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Managing the polymerization shrinkage of resin composite restorations: A

review

Article  in  SADJ: journal of the South African Dental Association = tydskrif van die Suid-Afrikaanse Tandheelkundige Vereniging · March 2007
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 REVIEW

Managing the Polymerization Shrinkage of

Resin Composite Restorations: A Review
SADJ February 2007, Vol 62 no 1 pp 16 - 22

Q Alomari: BDS, MS, FDSRCSI, Assistant Professor, Department of Restorative Sciences, Faculty of Dentistry, Kuwait University, Kuwait
Raed Ajlouni: BDS, MS, Assistant Professor, Department of General Dentistry, Baylor College of Dentistry, Dallas, TX, USA
Ridwaan Omar: BSc, BDS, LDSRCS, MSc, FRACDS, FDSRCSEd, Professor, Department of Restorative Sciences, Faculty of Dentistry, Kuwait
University, Kuwait

Corresponding author:
QD Alomari: Department of Restorative Sciences, Faculty of Dentistry, Kuwait University, P.O. Box 24923 Safat, 13110 Kuwait.Email: qalomari@hsc.
edu.kw, Fax: +965 263 4247

ABSTRACT posite/tooth interface. PS of posterior MANAGING THE STRESS

resin composite restorations may also GENERATED BY POLYMERIZATION
Polymerization shrinkage (PS) of resin induce mechanical stresses within SHRINKAGE (PS) OF RESIN
composites almost invariably generates the tooth structure via their bond to COMPOSITE RESTORATIONS
a degree of stress at the tooth/restora- enamel and dentin. With the levels
tion interface. The magnitude of the of bond strengths currently achiev- Several compensatory mechanisms
stresses so produced depends on resin able, it is not surprising that these aimed at minimizing the effects of PS
composite composition and its ability to stresses are reported to range from stresses at the resin composite/tooth
5,6
flow before solidification, which is, in 13MPa to 17MPa. The magnitude interface to reduce the risks of mar-
turn related to cavity configuration and of PS stresses depends on a number ginal gap formation, as well as meth-
curing characteristics of the composite. of factors: resin composite mate- ods aimed at minimizing tooth struc-
The purpose of the present article is to rial composition, its elastic modulus ture deformation or fracture have been
6
review the published literature on the (stiffness) and flow properties, rate reported. In general, these efforts can
management of PS, with special refer- and degree of conversion (polym- be divided into two broad groups:
ence to those elements that are under erization), the volume of the material
the control of the dentist. Available to be polymerized, and the geom- A. Mechanisms related to the properties
7
data from laboratory, finite element etry of the restoration. If the bond and characteristics of resin composites.
analysis and review articles, relating to tooth structure is strong enough, The mechanisms in this group are
8,9
to the methods and techniques that strain of tooth structure will occur. solely in the manufacturers’ domain,
have been proposed for managing Conversely, if the bond between the and include the ratios of material com-
the problem of PS, are included. On composite and tooth structure is less ponents, and the physical and chemical
the basis of the review, it may be con- than the force generated by PS, mar- characteristics of the composites
cluded that PS has negative effects on ginal failure and subsequent micro-
5,10
the resin composite/tooth interface. leakage will occur. Clinical effects 1. Resin composite flow: As mono-
The review identifies the preferred of strain relief have been noted as mers cross-link with other mono-
handling and/or management tech- white lines at the tooth-resin interface, mers, the mobile monomer mol-
niques that clinicians might employ cracks in enamel adjacent to the mar- ecules move closer and become
11,12
to reduce the levels of PS that might gins, and post-operative sensitivity. covalently bonded, resulting in
affect the restorations they place, The potential for PS to be a serious volumetric shrinkage. Part of the
and consequently reduce its adverse source of clinical failure is therefore, shrinkage occurs before solidifica-
effects. easy to see, and attempts at counter- tion (gel point) while the material
ing the problem would be beneficial still has the ability to flow. During
INTRODUCTION to the clinician and patients alike. solidification (post-gelation), there
The aim of this literature review was is a rapid increase in the stiffness
In vitro measurements of the polymer- to provide clinicians with an overview of the restorative material and as
ization shrinkage (PS) associated with of the available evidence relating to a result stresses are generated at
13
resin composites range from 0.2% to the problem of PS and its implica- the bonded surfaces. Studies have
1,2
2% linearly, and from 1.7% to 5.7% tions, and to make recommenda- found that the higher the modulus
3,4
volumetrically. Stress generated by tions regarding measures that may be of elasticity of the resin composite,
PS of a resin composite restoration taken to manage PS, and its adverse the greater the stress transferred to
is most destructive on the resin com- clinical outcomes. tooth structure, assuming the bond

