COSMETIC & RESTORATIVE CARE

An alternative method to reduce polymerization

shrinkage in direct posterior composite restorations
SIMONE DELIPERI, D.D.S.; DAVID N. BARDWELL, D.M.D., M.S.

Spreafico RC, Gagliani M. Composite resin restorations

on posterior teeth. InAdhesion
The silent revolution in dentistry. Chicago: Quintessence;
2000:253-76.

Yoshikawa T, Sano H, Burrow MF, Tagami J, Pashley

DH. Effects of dentin depth and cavity configuration
on bond strength.
J Dent Res 1999;78:898-905.

In three decades ago resine-based composite

was..

Wear resistance
Micro leakage
Secondary caries
Lack of appropriate proximal contact

In the past 10 years

dramatic improvement in newer-generation bonding
agents and resin-based composite formulations

Significantly improved wear resistance

good proximal contact and contour
polymerization shrinkage remains the
biggest challenge

Polymerization shrinkage

formation of a gap between resin-based

composite and the cavity wall
1.67 to 5.68 percent of the total volume
postoperative sensitivity and recurrent
caries
bonding failure

Stress from polymerization shrinkage is

influenc by

restorative technique
modulus of resin elasticity
polymerization rate
cavity configuration or C-factor.

C-factor is

ratio between bonded and unbonded

surfaces
an increase in this ratio results in
increased polymerization stress
-Three-dimensional cavity preparations (Class I) have the
highest (most unfavorable)

To minimize the stress from polymerization

shrinkage

improving placement techniques

improving material and composite
formulation
curing methods

Placement techniques and issues.

 The incremental technique

Direct shrinkage
Bulk technique

The incremental technique

polymerizing with resin-based composite
layers less than 2-millimeters thick
achieve good marginal quality
prevent distortion of the cavity wall
ensure complete polymerization of the
resin-based composite

 Horizontal technique
occlusogingival layering
generally used for small restorations
increases the C-factor.

 Three-site technique
clear matrix and reflective wedges
guide the polymerization vectors toward the
gingival margin.

 Oblique technique
wedge-shaped composite increments
prevent distortion of cavity walls and reduce
the C-factor
polymerization first through the cavity walls
and then from the occlusal surface
direct vectors of polymerization toward the
adhesive surface (indirect polymerization
technique)

 Successive cusp buildup technique

the first composite increment is applied to
a single dentin surface without contacting
the opposing cavity walls
And then wedge-shaped composite
increments
Each cusp then is built up separately
to minimize the C-factor in 3-D cavity
preparations

Figure 1. Schematic representation of wedge-shaped

composite increments (1-6) used to build up the enamel
proximal surface. F: Facial aspect. L: Lingual aspect.

Figure 2. Schematic representation of the flowable

composite increment (1) and wedge-shaped increments
(2-7) used to build up dentin;two increments (8 and 9)
are used to build up enamel using the successive cusp
buildup technique. F: Facial aspect. L: Lingual aspect.

Resin-based composite materials &

Dentin-enamel adhesive systems

Resin-based composite materials

By experimenting with particle size, shape and volume,
manufacturers have introduced resin-based composites with
differing physical and handling properties

microfill,
hybrid
microhybrid
packable
flow-able

TABLE 1

RESIN-BASED COMPOSITE CLASSIFICATION AND PHYSICAL PRPERTIES.

COMPOSITE
TYPE

AVERAGE PARTICLE
SIZE
(MICROMETERS)

FILLER
PERCENTAGE
(VOLUME %)

Wear
Resistance

Fracture
Toughness

polishability

0.04-0.01

35-50

1-3

70-77

F-G+

Microhybrid

0.4-0.8

56-66

Packable

0.7-20

48-65

P-G+

P-E+

Flowable

0.04-1

44-54

F-G+

Microfill
Hybrid

E: Excellent G: good F: fair P:poor

+

Varying among the same type of resin-based composite

PHYSICAL PROPERTIES

TABLE 2

CLINICAL INDICATIONS OF RESIN-BASED COMPOSITES.

