or color at a two-year recall.
Both techniques were found to be clinically successful.
10
Pack-
able composites have been found to be clinically successful over
multiple-year analyses.
11
While clinical function and longevity of esthetic composites
are the frst prerequisites, optimizing esthetics is desirable and in-
creasingly demanded by patients for all direct composite restora-
tions. Surface smoothness, polishability, luster (surface gloss), and
specifc shade attributes and techniques all play important roles in
the achievement of optimal esthetics.
Optimizing Esthetics in Composites
The esthetics of composite restorations is infuenced by the shape
and contouring of the restoration, which must mimic the natural
tooth in order to provide a natural appearance. In the case of pos-
terior restorations, the use of sectional matrices has considerably
simplifed the achievement of functional and esthetic contours.
Beyond the requirements of contour and shaping, and the use
of an appropriate technique that avoids moisture contamination
and utilizes an appropriate bonding system, esthetics is deter-
mined by the availability and appropriate selection of shade(s)
the fuorescence and translucency, value (degree of lightness or
darkness), chroma (intensity of the shade), hue, ability to offer
a chameleon effect, polishability, wear resistance, retention of
gloss and polish, and technique. Each of these plays a role in
developing and maintaining optimal esthetics.
Table 2. Factors in optimized composite esthetics
Shape and contour mimicking natural dentition
Functional and esthetic contours
Use of an appropriate technique
Avoidance of moisture contamination
Use of an appropriate bonding system
Selection of appropriate shade(s)
Polishability of the restorative material
Wear resistance
Retention of gloss and polish
4 www.ineedce.com
Shades and Shade Selection
Composite resin systems are available with multiple shades. The
number of available shades depends on the brand selected and
typically includes a number of shades in the VITA A, B, C, and D
ranges to cover the hues, chroma, and values that will be required
for natural-looking direct composite restorations. Shades are also
available and categorized by translucency and opacity. Regardless
of the technique used, if teeth are stained, the staining should be
removed prior to selecting a shade(s). Shade selection also should
occur prior to placement of a rubber dam, since this will affect
perception of color due to color perception interference with the
rubber dam and because a desiccated tooth appears whiter than a
moist or wet tooth.
Opacity and Translucency
Different shades offer greater or lesser opacity, opalescence, and
translucency. Opacity is an important property for composites,
offering fexibility by enabling the creation of many shades,
ranging from very translucent, which is required for incisal edges
and outer multilayering, to highly opaque, which is required for
the body of a restoration replacing dentin.
12
Opacity is essential
for deeper restorations and restorations with a darker pulpal
foor/underlying area, in order to prevent shine-through of the
darkened dentin. In extreme cases, opaquers and tinters may be
required.
13
Selecting opaque and/or translucent shades can be
critical for the esthetic outcome of an individual case,
14
and more
chromatic shades have been found to be more opaque.
15
Controlling the size and volume of fller particles is a con-
tributing factor to light-scattering properties and therefore
the perceived color and translucency of composite resins.
16
A
matching of fller size and resin is essential for light transmission
in composite resins and translucency. Translucency increases
as the restorative material becomes thinner, irrespective of the
shade used a consideration when using a multilayering tech-
nique.
17
Filler size in composite resins has been found to infu-
ence the transmission and refection of color, and it results in
variations in translucency and opalescence. Opalescence varies
with the size and amount of the fller. In general, increased fller
load decreases translucency.
18
Nanosized fller particles enable
the transmission of light, resulting in translucency. Their ability
to scatter blue light provides the nanoflled composite with opal-
escence, which enhances the lifelike appearance of composite
resin materials.

Table 3. Influence of filler on esthetics and strength
Transmission of light
Reflection of color
Variations in translucency
Variations in opalescence
Low filler is less strong
Viscosity
Single-Shade, Dual-Shade, and Multilayering
Techniques
From a practical perspective, there is a need for composite resin
systems that offer the ability to provide esthetic restorations using
only one shade. Single-shade restorations are simpler and quicker
to place. Single-shade restorations require that the composite be
able to blend in with the surrounding tooth structure through a
chameleon effect, such that the gradation from different areas of
the tooths structure to the restoration is not obvious and results in
a natural-looking restoration.
More esthetically demanding clinical situations can require
a dual-shade or multilayering technique to mimic the adjacent
tooth structure. Dual-shade restorative procedures are suited to
situations in which there may be substantial variations in two
adjacent areas for example, for a darker cervical versus coronal
area, or for a highly translucent and wide incisal edge versus the
more opaque coronal area being restored. When using a dual-
shade technique, the dentin color (body of the tooth) should be
selected frst, followed by the enamel shade (and if a translucent
shade is also used, this should be chosen last). Dietschi et al.
reported on a shading concept that compared enamel and dentin
shades with the opacity and specifc color of teeth. After compar-
ing teeth with similar chroma (green-red/blue-yellow values), it
was found that only the blue-yellow values varied. Translucency
was found to be relatively constant for dentin, and it increased
with age in enamel. From these conclusions, a simplifed dual-
layering technique was developed the natural layering con-
cept that uses a universal dentin hue and one of three enamel
hues, depending on the age of the patient (young, adult, and
old).