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 REVIEW

14 35
remains intact. To compensate for increases the viscosity and reduces expansion. Clinically, hygroscopic
24
this contraction and thus a relief of PS of resin composite. It follows expansion may force a class V resin
stress, it would be desirable for the that, in selecting products, dentists composite restoration to expand
restorative material to flow in the should be aware of the level of beyond the margins of the cavity
36
direction of the cavity walls dur- PS of the resin composite they are preparation.
15
ing early setting. When the flow using since it can affect their clini- 6. Clinical considerations: Given
ceases because of the increasing cal results. that the factors mentioned are
stiffness of the composite material, 3. Concentration of initiators inherent material properties that
a bonding agent able to withstand and inhibitors: Braga and cannot be controlled by the clini-
the contraction stresses is required. Ferracane25 have demonstrated cian, the correct choice of a mate-
The nature of the flow that occurs that increasing the inhibitor con- rial for a particular clinical task
depends on the type of resin com- centration reduces curing rate and will clearly be the clinician’s most
posite and the configuration of the contraction stresses in resin com- valuable input for the achievement
16
cavity. When the filler content or posites, without compromising the of positive clinical outcomes. Sound
the modulus of elasticity of the resin final degree of conversion. Other knowledge of the available prod-
composite is high, flow will be less.9 investigators found that by varying ucts would be the basis of mak-
Flow of the resin in the composite the concentration of initiators, the ing this choice, with good physical
also depends on the quality of the degree of conversion and reaction properties, and especially a low PS
17 26
bond between dentin and resin. kinetics can be regulated. being central to it. In areas where
If the resin is well-bonded to the 4. Amount of filler and coat- no or only low occlusal forces
tooth, PS will be directed towards ing: PS stresses is affected by apply, micro-filled composites can
a center located near the bond- two factors: the magnitude of be used because they have bet-
ed interface rather than toward the shrinkage and the modulus of ter polishability and at the same
30
the incident light, thus reducing elasticity of the resin composite. time produce lower PS stresses.
18
adverse shrinkage stress. On the Increasing the amount of filler in In areas of high occlusal load, the
other hand, when the shrinkage the composite results in decreasing physical properties of the material
forces are higher than the resin/ PS, but also increases the modu- become crucial, and hybrid com-
27-30
dental substrate bond, a gap will lus of elasticity. For example, posites should be used. However,
develop, increasing the chances micro-filled composites, which are manipulative techniques should
for post-operative sensitivity and less filled than hybrid composites, aim to reduce the PS stresses. The
2,19
recurrent caries.1 Incorporation have higher PS, and tend to devel- second part of this review will give
of voids into the resin composite op lower contraction stresses than a summary of these techniques.
14,30
will result in reduction of shrinkage hybrids. This has been attributed
31
stresses due to flow from the outer to their lower modulus of elasticity. B. Mechanisms under the clinician’s
surfaces of the voids and inhibition Similarly, nano-filled and highly- control Listed below are the factors and
of the setting reaction by oxygen in filled hybrid composites have been techniques that may influence the den-
20
the voids. shown to exhibit greater deforma- tist’s ability to minimise the amount and
2. Monomer system: According tion stresses than a hybrid compos- effects of PS:
21 9,32
to Stansbury, polymerization ite with a lower filler content. To
with expansion in volume can be reduce the rate at which modulus 1. Shape of the cavity: The shape
achieved with 2,3-bis (methylene) of elasticity of resin composites of the cavity determines its configu-
spiro-orthocarbonate monomers develops, non-bonded nano-fillers ration, or C-factor (the ratio of the
through a double ring-opening (uncoated colloidal silica) are cur- restoration’s bonded to un-bonded
process in which two bonds are rently used to provide internal sites surfaces). To illustrate this con-
cleaved for each new bond formed. for stress relief without compromis- cept, the C-factors of class I and
33
The resulting expansion can be ing the mechanical properties. class II cavities may be compared.
applied to counter the PS associ- 5. Hygroscopic expansion: Resin The C-factor influences the amount
ated with the conventional meth- composites absorb fluids from the of constraint imposed upon the
acrylate monomers used in dental oral cavity and swell with time. resin composite during polymeri-
composites. Expanding monomers, This hygroscopic expansion occurs zation, by the conflicting actions
based on epoxy and spiro-orthocar- days and weeks following place- of PS (away from the bonded sur-
bonate-based resins have been ment of the resin composite res- face) and interfacial bond strength
tested to determine their influence toration, after the negative effects (maintaining its integrity). The net
on the properties of dental com- of PS might already have been result is that both the mechani-
22,23 34
posites. Using high molecular occured. Nevertheless, it has been cal properties of the composite as
weight monomers (e.g. UDMA and shown that PS stresses were either well as the strength of the interface
Bis-EMA) in place of low molecular fully relieved, or converted into an between the composite and the
37
weight monomers (e.g. TEGDMA) “expansion stress”, by hygroscopic tooth substrate may be affected.