COMPOSITE TYPE

CLINICAL INDICATIONS

Microfill

Enamel replacement in Class III, IV and V restorations

Minimal correction of tooth form and localized
discoloration

Hybrid

Posterior resin-based composite restoration

Class V restoration
Dentin build-up in Class III and IV restoration

Microhybrid

Posterior and anterior direct composite restoration

Veneer
Correction of tooth form and discoloration

Packable

Posterior resin-based composite restoration

Flowable

Pit and fissure restoration

Liner in Class I, II and V restoration (dentin)

Dentin-enamel adhesive systems

Bonding to dentin introduced more recently and has improved over
the years

contemporary DAS(dentin-enamel adhesive

systems) around 22 Mpa
early bond strength to dentin ranged from 1 to 10
megapascals

..

Curing methods

soft-start polymerization
soft-start polymerization

(Miyazaki et al.)

composite exhibited improved physical properties

when cured at a low intensity and with slow
polymerization vs. higher intensity and faster
polymerization

 initially uses low-intensity curing

for a short period to provide sufficient
network formation on the top composite
surface

delaying
until the gel point

final high-intensity polymerization

 highly mineralized tissue (Enamel)

resulting in a lower flexibility and decreased ability in relief of
shrinkage stress

highC-factor restorations
high-modulus composites
transmit more polymerization shrinkage forces to the tooth

TABLE 3
RECOMMENDED PHOTOCURING INTENSITIES AND TIMES FOR ENAMEL AND DENTIN
BUILDUP.
BUILDUP
LOCATION

COMPOSITE SHADE
(PRODUCT NAME)

Proximal
Enamel

Pearl Smoke Pearl

Neutral/Pearl Frost
(Vitalescence)

Dentin

A2 (flowable, PermaFlo)
A3.5-A3-A2-A1 (Vitalescence)

Occlusal
Enamel

Pearl Smoke/Pearl
Neutral/Pearl Frost Trans
Smoke/Trans Mist/Trans
Frost (Vitalescence)

POLYMERIZATION
TECHNIQUE

INTENSITY
MW/CM2)

Pulse

200 (300)

Progressive curing

(300)

Pulse

200 (600)

Vitalescence and PermaFlo are manufactured by Ultradent Products Inc., South Jordan, Utah.
mW/cm2: Milliwatts per square centimeter.

Intensity at first polymerization (intensity after waiting period).

Photocuring time at first polymerization (time after waiting period).

INTENSITY
MW/CM2)
3 (40)

(40)

3 (10 occlusal],
10 [facial], 10
[palatal])

Figure 3. Preoperative occlusal view

of tooth no. 3.

Figure 4. Tooth no. 3 after a rubber dam was placed,

caries was removed and the cavity preparation was
completed with a gingival butt joint and no bevel either
on the axial or occlusal surface

Figure 5. A matrix was placed to protect adjacent

tooth structure during cavity preparation and etching.
Then etching was performed using 35 percent
phosphoric acid.

Figure 6. Enamels and dentins glossy

appearances after application of a
fifth-generation, 40 percent filled
ethanol-based adhesive system.

Figure 7. A sectional matrix, plastic

wedge and G-ring placed to
reconstruct the proximal surface.

Figure 8. Tooth no. 3 after the enamel

proximal surface was built up using
the Pearl Neutral enamel shade of the
microhybrid composite (Vitalescence,
Ultradent Products Inc., South Jordan,
Utah).

Figure 9. Tooth no. 3 after the sectional matrix, plastic

wedge and G-ring were removed and the A2 shade of the
flowable composite (PermaFlo, Ultradent Products Inc.,
South Jordan, Utah) was applied to a single dentin
surface.

Figure 10. A and B. Tooth no. 3 after wedge-shaped

composite increments of A3. 5, A3 and A2 shades of the
microhybrid composite (PermaFlo, Ultradent Products Inc.,
South Jordan, Utah) were used to reconstruct dentin

Figure 11. Tooth no. 3 after Pearl Neutral

enamel shade of the microhybrid composite
(Vitalescence, Ultradent Products Inc., South
Jordan, Utah) was used to build up the occlusal
surface according to the successive cusp
buildup technique.

Figure 12. Postoperative occlusal view

of tooth no. 3.