19
Multilayering techniques are the most time-consuming
and complex, requiring more shades to be used, but they offer
the most esthetic solution for specifc cases. The blending effect
varies with the size of the restoration.
20
Advanced layering tech-
niques can also utilize color tints to modify composite shades,
such as for the creation of hypocalcifcation-like areas to mimic
adjacent teeth with hypocalcifcations where these are not being
treated.
21

It is important when using dual- or multiple-shade techniques
to use the same brand of composite and the shade guide for that
composite system. The translucency and shade of composites,
while almost universally using the VITA shade guide system for
labeling purposes, show variation across brands.
22
For multilayer-
ing techniques, the blending effect depends on both the specifc
brand of composite and the shades used.
23
Signifcant differences in
color, translucency, and fuorescence have also been found between
fowable and packable (universal) composites that were different
brands but labeled as the same shades.
24
Curing and polishing
change the color and translucency of a composite resin, again vary-
ing by brand and shade.
25,26,27
The shade guide, not uncured resin,
should be used for shade selection. Alternatively, recently cured
resin can be used.
28
It is also important to consider the availability
and quality of light within the daylight UV spectrum when select-
ing shades. As the daylight UV varies, so too does the perceived
color of composite resins
29
and teeth. The use of computerized
www.ineedce.com 5
shade guide determination through colorimetric analysis, together
with the use of multilayering with nanoflled composites, was
found in one study to result in improved esthetics.
30

In selecting a composite, suffcient shades should be available
in the same brand of composite to satisfy clinical requirements for
single-shade, dual-shade, and multilayering techniques. Either an
accurate match to the VITA Classical shade guide, or an accurate
custom shade guide must be available for the selected composites
shade system.
Table 4. Tips for Multilayering Techniques
Use the same brand of composite for all layers
Ensure the amount and quality of daylight is adequate for shade selection
Do not use uncured resin to determine shades
Use the VITA shade guide if the composite system accurately mimics this
Use a custom shade guide if the composite system has custom
shade labeling
Surface Attributes and Esthetics
Surface smoothness and retention of surface gloss are important
for function and esthetics.
31
A high-gloss, smooth surface refects
light, giving a more natural appearance. The scattering and ab-
sorption of light on rough surfaces results in a darker, duller ap-
pearance. The initial smoothness of composite resins is infuenced
by the fller particle size and the technique used for polishing and
fnishing the resin. Composite resins with smaller fller particles
are smoother and exhibit greater luster than do larger particle-size
flled resins, thus explaining the greater surface smoothness and
polish seen in both microflled and nanoflled composite resins.
Nanoflled composite resin containing nanoclusters has been
shown to exhibit high translucency, polishability, and gloss, and its
long-term polish is comparable to the characteristics of microflled
composite resins. Nanoflled translucent shades retained polish
better than did similar microflled shades.
32,33
Microhybrids are
not as glossy or smooth, but their polishability and esthetics have
been enhanced in recent years.
34
Polishing Composites
Composites can be polished using two-step or one-step systems.
These can include the use of silicon tips, Sof-Lex discs, rub-
ber cups, and polishing pastes and liquid polishers. Polishing
composites has been found to achieve the greatest improvement in
surface gloss within fve seconds of polishing.
35
One-step polish-
ing systems are suitable for nanocomposite polishing (Filtek
Supreme Plus (or XT outside of US); Grandio; CeramX; Premise;
and Tetric EvoCeram) as well as fowable restorative materials;
polishing results in a more stain-resistant surface.
36,37
Surface
sealants have been recommended for use following fnishing
and polishing in order to impart the smoothest surface.
38
It has
also been found that removing the outer surface layer during
polishing helps stain resistance.
39
The optimal polisher depends
on the specifc composite.
40

Table 5. Surface smoothness and polisher
Mylar PoGo OptraPol One Gloss
Filtek
Supreme
Plus
Smoother Smoother Rougher Rougher
Grandio Smoother Smoother Rougher Rougher
Tetric
EvoCeram
Less rough Roughest Less rough Less rough
Premise No significant differences
CeramX No significant differences
Source: Ergucu et al. Operative Dentistry, 2007.
It is therefore important to follow the manufacturers recom-
mendations for specifc composites.