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 REVIEW

Generally, the lower the number and a lower degree of conversion nation for this is that the resin inter-
of free, un-bonded surfaces in the which results in a reduction in diffusion zone (the hybrid layer)
cavity, the less the ability of the both the volumetric shrinkage and functions as a stress relaxation layer,
6
resin to flow, and therefore the the elastic modulus. The improve- since it has a lower modulus of elas-
greater the contraction stress at ment in marginal adaptation by ticity than the underlying mineralised
38
the bonded surfaces. Restorations the use of the “directed shrinkage” dentin.69 The clinical use of unfilled
with a C-factor of <1 are the only technique using self-cured resin resin in thick layers does, how-
ones likely to survive polymeriza- composite in the first increment ever, have two problems: firstly, the
tion contraction stresses. When the of the restoration noted by some material is radiolucent, interfering
52,53
C- factor is >1, the results are authors, was not confirmed in with later radiographic diagnosis;
54-56
unpredictable under clinical situa- other studies. and secondly, the material’s fluidity
39-43
tions. Incremental placement of 4. The use of bases and liners: Among would make application somewhat
a resin composite restoration and the available adhesive systems, only difficult in some areas of the cav-
the use of a base material, such as the conventional 3-step etch-and- ity.70 Thus, the use of filled bond-
glass ionomer cement, decreases rinse adhesives bond sufficiently to ing agents might accommodate the
57
the volume of the resin composite dentin to withstand the PS stresses. stresses of PS more efficiently than
placed, thus generating more free The use of a glass-ionomer liner unfilled adhesives.71
surface (low C-factor) relative to will solve the problem of adhesive 6. Modifying the curing light
44,45
the amount of resin. Clinically, and cohesive failures of the bond- intensity: The minimum intensity
conservative cavity preparation ing agents, mainly at the floor of of the conventional halogen curing
with rounded internal line angles the cavity where strain is maxi- light should be 400mW/cm2 and
45,55
is recommended because it will mally concentrated. Ikemi and the curing time 60 seconds for each
46,72
have less surface area than a box- Nemoto58 demonstrated that a 2mm increment. Increasing light
shaped cavity and therefore the thicker lining application decreases intensity will increase the PS and thus
59 6,73
C-factor will be reduced. shrinkage stresses. Knight recom- the level of stress. High-intensity
2. Size and position of resin mended simultaneous light acti- curing light units have been shown
increments placed in the cav- vation of the glass-ionomer liner to negatively affect the integrity of
74,75
ity: The shrinkage stress is directly and the resin composite restora- the restoration-cavity interface.
related to the volume of compos- tion, suggesting that the PS of Therefore, interfacial integrity is bet-
46
ite. Because the thickness of incre- the resin may be taken up by the ter preserved with low light intensity
mental layers will have an effect uncured glass-ionomer cement, because it extends the visco-elastic
76,77
on the volume, layers should not so reducing the internal stress of stage of the setting material. The
exceed 2mm, with 1mm being the the restoration. Using a liner of use of soft-start polymerization (i.e.
47
ideal. Compared with other filling low elastic modulus, for exam- initially curing the composite at low
techniques, in terms of the tran- ple resin-modified glass-ionomer, light intensity, followed by full inten-
sient stresses induced at the resin flowable composite, or filled adhe- sity light) to permit greater flow and
composite/tooth interface during sive system has been found to stress relief in the composite has
78-80
polymerization, horizontal incre- reduce the PS stresses, formation been suggested. Marginal integ-
44,48 60-65
ments exhibit the least stresses. of voids, and marginal leakage. rity studies with ‘soft-start’ polym-
On the other hand, using finite However, other research has shown erization show contradictory results,
element analysis, other research- that flowable composite linings, with some showing improved mar-
81-84
ers showed that incremental filling especially when used in thick lay- ginal integrity, and finding no
66
techniques increase the deforma- ers, will increase microleakage. significant differences compared
49 85,86
tion of the restored tooth. This can be due to the fact that with conventional curing modes.
3. Light- or chemically-cured com- these materials have higher linear A further development on staged
posite: Chemically-cured compos- polymerization displacement and curing is the pulse-delay cure, where
67
ites produce the lowest polymeriza- polymerization stresses. a combination of low initial energy
50
tion contraction stresses. For the 5. Increasing the thickness of the den- density followed by a lag period
light-cured type, micro-filled com- tin bonding agent: It has been before a final high-intensity light
posite is intermediate (due to their reported that a dentin bond layer irradiation has been found to pro-
lower modulus of elasticity) and thickness of 125µm or more will vide a reduction of polymerization
87-89
the hybrid composite produces the reduce bond stress to a level below contraction stresses. Although
30,51
highest stresses. The reduced the bond strengths reported for staged-light curing protocols can
63
stresses in self-cured composites dentin bonding agents. The sim- reduce PS stresses, this can be mis-
may be due to two factors: the ple method of multiple consecu- leading if the reduced shrinkage
delay in stress build-up within the tive coating during dentin bond- stresses is due to decrease in final
composite due to a slower setting ing improved bond strength and degree of conversion and therefore
68
rate and a resultant extended flow, reduced nano-leakage. The expla- reduced mechanical properties of