Before

After

To minimize the stress from polymerization

shrinkage

improving placement techniques

placing successive layers of wedgeshaped composite(1- to 1.5-mm) to
decrease the C-factor

To minimize the stress from polymerization

shrinkage

improving material and composite

formulation
select different composite materials
to restore dentin (flowables and
microhybrids) and enamel
(microhybrids)

To minimize the stress from polymerization

shrinkage

curing methods
soft-start polymerization

EXPERIMENTAL
REVIEW

ARTICLE

Thesuitabilityofpackableresinbased
compositesforposteriorrestorations

 Modulus of elasticity
Vickers hardness
Depth of cure
Scraping
Producing a hardness profile

TABLE 1

RESTORATIVE MATERIALS INVESTIGATED.

MATERIAL
CATEGORY

BRAND
NAME

SHADE

FILLER
VOLUME
(%)

FILLER
WEIGH
T (%)

AVERAGE
FILLER
SIZE (m)

MANUFACTURER

Solitaire

A20

90

66

2.0 - 20

Heraeus Kulzer,
Wehrheim, Germany

Definite

A2

61

77

1.0

Degussa AG, Hanau,

Germany

SureFil

A2

66

82

0.8

Dentsply De Trey,
Konstanz, Germany

Alert

A2

70

84

0.7 (glass
fibers: 60 80)

Jeneric/Pentron,
Wallingford, Conn.

Hybrid
Composite

Tetric
Ceram

A2

60

78

0.7

Ivoclar Vivadent,
Schaan,
Liechtenstein

IonReleasing
Composite

Ariston
pHc

universal

59

79

1.3
(alkaline
glass: 1.6)

Ivoclar Vivadent,
Schaan,
Liechtenstein

Packable
Resin-Based
Composite

* Based on information from individual manufacturers.

+ micrometer.

TABLE 2
MEAN VALUES AND STANDARD DEVIATIONS.
COMPOSITE
MATERIAL

ELASTIC
MODULUS
(GPa)

VICKERS
CURING DEPTH (mm*)

HARDNESS (HV
By Producing
By Scraping
0.2/40)
Hardness Profile

Solitaire

4.4 (0.3)a

41.7 (3.5)a

3.0 (0.2)c,d

2.6 (0.2)a,b

Definite

6.3 (0.9)b

65.8 (1.6)c

2.5 (0.0)a,b

2.6 (0.3)a,b

SureFil

9.3 (0.9)c

70.4 (9.0)c,d

2.7 (0.3)b,c

2.8 (0.3)b

12.5 (2.1)d

75.2 (10.9)d

3.5 (0.6)e

3.5 (0.4)c

Tetric Ceram

6.8 (0.5)b

54.8 (1.1)b

3.2 (0.3)d,e

2.9 (0.2)b

Ariston pHc

7.3 (0.8)b

66.5 (2.6)c

2.2 (0.3)a

2.3 (0.3)a

Alert

*Superscript letters indicate statistically homogeneous subsets (Tukey test, = .05).

Manufacturers are as follows: Solitaire, Heraeus Kulzer, Wehrheim, Germany; Definite, Degussa AG, Hanau, Germany;
Surefil, Dentsply De Trey, Konstanz, Germany; Alert, Jeneric/Pentron; Tetric Ceram and Ariston pHc, Ivoclar Vivadent,
Schaan, Liechtenstein.

GPa: Gigapascal.

HV: Vickers hardness.

**mm: Millimeters.

Figure. Determination of
curing depth of the tested
materials by scraping vs.
producing a hardness profile

(r2 = 0.9945). mm: Millimeters.

Manufacturers are as follows: Ariston pHc
and Tetric Ceram, Ivoclar Vivadent,
Schaan, Liechtenstein; Definite, Degussa
AG, Hanau, Germany; Solitaire, Heraeus
Kulzer, Wehrheim, Germany; SureFil,
Dentsply De Trey, Konstanz, Germany;
Alert, Jeneric/Pentron.

CONCLUSIONS

Packable composites that are promoted

for the restoration of stress-bearing
posterior carious lesions are quite
different in their mechanical and physical
properties