Wear Resistance and Surface Roughness
Over time, surface roughness develops in response to abrasion (as
well as acid erosion) of composite surfaces. In vitro three-surface
wear testing and simulated cycles of toothbrushing are used to
measure the anticipated susceptibility of composite resins to in-
traoral abrasion from mastication or toothbrushing. In one study,
in vitrosimulated toothbrushing resulted in rougher surfaces in
microflled and microhybrid composites than it did in packable
composites, compomers, and resin-modifed glass ionomers. Pol-
ishing composite resins at recall appointments can help to reduce
surface roughness that has developed and to impart a smooth
surface.
41
Both the amount of surface wear and mechanism of wear
over time have been found to differ among resins. Surface roughness
is also positively correlated with staining of composites.
42
Very small particles contained in microflled resins result in
an even wear pattern and thus retention of a smoother surface.
The combination of nanofllers around nanoclusters results in
removal during wear of the very small nanoflled particles that
are packed in the nanocluster surface, again resulting in a more
even pattern of wear and a smoother surface. Scanning electron
micrographs (SEM) have demonstrated the removal of individual
small nanofller particles from larger zirconia-silica nanoclusters.
43

In contrast, SEMs of microhybrid resins show larger defects at the
surface following wear, proposed to be due to the removal of larger
individual particles that leave voids and a less even pattern of wear,
resulting in a rougher surface than observed with microflled and
nanoflled composites.
44

Figure 1. Scanning electron micrographs of composite fillers
Nanofiller Hybrid filler
Courtesy of Dr. Jorge Perdigao
6 www.ineedce.com
Surface wear results in loss of gloss followed by loss of the layer
below the gloss. In vitro data indicates that the microhardness
of a nanoflled composite (Filtek Supreme) is higher than that of
microflled composites, attributable to the fller.
45
The aging of esthetic restorative materials results in surface
changes and therefore changes in the light-scattering absorption
properties of glass ionomers, modifed glass ionomers, compom-
ers, and resin composites.
46
Aging of fowable composites has also
been found to result in more color changes compared to universal
composites.
47
Accelerated in vitro aging was found in one in vitro
study to result in the loss of translucency but not to affect opacity
of composite resins.
48
Bacterial Considerations
A smooth, glossy appearance is also important to reduce the po-
tential for bacterial adhesion and the accumulation of bioflm. In
vitro studies have found amalgam to be bactericidal and to inhibit
the formation of bioflm.
49,50
The converse has been found with
resin-based restorative materials, although, interestingly, the ex-
perimental addition of microparticulate silver to composite resin
material has been found in vitro to have a bactericidal effect as well
as to inhibit bacterial adhesion.
51
These fndings increase the impor-
tance of selecting a material that both achieves and retains a smooth
surface.
52
In vitro studies on packable resin composites, compomers
(polyacid-modifed composite resins), and glass ionomer cements
found no antibacterial properties for these materials, while one
found a minimal effect for a few days with composite resin.
53,54,55,56
In
the case of the packable composites tested, newly polymerized resin
would actually support the development of bioflm, and one study
found that bacteria formed a dense bioflm on composite resin.
57,58
Combining Strength and Esthetics
While predictable and reliable esthetics is important, this must
not result in compromised functionality. Microflled resins are
highly esthetic, suitable for anterior restorations in low stress-
bearing restorations. Microhybrid and nanoflled composites are
suitable for stress-bearing restorations. Some variability in the
mechanical properties of different nanoflled composites has been
found in in vitro testing.
59
Beun et al. compared the mechanical properties of nanoflled
(Filtek Supreme, Grandio, and Grandio Flow), microhybrid, and
microflled composites. The nanoflled composites had an elastic
modulus and physical properties at least equivalent or better than
those of universal composite and superior to those of microflled
composite.
60
One study comparing the properties of nanoflled
composite resin containing nanoclusters (Filtek Supreme Uni-
versal Restorative)

and microflled and hybrid resin composites
found that nanoflled/nanocluster composites offered physical
characteristics and strength comparable to those of microhybrid
composites. Physical characteristics measured and compared in-
cluded wear resistance also a factor in esthetics, compressive and
diametral strengths, and fracture resistance.
61
The same nanoflled
composite was found in other in vitro testing to have higher diame-
tral tensile strength than did microhybrid composites.
62
Latest Developments in Composite Resins
Recent developments in composite resin technology have included
reductions in polymerization shrinkage and in polymerization
stress. These have been achieved through increased fller loads and
novel chemical technology. Polymerization shrinkage, and there-
fore stress, has been reduced through the use of silorane-ring-based
chemistry (Filtek LS)
63
as well as by increasing conversion rate of
the monomer.
64
Direct reduction of polymerization stress has now
also been achieved through the use of a polymerization modulator
to reduce stress (SureFil SDR). A recent development has im-
proved esthetics in a high-strength, esthetic nanoflled composite.