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 REVIEW

90
the composite. Beside the curing 9. Fabrication of indirect inlays: the PS stresses. Even though no clinical
rate, the total energy delivered to The advantages of indirect compos- studies have yet been published to con-
the composite can also affect con- ite inlays over directly placed resto- firm their possible benefits, the use of
traction stress. While high ener- rations might include the reduc- staged light curing protocols may pro-
gy density for curing composites tion of PS stresses, increased wear vide further ways to decrease the forces
has been associated with superior resistance, and better control of the of PS. Re-bonding or sealing all the
mechanical properties and degree anatomy and occlusion of the res- accessible margins of the resin-based
47 105
of conversion, the relationship is toration. Studies have shown the composite restoration with an unfilled
91
not linear. At the same time, the clinical success of this type of resto- resin after finishing and polishing the
106,107
relationship between energy den- ration. Disadvantages include restoration might reduce the occurrence
sity and post-gel shrinkage strain extended treatment time, more of the micro-gaps resulting from PS.
was found to be linear, which laboratory expenses, and the sac- However, it should be remembered that
means that high energy densities rifice of tooth structure in accord- minimising PS, while maximising the
also translate into higher stress ance with guidelines for inlay and degree of conversion of the restoration
levels, although not necessarily onlay preparation designs. The use are seemingly antagonistic goals. In
resulting in superior mechanical of resin or ceramic inlays/onlays spite of many efforts to overcome this
91,92
properties. is to be encouraged, especially in problem, reconciling the twin impera-
7. Using glass-ceramic or pre- large restorations, as alternatives to tive remains the biggest challenge in
43
polymerized inserts: Inserts will direct resin composites. directly placed composite restorations.
reduce PS by reducing the volume 10. Using a decoupling technique: When the restoration is large indirect
93,94
of polymerizing resin. Glass In this technique, PS stresses at the techniques have to be considered.
inserts bond well to resin compos- cervical tooth-restoration interface
ite, increase restoration strength, were minimised by separating the CONCLUSIONS
reduce PS and reduce marginal initial gingival increment of resin Polymerization shrinkage produces some
95-97
leakage. The integration of composite from the body of the well-recognised, undesirable effects
the inserts also lowers the overall restoration using a polyurethane on the resin composite/tooth interface.
98
coefficient of thermal expansion. varnish.108 Clinical research is Although these cannot be completely
Another issue of concern to clini- needed to prove the efficacy of this eliminated, it is within the dentist’s ambit
cians is that tight, anatomically- method. to utilise certain techniques, based on
correct proximal contacts are still current best practice recommendations,
