THE SPECTRUM OF COMPOSITES:NEW TECHNIQUES AND MATERIALS

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

A B S T R A C T

Background. During the past 25 years, Clinical Implications. This article

advances in adhesive technology and composite-based reviews advances in composite-based resin materi-
resins have provided dentists and patients with new als. It discusses composition and classification of
treatment options. This technology provides patients current resin-based composite. It also reviews tech-
with more tooth-conserving and highly esthetic niques for successful placement of these materials
restorations. and provides a discussion of current concepts of po-
lymerization.

The introduction of composite-based resin tech- Some adhesives combine the etching with the
nology to restorative dentistry was one of the priming steps, resulting in the so-called “self-
most significant contributions to dentistry in the etching primers,” which simultaneously etch and
last century. The advantages of bonded restora- infiltrate enamel and dentin. Other adhesives,
tions include conservation of sound tooth struc- “single-bottle primer/adhesives,” etch tooth struc-
ture, reduction of microleakage, prevention of ture followed by a combined priming and bonding
postoperative sensitivity, marginal staining and step. Nevertheless, the long-term efficacy of
recurrent caries, transmission and distribution of these simplified systems needs to be proven.1
functional stress across the bonding interface to
COMPOSITE-BASED RESINS
the tooth. Bonded restorations also offer the
potential for tooth reinforcement (deteriorated By definition a composite is a material that con-
restorations can be repaired with minimal or no sists of two or more components. Typically a den-
additional loss of tooth material), cosmetic tal resin composite contains an organic binder
restoration and recontouring of teeth with little and an inorganic filler incorporated into a system
or no preparation, and diminished need for use of that would induce polymerization. Usually the
liners and bases.1 filler particles are coated with a coupling agent
Today, improvements in formulations, opti- to bond to the resin matrix.2
mization of properties and the development of Change of size and filler-loading has improved
new techniques for placement have made the the wear resistance of the early composite resins.
restoration of direct composite more reliable and Modern composite systems contain filler such as
predictable. quartz, colloidal silica, silica glass containing
This article discusses the range of new materi- barium, strontium and others. This filler
als used in composite-based resins, as well as increases strength and modulus of elasticity and
new techniques for using them. reduces the polymerization shrinkage, the coeffi-
cient of thermal expansion, and the water
ADHESION
sorption.3
Conventional adhesives work in three steps— The generalized wear behavior of composite-
etching, priming and bonding. In an effort to based resins has become less and less important
simplify bonding procedures, recently manufac- compared to other criteria. A major drawback of
turers have tried to eliminate or combine steps. current composite-based resins is that they con-