Changes in the synthesis of nanoclusters in nanoflled composite
resin (Filtek Supreme Ultra) have demonstrated improved polish
retention and handling, while maintaining wear resistance, in in
vitro testing. The same material has fracture toughness equal to
that of the upper range of other composites, as well as high fexural
strength.
65

The cases below illustrate the use of this new nanoflled/nano-
cluster composite for single-shade and multilayering techniques.
Case Studies
Case 1. Multi-layering technique
The patient presented with an old, worn and defective composite.
After discussion, it was decided to replace the Class IV compos-
ite. The old composite was removed, followed by etching of the
enamel and dentin, rinsing and drying, then use of the bonding
agent. The composite (Filtek
TM
Supreme Ultra universal com-
posite) was then layered for optimal esthetics, using a thin layer of
WE, followed by A1 to create a dentin replacement layer at the
lobes. This was followed by application of grey translucent shade
between the lobes and B1 enamel shade. The fnal restoration was
polished using a Sof-Lex disc, followed by a cup brush and polish
for an esthetic, high gloss smooth surface fnish.
Figure 2. Old, worn composite restoration
Figure 3. Old composite removed
www.ineedce.com 7
Figure 4. Etchant applied
Figure 5. Bonding agent applied
Figure 6. Thin layer of WE against impression template
Figure 7. Cured lingual wall of WE
Figure 8. Application of B1 enamel
Figure 9. Final, polished restoration
Case 2. Single-shade restoration
In this case the patient presented with a carious DO lesion, visible
unaided as well as radiographically. The patient preferred an esthetic
composite restoration. After removing the carious enamel and den-
tin, the tooth was frst etched, rinsed and dried, and then the adhe-
sive layer applied. Shade A3 body was then used and the composite
resin syringed directly into the preparation. The composite was then
packed into the tooth and light-cured. Finishing of the restoration
was achieved using a fne diamond for fne occlusal contouring, fol-
lowed frst by a Sof-Lex disc and then a brush cup and polish.
Figure 10. Carious DO lesion
Figure 11. Etchant applied
Figure 12. Adhesive applied
8 www.ineedce.com
Figure 13. Nanofilled, nanocluster composite, shade A3, syringed into
preparation
Figure 14. Packing of composite into preparation
Figure 15. Final, esthetic single-shade posterior restoration
Summary
Esthetic composite restorations have gained popularity with pa-
tients and increased usage by clinicians. During the development
of composite restorations, several categories have been developed.
Current composites can be categorized as microflled, (micro)
hybrid, and nanoflled, as well as fowable and packable. Recent
developments in composite technology have resulted in improved
physical characteristics and improved esthetics, without compro-
mising strength. Each type of composite offers different physical
and esthetic characteristics that must be considered when selecting
a composite and technique for individual cases.
References
1 Roulet JF. Benefts and disadvantages of tooth-coloured alternatives to
amalgam. J Dent. 1997;25(6):459-73.
2 Setcos JC, Staninec M, Wilson NH. Bonding of amalgam restorations:
existing knowledge and future prospects. Oper Dent. 2000;25(2):121-9.
3 Mahler DB, Engle JH. Clinical evaluation of amalgam bonding in Class
I and II restorations. J Am Dent Assoc. 2000;131(1):43-9.
4 Burke FJ. Amalgam to tooth-coloured materials--implications for
clinical practice and dental education: governmental restrictions and
amalgam-usage survey results. J Dent. 2004;32(5):343-50.
5 Small BW. Direct resin composites for 2002 and beyond. Gen Dent.
2002;50(1):30-3.
6 Eliades GC, Caputo AA, Vougionklakis A. Composition, wetting
properties and bond strength with dentin of six new dentin adhesives.
Dent Mater. 1985; 1:1706.
7 Wilson EG, Mandradjieff M, Brindock T. Controversies in posterior
composite resin restorations. Dent Clin North Am. 1990 ;34(1):27-44.
8 Leinfelder KF. Using composite resin as a posterior restorative material.
J Am Dent Assoc. 1991;122(4):65-70.
9 Leinfelder KF. Using composite resin as a posterior restorative material.
J Am Dent Assoc. 1991 Apr;122(4):65-70.
10 Efes BG, Drter C, Gme Y, Koray F. Two-year clinical evaluation of
ormocer and nanofll composite with and without a fowable liner. J
Adhes Dent. 2006;8(2):119-26.
11 Kiremitci A, Alpaslan T, Gurgan S. Six-year clinical evaluation of
packable composite restorations. Oper Dent. 2009;34(1):11-7.
12 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in
advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.
13 Dias WR, Pereira PN, Swift EJ Jr. Maximizing esthetic results in
posterior restorations using composite opaquers. J Esthet Restor Dent.
2001;13(4):219-27.