difficult to achieve in posterior Clinical implications: Direct resin which can reduce the extent, and conse-
resin composite restorations. Pre- composites may be used to restore quently the effects of PS. A summarising
polymerized composite inserts and small to moderate-size carious lesions, account of the factors that give rise to,
glass-ceramic inserts are increas- or to replace restorations of the same and influence polymerization shrinkage,
ingly recommended to help the size. Modified conservative tooth prep- as well as its negative effects have been
clinician to obtain good proxi- arations should be used when using were described, with particular empha-
mal contact, while at the same indirect resin restorations for larger res- sis on those that are under the dentist’s
time limiting the overall volumetric torations. To reduce the effects of PS, control.
99,100
shrinkage of the restoration. cavities prepared for resin composite
However, in spite of these obvious restorations should have rounded inter- REFERENCES
advantages, inserts have the risk nal line angles and be as conservative
1. Hansen, EK. Contraction Pattern of
of chipping or debonding from the as possible in design. This will reduce Composite Resins in Dentin Cavities. Scand
101
bulk of the restoration. the volume of material used, and thus J Dent Res 1982; 90: 480-3.
8. Sealing the margins of the the PS. Clinicians should use a filled 2. Rees, JS. Jacobsen, PH. The Polymerization
restoration with unfilled resin: dentin bonding agent with a proven Shrinkage of Composite Resins. Dent Mater
1989; 5: 41-44.
After finishing the restoration, it clinical track record, and strictly follow 3. Bausch, JR. De Lange, K.Davidson, CL.
has been suggested that the mar- the manufacturer’s instructions. Dentin Peters, A. De Gee, AJ. Clinical Significance
gins be re-bonded with a low-vis- bonding agents should be applied in of Polymerization Shrinkage of Composite
cosity resin to reduce micro-leak- more than one layer. Resin composites Resins. J Prosthet Dent 1982; 48: 59-67.
4. Bowen, RL. Rapson, JE. Dickson, G.
age and reseal the marginal gap should be placed in increments not Hardening Shrinkage and Hygroscopic
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resulting from PS. Although thicker than 2mm, while, for opaque Expansion of Composite Resins. J Dent Res
clinically not proven, using unfilled shades, a maximum of 1mm thickness is 1982; 61: 654-8.
or low-filled resins to seal the preferable. Furthermore, the first incre- 5. Davidson, CL. De Gee, AJ. Feilzer, A. The
Competition Between the Composite-Dentin
margins of restorations might, on ment of the composite should always be Bond Strength and the Polymerization
clinical grounds, be suggested as placed in the deepest part of the prepa- Contraction Stress. J Dent Res 1984; 63:
a way of eliminating some of the ration. In moderate to large cavities, the 1396-9.
negative effects of PS and improve use of a resin-modified glass-ionomer THE REST OF THIS ARTICLE’S REFERENCES (6-108) WILL BE
the restoration longevity. liner might help by absorbing some of PUBLISHED IN THE ONLINE SADJ. www.sadanet.co.za ~

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