26S JADA, Vol. 131, June 2000

Copyright ©1998-2001 American Dental Association. All rights reserved.
tract or shrink during conver- in various con-
sion from monomer to polymer. centrations to
The resin matrix of all compos- dilute them.
ite-based resin restorative Multiple
materials shrinks volumetrical- fillers are used
ly approximately 10 percent in composite-
during polymerization.4 This based resins.
polymerization stresses the The first com-
adhesive between the tooth and posite-based
the restorative material, fre- dental resins
quently resulting in failure of were based on
this bond. This marginal break- pure silica;
down results in marginal infil- because of the
tration.5 Shrinkage is markedly hardness of this
reduced by the incorporation of material, it was
filler particles and, therefore, difficult to pro- Figure 1. Scanning electron micrograph of a hybrid
the higher the filler loading, the duce small par- resin-based composite (Esthet-X, Dentsply Caulk).
Numerous resin-based composites are now avail-
less shrinkage should take ticles and the able with smaller and more polishable distribution
place. final polymer- of particles (magnification × 10,000).
ized composite
CLASSIFICATION OF
COMPOSITE-BASED
was difficult to finish and pol- the filler percentage increases.
RESINS ish. To circumvent the hardness Reducing the size of the filler
problem, aluminum and lithium particle also enhances the pol-
Modern composite-based resins are used; barium, zinc, boron ishability of the composite.
are composed of a resin or and yttrium are used to impart Particle size has been contin-
matrix, fillers, and interfacial radiolucency. Ytterbium fluo- uously reduced since the advent
phase to couple the filler with ride is also incorporated to ren- of composite-based resin.
the matrix and initiators for der fluoride-releasing compos- Earlier dental composite-based
polymerization. ites; however, fluoride is resins used the average particle
The matrix phase is com- released in small amounts. The size of about 20 micrometers.
silica glasses are covered with Modern composite-based resins
silane coupling agents, difunc- use particles averaging from
A number of
tional molecules, which bond less than 1 to 0.1 µm in combi-
commercially with the silica’s hydroxyl nation with fumed silica parti-
available composite- groups in one end and with the cles of 0.04 µm, as in hybrid
double bond of the monomer composite-based resins, or
based resins lack
matrix in the other end. The fumed silica alone, as in com-
the necessary filler is the portion of the com- posite-based microfill resins.
radiopacity. posite-based resin that primari- The filler, the resin, the poly-
ly affects its properties. The merization process and water
size has a direct effect on sur- sorption also influences the
face roughness and in the optical properties of the final
posed of organic difunctional amount of filler capable of being composite.6
monomers. Most commercially incorporated. Use of small par- Composite-based resins can
available composite-based ticles results in an increase in be classified according to their
resins contain bisphenol-A gly- surface area, which impedes particle size7:
cidyl methacrylate, urethane higher loading. The amount of dmacrofilled—more than 10
dimethacrylate or modified ure- filler affects the physical prop- µm up to 100 µm;
thane dimethacrylate. Because erties, and as a general rule the dmidsize filled—less than 10
these monomers are extremely higher the loading, the higher and more than 1 µm;
viscous for their use in com- the strength of the final com- dminifilled—less than 1 and
posed-based resins, triethylene posite-based resin restoration. more than 0.1 µm;
glycol dimethacrylate is added Viscosity is also increased as dmicrofilled—less than 0.1 µm.

JADA, Vol. 131, June 2000 27S

Copyright ©1998-2001 American Dental Association. All rights reserved.
 FLOWABLES

Introduction of flowable com-

posite-based resins is a recent
event.15 An example of an
advantage is that flowable com-
posite-based resins possess the
potential for flowing into a
small undercut. Because of the
material’s flexibility, it can be
used for restoration of abfrac-
tion 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 restora-
Figure 2. Abfraction lesion, com- Figure 3. Canine restored with a
tions.16 The application of a
monly caused by tooth flexure flowable resin-based composite. flowable as a liner in difficult-
during mastication. A resin-based composite with a to-access areas is becoming pop-
lower elastic modulus is recom-
mended for the restoration of ular; however, long-term clini-
Commonly, composite-based abfraction lesions. cal studies are not yet available
resins are referred as hybrids or to support the use of a flowable
microfills. A hybrid resin is a is the radiopacity of the compos- composite as a liner at this
composite in which at least ite-based resin. The type of filler time.
seven to 15+ percent microfiller directly influences radiopacity. A recently published article
of fumed silica has been added Radiopacity is attained through observed that placement of
8
to the mixture (Figure 1). A the incorporation of elements flowable composite-based resins
composite-based microfill resin with high atomic number into into the proximal box of a Class
is exclusively composed of the inorganic filler phase. II restoration in permanent
microfill particles. Hybrids Optimal radiopacity should be teeth may contribute to reduc-
incorporate fumed silica to help greater than enamel. However, tion in microleakage at the
with the handling properties. a number of commercially avail- cavosurface margin when com-
Due to the increase in surface able composite-based resins lack pared to the placement of an
area when incorporating micro- the necessary radiopacity.11-16 injectable glass ionomer.17
fill particles, heavy loading is Barium is the element most Another recent publication
impossible. To circumvent the commonly incorporated into reported reduction in
problem and increase the filler composite-based resins to microleakage on Class I
percentage, fumed silica is increase radiopacity. Excessive restorations when using flow-
incorporated in a variety of incorporation of radiopaque able composite-based resins.18 A
manners, prepolymerized fillers, glasses results in a reduction in thick adhesive layer or a com-
agglomerated and sintered the translucency of these mate- posite-based resin showing
agglomerated particles.9 rials. greater toughness similar to the
Composite-based resins Recently, manufacturers flowable may be sufficiently
should have a range of translu- have been paying attention to energy-absorbing,16 may com-
cency and opacity that reflects the polishing of resin compos- pensate for the polymerization
that of enamel and dentin. ites. Proper polishing reduces stress due to elastic properties
Translucency and opacity have wear and better simulates the and may reduce gap formation.19
been reported in the literature appearance of enamel. A num- Clinicians should be careful
for commercially available com- ber of hybrid composite-based in selecting flowable composite-
posite-based resins.10 resins are now available with based resins as many of them
Another important character- smaller and more polishable on the market do not exhibit a
istic that should be considered distribution of particles. radiopacity equal to or greater