14 Ikeda T, Sidhu SK, Omata Y, Fujita M, Sano H. Colour and translucency
of opaque-shades and body-shades of resin composites. Eur J Oral Sci.
2005;113(2):170-3.
15 Yu B, Lee YK. Infuence of color parameters of resin composites on
their translucency. Dent Mater. 2008;24(9):1236-42. Epub 2008 Mar
28.
16 Lee YK. Infuence of scattering/absorption characteristics on the color
of resin composites. Dent Mater. 2007 ;23(1):124-31. Epub 2006 Feb
17.
17 Kamishima N, Ikeda T, Sano H. Color and translucency of resin
composites for layering techniques. Dent Mater J. 2005;24(3):428-32.
18 Lee YK. Infuence of fller on the difference between the transmitted
and refected colors of experimental resin composites. Dent Mater.
2008;24(9):1243-7. Epub 2008 Mar 17.
19 Dietschi D, Ardu S, Krejci I. A new shading concept based on natural
tooth color applied to direct composite restorations. Quintessence Int.
2006;37(2):91-102.
20 Paravina RD, Westland S, Imai FH, Kimura M, Powers JM. Evaluation
of blending effect of composites related to restoration size. Dent Mater.
2006;22(4):299-307. Epub 2005 Aug 8.
21 Chalifoux PR. Composite tints: mixing composite materials to alter
color and techniques to simulate hypocalcifcation and craze lines.
Compend Contin Educ Dent. 2004;25(8):583-4, 586, 588 passim; quiz
592, 613.
22 Yu B, Lee YK. Translucency of varied brand and shade of resin
composites. Am J Dent. 2008;21(4):229-32.
23 Paravina RD, Westland S, Kimura M, Powers JM, Imai FH. Color
interaction of dental materials: blending effect of layered composites.
Dent Mater. 2006;22(10):903-8. Epub 2005 Dec 27.
24 Yu B, Lee YK. Differences in color, translucency and fuorescence
between fowable and universal resin composites. J Dent. 2008
Oct;36(10):840-6. Epub 2008 Jul 14.
25 Lee YK, Lim BS, Rhee SH, Yang HC, Powers JM. Color and
translucency of A2 shade resin composites after curing, polishing and
thermocycling. Oper Dent. 2005;30(4):436-42.
26 Lee YK, Lim BS, Rhee SH, Yang HC, Powers JM. Changes of optical
properties of dental nano-flled resin composites after curing and
thermocycling. J Biomed Mater Res B Appl Biomater. 2004;71(1):16-
21.
27 Lee YK, Lim BS, Rhee SH, Yang HC, Powers JM. Changes of optical
properties of dental nano-flled resin composites after curing and
www.ineedce.com 9
thermocycling. J Biomed Mater Res B Appl Biomater. 2004;71(1):16-
21.
28 Sidhu SK, Ikeda T, Omata Y, Fujita M, Sano H. Change of color
and translucency by light curing in resin composites. Oper Dent.
2006;31(5):598-603.
29 Lee YK, Kim JH, Ahn JS. Infuence of the changes in the UV component
of illumination on the color of composite resins.
J Prosthet Dent. 2007;97(6):375-80.
30 Milnar FJ. Selecting nanotechnology-based composites using
colorimetric and visual analysis for the restoration of anterior dentition:
a case report. J Esthet Restor Dent. 2004;16(2):89-100.
31 Koupis NS, Marks LA, Verbeeck RM, Martens LC.Review: fnishing
and polishing procedures of (resin-modifed) glass ionomers
and compomers in paediatric dentistry. Eur Arch Paediatr Dent.
2007;8(1):22-8.
32 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in
advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.
33 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in
advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.
34 Morgan M. Finishing and polishing of direct posterior resin restorations.
Pract Proced Aesthet Dent. 2004;16(3):211-7.
35 Heintze SD, Forjanic M, Rousson V. Surface roughness and gloss of
dental materials as a function of force and polishing time in vitro. Dent
Mater. 2006;22(2):146-65.
36 Ergc Z, Trkn LS, Aladag A. Color stability of nanocomposites
polished with one-step systems. Oper Dent. 2008;33(4):413-20.
37 Ozel E, Korkmaz Y, Attar N, Karabulut E. Effect of one-step polishing
systems on surface roughness of different fowable restorative materials.
Dent Mater J. 2008;27(6):755-64.
38 Attar N. The effect of fnishing and polishing procedures on the
surface roughness of composite resin materials. J Contemp Dent Pract.
2007;8(1):27-35.
39 Ergc Z, Trkn LS, Aladag A. Color stability of nanocomposites
polished with one-step systems. Oper Dent. 2008;33(4):413-20.
40 Ergc Z, Trkn LS. Surface roughness of novel resin composites
polished with one-step systems. Oper Dent. 2007;32(2):185-92.
