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 resinbased 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 resinbased 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 %) PHYSICAL PROPERTIES
Wear Resistance Fracture Toughness polishability

Microfill Hybrid Microhybrid Packable Flowable

0.04-0.01 1-3 0.4-0.8 0.7-20 0.04-1

35-50 70-77 56-66 48-65 44-54

E F-G+ E P-G+ P

F E E P-E+ P

E G G P F-G+

E: Excellent G: good F: fair P:poor + Varying among the same type of resin-based composite

TABLE 2

CLINICAL INDICATIONS OF RESIN-BASED COMPOSITES.

COMPOSITE TYPE Microfill CLINICAL INDICATIONS
Enamel replacement in Class III, IV and V restorations Minimal correction of tooth form and localized discoloration Posterior resin-based composite restoration Class V restoration Dentin build-up in Class III and IV restoration Posterior and anterior direct composite restoration Veneer Correction of tooth form and discoloration Posterior resin-based composite restoration Pit and fissure restoration Liner in Class I, II and V restoration (dentin)

Hybrid

Microhybrid

Packable Flowable

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)* Pearl Smoke Pearl Neutral/Pearl Frost (Vitalescence) A2 (flowable, PermaFlo) A3.5-A3-A2-A1 (Vitalescence) Pearl Smoke/Pearl Neutral/Pearl Frost Trans Smoke/Trans Mist/Trans Frost (Vitalescence) POLYMERIZATION TECHNIQUE Pulse INTENSITY MW/CM2) 200 (300) INTENSITY MW/CM2) 3 (40)

Proximal Enamel

Dentin

Progressive curing

(300)

(40)

Occlusal Enamel

Pulse

200 (600)

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

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).

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

The suitability of packable resin-based composites for posterior restorations

 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 (%)
90 61

FILLER WEIGH T (%)

66 77

AVERAGE FILLER SIZE (m)

2.0 - 20 1.0

MANUFACTURER

Packable ResinBased Composite

Solitaire Definite

A20 A2

Heraeus Kulzer, Wehrheim, Germany Degussa AG, Hanau, Germany Dentsply De Trey, Konstanz, Germany Jeneric/Pentron, Wallingford, Conn. Ivoclar Vivadent, Schaan, Liechtenstein Ivoclar Vivadent, Schaan, Liechtenstein

SureFil

A2

66

82

0.8

Alert

A2

70

84

0.7 (glass fibers: 60 80) 0.7

Hybrid Composite IonReleasing Composite

Tetric Ceram Ariston pHc

A2

60

78

universal

59

79

1.3 (alkaline glass: 1.6)

* Based on information from individual manufacturers. + micrometer.

TABLE 2 MEAN VALUES AND STANDARD DEVIATIONS.*

COMPOSITE MATERIAL ELASTIC MODULUS (GPa) VICKERS HARDNESS (HV 0.2/40) CURING DEPTH (mm**)
By Producing Hardness Profile By Scraping

Solitaire
Definite SureFil

4.4 (0.3)a
6.3 (0.9)b 9.3 (0.9)c

41.7 (3.5)a
65.8 (1.6)c 70.4 (9.0)c,d

3.0 (0.2)c,d
2.5 (0.0)a,b 2.7 (0.3)b,c

2.6 (0.2)a,b
2.6 (0.3)a,b 2.8 (0.3)b

Alert Tetric Ceram Ariston pHc

12.5 (2.1)d 6.8 (0.5)b 7.3 (0.8)b

75.2 (10.9)d 54.8 (1.1)b 66.5 (2.6)c

3.5 (0.6)e 3.2 (0.3)d,e 2.2 (0.3)a

3.5 (0.4)c 2.9 (0.2)b 2.3 (0.3)a

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