28S JADA, Vol. 131, June 2000

Copyright ©1998-2001 American Dental Association. All rights reserved.
than that of enamel. A low are very tech-
radiodensity flowable should be nique-
avoided in Class II restorations sensitive.22 The
to prevent confusion in determi- operating field
nation of recurrent caries.20 must be kept
absolutely
PACKABLE
COMPOSITE-BASED
clean and dry
RESINS during the
insertion of the
Recently, packable composite- composite-
based resins have been intro- based resins.
duced in an attempt to address Inability to
certain issues such as shrink- achieve mois-
age, wear and handling. They ture control Figure 4. One year recall of a restored premolar
have been mistakenly called will lead to clin- with a packable posterior resin-based composite
(SureFil, Dentsply Caulk).
“condensable composites,” but ical problems;
they do not condense. They therefore, place-
offer higher viscosity trying to ment of a rubber dam is highly proximal surface being
mimic amalgam placement recommended, if not essential. restored. Prewedging of the
techniques. They offer the Water, moisture or saliva are tooth will protect the intersep-
potential to obtain a better contaminants. tal dam and soft tissue, prevent
proximal contact when packing Good marginal adaptation damage during tooth prepara-
them against a matrix band. requires adequate physical and tion and create a rapid tooth
To obtain such a characteris- mechanical properties of the separation to compensate for
tic, manufacturers use a higher filling material and its careful the matrix band. It is therefore
percentage of irregular (mixture manipulation. The use of com- easier to achieve adequate con-
of different size particles or posite resin for direct restora- tact with the adjacent tooth fol-
glass rods) or porous filler tions demands careful and lowing removal of the matrix
(packables are generally loaded thoughtful clinical application. once the resin is inserted.
in excess of 80 percent, and tra- Incremental layering tech- Using finite element analysis
ditional hybrids are generally niques have been recognized as on Class V restorations, it was
loaded less than 80 percent) to the technique of choice to mini- suggested that bulk filling of
reduce the amount of resin, mize stresses from polymeriza- light-cured composite-based
increasing the viscosity and cre- tion shrinkage.13,23 Gaps may resins should be used in
ating this particular handling develop when the bonding restorations that are sufficient-
property. Unlike conventional capacity of the adhesive system ly shallow to be cured to their
hybrids, this category of com- is insufficient to resist the full depth.26 A previous study
posite-based resins is relatively forces of polymerization shrink- reported similar results con-
resistant to displacement dur- age of the composite.24,25 cluding that none of the place-
ing insertion (packing). Early Although the universal ment techniques (incremental
clinical results are encouraging; matrix band is a versatile or bulk) improved the adapta-
in recent clinical trials on instrument, it does not meet all tion at the gingival margin.
SureFil (Dentsply Caulk), the criteria with respect to contour They did demonstrate, however,
one-year recall showed restora- and form. Two major disadvan- that the incremental techniques
tions with no open contacts, tages of the universal matrix ensured the complete polymer-
acceptable clinical wear and are that it allows curing only ization of the composite-based
amalgamlike handling proper- from the occlusal aspect and is resin.27
ties21 (Figure 4). not anatomically shaped for
POLYMERIZATION OF
contour. Precontour bands RESIN-BASED
TECHNIQUE FOR
PLACEMENT
requiring little or no adjust- COMPOSITES
ment are desirable. The matrix
Placement procedures for com- will provide axial confinement Polymerization of resin-based
posite-based resin restorations of the resin and convexity to the composites has received consid-