41 Neme AL, Frazier KB, Roeder LB, Debner TL. Effect of prophylactic
polishing protocols on the surface roughness of esthetic restorative
materials. Oper Dent. 2002;27(1):50-8.
42 Lu H, Roeder LB, Lei L, Powers JM. Effect of surface roughness
on stain resistance of dental resin composites. J Esthet Restor Dent.
2005;17(2):102-8; discussion 109.
43 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in
advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.
44 Ibid.
45 Barros BACD, Lopes GC, Baratieri LN, Araujo E. Surface microhardness
of different resin composites. IADR; Abstact 0574;2004.
46 Lee YK, Lim BS, Rhee SH, Yang HC, Lim YK. Changes in scattering
and absorption properties of esthetic flling materials after aging. J
Biomed Mater Res B Appl Biomater. 2007;80(1):131-9.
47 Yu B, Lee YK. Comparison of the color stability of fowable and
universal resin composites. Am J Dent. 2009;22(3):160-4.
48 Lee YK, Lu H, Powers JM. Changes in opalescence and fuorescence
properties of resin composites after accelerated aging. Dent Mater.
2006 Jul;22(7):653-60.
49 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial
analysis of amalgam and composite resins. J Dent. 2007;35(3):201-6.
50 Willershausen B, Callaway A, Ernst CP, Stender E. The infuence of
oral bacteria on the surfaces of resin-based dental restorative materials:
an in vitro study. Int Dent J. 1999;49(4):231-9.
51 Brgers R, Eidt A, Frankenberger R, Rosentritt M, Schweikl H, Handel
G, Hahnel S. The anti-adherence activity and bactericidal effect of
microparticulate silver additives in composite resin materials. Arch
Oral Biol. 2009;54(6):595-601. Epub 2009 Apr 16.
52 Quirynen M, Bollen CM. The infuence of surface roughness and
surface-free energy on supra- and subgingival plaque formation in
man. A review of the literature. J Clin Periodontol. 1995;22(1):1-14.
53 Matalon S, Slutzky H, Weiss EI. Surface antibacterial properties of
packable resin composites: part I. Quintessence Int. 2004;35(3):189-
93.
54 Matalon S, Weiss EI, Gozaly N, Slutzky H. Surface antibacterial
properties of compomers. Eur Arch Paediatr Dent. 2006;7(3):136-41.
55 Slutsky H, Weiss EI, Lewinstein I, Slutzky S, Matalon S. Surface
antibacterial properties of resin and resin-modifed dental cements.
Quintessence Int. 2007;38(1):55-61.
56 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial
analysis of amalgam and composite resins. J Dent. 2007;35(3):201-6.
57 Matalon S, Slutzky H, Weiss EI. Surface antibacterial properties of
packable resin composites: part I. Quintessence Int. 2004;35(3):189-
93.
58 Willershausen B, Callaway A, Ernst CP, Stender E. The infuence of
oral bacteria on the surfaces of resin-based dental restorative materials:
an in vitro study. Int Dent J. 1999;49(4):231-9.
59 Mota EG, Oshima HM, Burnett LH Jr, Pires LA, Rosa RS. Evaluation of
diametral tensile strength and Knoop microhardness of fve nanoflled
composites in dentin and enamel shades. Stomatologija. 2006;8(3):67-
9.
60 Beun S, Glorieux T, Devaux J, Vreven J, Leloup G. Characterization
of nanoflled compared to universal and microflled composites. Dent
Mater. 2007;23(1):51-9.
61 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in
advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.
62 Lopes GC, Zucco J, De Lucca C, Baratieri L, Vieira L. Diametral tensile
strength of micro-hybrid composite resins. IADR; Abstact 0585;2004.
63 Ilie N, Jelen E, Clementino-Luedemann T, Hickel R. Lowshrinkage
composite for dental application. Dent Mater J. 2007;26(2):149-55.
64 Bracho-Troconis C, Rudolph S, Boulden J, Wong N. Conversion vs.
Shrinkage of NDurance, Dimer Acid based Nanohybrid Composite.
IADR. 2008, Rotonto July 1-4. Abstract 1812.
65 Kobussen GA, Craid BD, Halvorson RH, Doruff MC, Bigham WS.
Optical Properties of an Experimental Highly Aesthetic Composite
Restorative. IADR 2009, April 1 3, Miami. Avstract 1508.
Author Profile
Robert C. Margeas, DDS, FAGD
Dr. Margeas graduated from the University of Iowa College
of Dentistry in 1986 and completed his AEGD residency
the following year. He is currently an adjunct professor in
the department of Operative Dentistry at the University of
Iowa. He is Board Certifed by the American Board of Op-
erative Dentistry. He is a Diplomate of the American Board of Aesthetic
Dentistry , a Fellow of the Academy of General Dentistry and International
Team of Oral Implantologists (ITI). He has written numerous articles on
esthetic and implant dentistry, and lectures and presents hands-on courses
nationally and internationally on those subjects. He serves on the Editorial
Advisory board of Inside Dentistry, Compendium, and is a contributing
editor to Dentistry Today and Oral Health in Canada. Dr. Margeas main-
tains a full-time private practice focusing on comprehensive restorative and
implant dentistry in Des Moines, Iowa.
Disclaimer
Dr. Margeas has been a speaker on behalf of 3M ESPE as well as
other composite manufacturers.
Reader Feedback
We encourage your comments on this or any PennWell course.
For your convenience, an online feedback form is available at www.
ineedce.com.
Online Completion
Use this page to review the questions and answers. Return to
www.ineedce.com and sign in. If you have not previously purchased
the program select it from the Online Courses listing and complete the
online purchase. Once purchased the exam will be added to your Archives
page where a Take Exam link will be provided. Click on the Take Exam link,
complete all the program questions and submit your answers. An immedi-
ate grade report will be provided and upon receiving a passing grade your
Verifcation Form will be provided immediately for viewing and/or printing.
Verifcation Forms can be viewed and/or printed anytime in the future by
returning to the site, sign in and return to your Archives Page.
Questions
1. Esthetic solutions for restorations must be
achieved in tandem with _______________.
a. the functional requirements of strength
b. physical compatibility with the surrounding tooth
structure
c. volumetric and morphologic stability
d. all of the above
2. The use of amalgam for posterior restorations
has gradually increased in recent years.
a. True
b. False
3. Early composite resins _______________.
a. were typically quartz-flled
b. did not meet the compressive and tensile force require-
ments for posterior restorations
c. had high surface roughness and low polishability
d. all of the above
4. Early posterior composite materials were still
unsuitable for posterior restorations in which
high compressive strength was required to
resist occlusal and masticatory forces.
a. True
b. False
5. Composite resin is currently available as
_______________ composite.
a. microflled
b. microhybrid
c. nanoflled
d. all of the above
6. The addition of various sizes and types of
fllers has altered the physical and esthetic
properties of composites.
a. True
b. False
7. Microflled composite resins
_______________.
a. contain crushed fller particles, typically prepolymer-
ized and comprised of resin and fumed silica
b. have a lower fller load than microhybrid composite
resins
c. offer high polishability and excellent esthetics
d. all of the above
8. Microhybrid composite resins
_______________.
a. develop a rougher surface over time
b. offer strong physical properties
c. are suitable for stress-bearing restorations
d. all of the above
9. Nanoflled composite resins have high fller
loads in order to obtain strength and wear
resistance similar to that of microhybrid
composite resins.
a. True
b. False
10. Flowable composite resins _______________.
a. have lower fller loads than packable composites
b. fow and conform to the preparation margins
c. have a high viscosity
d. a and b
11. One study comparing restorations using
nanoflled composite resin with and without
an underlying layer of fowable composite
found both to be clinically successful.
a. True
b. False
12. The value of a composite shade refers to the
_______________.
a. use of hues
b. degree of lightness or darkness
c. the opacity of the shade
d. none of the above
13. Chroma refers to the _______________.
a. color of a shade
b. opalescence of a shade
c. intensity of a shade
d. none of the above
14. If teeth are stained, the staining should be
removed prior to selecting a shade(s).
a. True
b. False
15. Selecting a shade while a rubber dam is on
the teeth can affect the choice of shade due to
the _______________.
a. altered color perception because of the infuence of the
rubber dam itself
b. altered appearance of dessicated teeth
c. altered number of teeth that are visible
d. a and b
16. Opacity in a composite _______________.
a. enables the creation of many shades ranging from
opaque to highly translucent
b. is higher in more chromatic shades
c. is essential for deeper restorations
d. all of the above
17. Selecting opaque and/or translucent shades
can be critical for the esthetic outcome of an
individual case.
a. True
b. False
18. The size and volume of fller particles in a
composite resin _______________.
a. contributes to light-scattering properties
b. infuences the perceived color
c. infuences the perceived translucency
d. all of the above
19. Nanosized fller particles _______________.
a. enable the transmission of light
b. scatter blue light
c. enhance the lifelike appearance of composite resin
materials
d. all of the above
20. In general, increased fller load decreases
translucency.
a. True
b. False
21. Single-shade restorations _______________.
a. require that the composite be able to blend in with the
surrounding tooth structure
b. are quicker and simpler to place than dual or multiple
shade restorations
c. are rarely practical
d. a and b
22. When using a dual shade technique, the
dentin color should be selected frst, followed
by the enamel shade and then, if used, the
translucent shade.