JADA, Vol. 131, June 2000 29S

Copyright ©1998-2001 American Dental Association. All rights reserved.
erable attention owing to the SUMMARY 11. Bouschlicher MR, Cobb DS, Boyer DB.
Radiopacity of compomers, flowable and con-
introduction of high-intensity ventional resin composites for posterior
energy output light sources and This article discussed a range of restorations. Oper Dent 1999;24(1):20-5.
12. Leinfelder KF. Restoration of abfracted
other methods of light exposure. new materials and placement lesions. Compend Contin Educ Dent
During polymerization, the techniques for resin-based com- 1994;15(11):1396-400.
13. Baratieri LN, Ritter A, Perdigao J,
monomer is converted to poly- posite restorations. Even Felippe LA. Direct posterior composite resin
mer. This results in shrinkage though the resin-based compos- restorations: current concepts for the tech-
nique. Pract Periodontics Aesthet Dent
of the resin, causing stress at ite restorative materials of 1998;10(7):875-86.
bonded interface and adjacent today are a vast improvement 14. Watts D. The structural scope of bioma-
terials as amalgam alternatives. Trans Acad
tooth structure.28 over what was previously Dent Mater 1996;9:51-67.
Polymerization stress initial- offered, the placement of com- 15. Flowable resins—status report no. 1.
Clin Res Associates Newsletter 1997;21(2):1.
ly is relieved by composite flow posite-based resin restorations 16. Bayne SC, Thompson JY, Swift EJ Jr.,
until it reaches the so-called remains technique-sensitive Stamatiades P, Wilkerson M. A characteriza-
tion of first-generation flowable composites.
“gel point.” Before this point, and complex. However, these JADA 1998;129(5):567-77.
the resin-based composite is materials provide patients with 17. Payne JH IV. The marginal seal of
Class II restorations: flowable composite
flexible and accommodates to the esthetically acceptable resin compared to injectable glass ionomer. J
relieve stress. After this gel restorations they seek. ■ Clin Pediatr Dent 1999;23(2):123-30.
18. Ferdianakis K. Microleakage reduction
point is reached, the composite Dr. Fortin is associate professor, from newer esthetic restorative materials in
changes to an unyielding state Department of Operative Dentistry, permanent molars. J Clin Pediatr Dent
Université de Montréal, Faculté de Médecine 1998;23(3):221-9.
in which the shrinkage stress is Dentaire, Édouard Montpetit, Montréal, 19. Kemp-Scholte CM, Davidson CL.
transmitted to the tooth struc- Québec, Canada H3T 1J4. Address reprint Marginal integrity related to bond strength
requests to Dr. Fortin. and strain of composite resin restorative sys-
ture. It has been observed that tems. J Prosthet Dent 1990;64:658-64.
the longer the pre-gel point Dr. Vargas is an associate professor, 20. Murchison DF, Charlton DG, Moore
Department of Operative Dentistry, The WS. Comparative radiopacity of flowable
time, the less the stress in the University of Iowa, Iowa City, Iowa. resin composites. Quintessence Int
post-gel phase.29 1999;30:179-84.
1. Van Meerbeek B, Perdigao J, Lambrechts 21. Perry R, Kugel G, Leinfelder K. One-
High-intensity energy output P, Vanherle G. The clinical performance of year clinical evaluation of SureFil packable
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resin-based composite.

30S JADA, Vol. 131, June 2000

Copyright ©1998-2001 American Dental Association. All rights reserved.