a. True
b. False
23. Multilayering techniques _______________.
a. require the most shades
b. are the most time-consuming and complex
c. offer the most esthetic solution for specifc cases
d. all of the above
24. It is important when using dual- or
multiple-shade techniques to use the same
brand of composite and the shade guide for
that composite system.
a. True
b. False
25. Shade selection for a composite can be
determined using _______________.
a. the shade guide or uncured resin
b. uncured or cured resin
c. the shade guide or cured resin
d. the shade guide for a glass ionomer
26. A high-gloss, smooth surface
_______________.
a. refects light
b. results in an appearance that is not as dark or dull as a
rough surface
c. gives a more natural appearance
d. all of the above
27. The combination of nanofllers around
nanoclusters has been shown to result in a more
even pattern of wear and a smoother surface.
a. True
b. False
28. In vitro data indicates that the microhard-
ness of a nanoflled composite is higher than
that of microflled composites, attributable to
the fller.
a. True
b. False
29. A smooth, glossy surface can reduce the
potential for bacterial adhesion and the
accumulation of bioflm.
a. True
b. False
30. Each type of composite offers different
physical and esthetic characteristics that must
be considered when selecting a composite and
technique for an individual case.
a. True
b. False
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
For IMMEDIATE results,
go to www.ineedce.com to take tests online.
Answer sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
Payment of $59.00 is enclosed.
(Checks and credit cards are accepted.)
If paying by credit card, please complete the
following: MC Visa AmEx Discover
Acct. Number: _______________________________
Exp. Date: _____________________
Charges on your statement will show up as PennWell
If not taking online, mail completed answer sheet to
Academy of Dental Therapeutics and Stomatology,
A Division of PennWell Corp.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
AGD Code 253
AUTHOR DISCLAIMER
Dr. Margeas has been a speaker on behalf of 3MESPE as well as other composite manufacturers.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant from3MESPE.
No manufacturer or third party has had any input into the development of course content.
All content has beenderivedfromreferences listed, andor the opinions of clinicians. Please
direct all questions pertaining to PennWell or the administration of this course to Machele
Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com.
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be sure to complete the
survey included with the course. Please e-mail all questions to: macheleg@pennwell.com.
INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confrmation of passing by receipt of a verifcation
form. Verifcation forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efcacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily refect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the feld related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
COURSE CREDITS/COST
All participants scoring at least 70%(answering 21 or more questions correctly) on the
examination will receive a verifcation form verifying 4 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
credit. Please contact PennWell for current term of acceptance. Participants are urged to
contact their state dental boards for continuing education requirements. PennWell is a
California Provider. The California Provider number is 4527. The cost for courses ranges
from $49.00 to $110.00.
Many PennWell self-study courses have been approved by the Dental Assisting National
Board, Inc. (DANB) and can be used by dental assistants who are DANB Certifed to meet
DANBs annual continuing education requirements. To fnd out if this course or any other
PennWell course has been approved by DANB, please contact DANBs Recertifcation
Department at 1-800-FOR-DANB, ext. 445.
RECORD KEEPING
PennWell maintainsrecordsof your successful completion of any exam. Pleasecontact our
ofces for a copy of your continuing education credits report. This report, which will list
all credits earned to date, will be generated and mailed to you within fve business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100%satisfed with this course can request a full refund by
contacting PennWell in writing.
2009 by the Academy of Dental Therapeutics and Stomatology, a division
of PennWell
COMP119PAT
Educational Objectives
1. Know the categories of composite resin restorative materials available and their characteristics and indications for use.
2. Know the modes of failure for composite resin restorative materials.
3. Know the shade considerations involved in the attainment of esthetics in composite resin restorations and the use of
diferent shading and layering techniques.
4. Know the relevance of a smooth surface and gloss as well as polishability, and factors infuencing these.
Course Evaluation
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No
Objective #2: Yes No Objective #4: Yes No
2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0
3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0
4. How would you rate the objectives and educational methods? 5 4 3 2 1 0
5. How do you rate the authors grasp of the topic? 5 4 3 2 1 0
6. Please rate the instructors efectiveness. 5 4 3 2 1 0
7. Was the overall administration of the course efective? 5 4 3 2 1 0
8. Do you feel that the references were adequate? Yes No
9. Would you participate in a similar program on a diferent topic? Yes No
10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
11. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
___________________________________________________________________
12. What additional continuing dental education topics would you like to see?
___________________________________________________________________
___________________________________________________________________
ANSWER SHEET
Composite Restoration Esthetics
Name: Title: Specialty:
Address: E-mail:
City: State: ZIP: Country:
Telephone: Home ( ) Ofce ( )
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822
Please check here if you wish to receive future communications from
the sponsor of this course, 3M ESPE
Customer Service 216.398.7822