CLINICAL EBOOK SERIES

POWERED BY

DEVELOPMENTS IN
RESTORATIVE
DENTISTRY
FEBRUARY 2021

2 C E C R E D I T S

DENTAL MATERIALS

Low-Shrink Composite Resins: A Review

of Their History, Strategies for Managing
Shrinkage, and Clinical Significance
Mark L. Pitel, DMD

C L I N I C A L C A S E

ADHESIVE DENTISTRY

A Practical, Flowable Technique for

Restoring a Worn Dentition
Giancarlo Romero, DDS, MS

SUPPORTED BY AN UNRESTRICTED GRANT FROM BISCO • Published by AEGIS Publications, LLC © 2021
 Materials Make
the Method
of Continuing Education in Dentistry

W
FEBRUARY 2021 | www.compendiumlive.com

PUBLISHER
Matthew T. Ingram
of Continuing Education in Dentistry
SPECIAL PROJECTS DIRECTOR
elcome to another edition of the C. Justin Romano
Compendium eBook series in which SPECIAL PROJECTS COORDINATOR
June Portnoy
we focus on restorative dentistry. of Continuing Education in Dentistry
MANAGING EDITOR
As dental materials continue to be Bill Noone

developed at a brisk pace, it is criti- CREATIVE

Claire Novo
cal that clinicians stay abreast of the latest innovations and
EBOOK DESIGN
understand how they can affect outcomes. In this eBook, we Jennifer Barlow

address two topics in particular that offer insights into key

areas of this dental specialty.
In the first article, the author presents an overview of the
history of direct esthetic restorative materials, namely com-
posite resins. This continuing education opportunity includes
a review of monomer and polyment development and a dis-
cussion of strategies for reducing polymerization shrinkage.
Copyright © 2021 by AEGIS Publications, LLC. All
rights reserved under United States, International and
Pan-American Copyright Conventions. No part of this
publication may be reproduced, stored in a retrieval
system or transmitted in any form or by any means
without prior written permission from the publisher.
PHOTOCOPY PERMISSIONS POLICY:
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Clearance Cen­ter (CCC), Inc., 222 Rosewood
Drive, Danvers, MA 01923. Per­mission is granted
for photocopying of specified articles provided
the base fee is paid directly to CCC.

Evaluating the clinical significance of these materials is aided Printed in the U.S.A.

by an understanding of the material chemistry, including the

mechanics behind shrinkage and stress, and strategies for re-
ducing these effects among composite resins, including the use
of certain fillers and the appropriate application methods, such
as incremental layering versus bulk placement.
Featuring a discussion of adhesive dentistry, the next article
showcases a method for the direct restoration of worn dentition
that is an alternative to conventional, full-mouth rehabilitation
involving root canal treatment. This flowable technique allows
Chairman & Founder
the clinician to reestablish the proper VDO, occlusion, and es- Daniel W. Perkins
thetics before completing the case with final ceramic materials. Vice Chairman & Co-Founder
Anthony A. Angelini
Overall, the method can be accomplished in only one or two
Chief Executive Officer
sessions, eases the financial burden of treatment, and preserves Karen A. Auiler

the marginal peripheral enamel for increased bond strenth. Corporate Associate
Jeffrey E. Gordon
These two articles are just a sampling of the many resources Media Consultant, East
Compendium has available on the all-encompassing topic of Scott MacDonald
Subscription and CE information
restorative dentistry. Visit aegisdentalnetwork.com/cced/ Hilary Noden
877-423-4471, ext. 207
restorative for a wide array of clinical articles covering this hnoden@aegiscomm.com
category of dentistry.

Sincerely,

Louis F. Rose, DDS, MD

Editor-in-Chief AEGIS Publications, LLC
140 Terry Drive, Suite 103
lrose@aegiscomm.com Newtown, PA 18940

2 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 2 www.compendiumlive.com

 CONTINUING EDUCATION 1 LOW-SHRINK COMPOSITE RESINS

Low-Shrink Composite Resins:

A Review of Their History,
Strategies for Managing Shrinkage,
and Clinical Significance
Mark L. Pitel, DMD

ABSTRACT: Despite numerous advances in composite resin technology over the course
of many decades, shrinkage behavior and the resultant stresses inherent to direct placed
composite restorations continue to challenge clinicians. This overview of composite res-
ins includes a review of their history and development along with a discussion of strategies
for reducing polymerization shrinkage. An assessment of the clinical significance of these
materials is also provided, including a discussion of the differences between polymerization
shrinkage and stress, incremental layering versus bulk placement, and the emergence of
lower shrinkage stress monomer chemistry.

LEARNING OBJECTIVES

• Discuss the history and • Describe strategies for • Explain the clinical
development of direct esthetic reducing polymerization significance and
restorative materials shrinkage among composite the determinants of
resins, including the use of polymerization shrinkage and

T
various filler particles stress

hough esthetic dentistry is largely 1930s in indirectly processed dental laboratory

considered to be a fairly modern
innovation, the early history of es-
thetic restorative materials can be
traced back to 1843 with the dis-
covery of acrylic acid by Josef Redtenbacher,
a German chemist.1 By 1900, this simple com-
pound led to the synthesis of methacrylic acid
and, more importantly, its methyl ester, methyl
methacrylate (Figure 1). Like the monomers
found in most modern resin composites, liquid
methyl methacrylate can be induced via free
radical initiation to polymerize at its C=C dou-
ble bond into a solid polymer referred to as poly
(methyl methacrylate). Poly (methyl methacry-
late) found its first use in dentistry in the early
materials such as denture bases and later for
indirect tooth-colored filling materials.2
Polymers are typically large molecules com-
posed of repeating smaller subunits called
monomers. Although there is no absolute re-
quirement as to the physical states of a mono-
mer or polymer, monomers used in dentistry
are normally liquids that transform into a sol-
id polymer during a chemical reaction called
“polymerization.” The polymerization reaction
typically requires some type of catalyst system
or infusion of heat or energy that alters the
monomer molecules to an unstable thermody-
namic or electronic state, such as that of a free
radical. Once destabilized, they polymerize to

DISCLOSURE: The author declares no financial affiliation with any of the companies mentioned in this article.

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 CONTINUING EDUCATION 1
Fig 1.
Fig 2.
Fig 1. Methyl methacrylate chemical structure.
Fig 2. Epoxide rings of epoxy resins.
reach a more stable electrochemical state. The
extent to which the monomers can be trans-
formed into a polymer is called the “degree
of conversion.” Thus, if all available mono-
mer molecules could be induced to polymer-
ize, there would theoretically be 100% degree
of conversion. For current dental polymers,
the degree of conversion is usually much less
than 100%. “Polymerization shrinkage” oc-
curs when the molecules of a liquid monomer
take up less space as they change from the liq-
uid state into a solid polymer state.
More History and Development
When the benzoyl peroxide-tertiary amine
initiator reaction was discovered, it allowed
methyl methacrylate-based materials to cure
at room or oral temperatures and paved the
way for using them in direct filling restora-
tions. Unfortunately, direct restorations made
with methyl methacrylates had a disappoint-
ing clinical performance, including high wear
rates, high incidence of secondary decay, poor
color stability, and adverse pulpal reactions.
4 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 2 www.compendiumlive.com
LOW-SHRINK COMPOSITE RESINS
Two deterrents to using methyl methacrylates
for direct restorations are their low conversion
rate, which leads to a high content of unset re-
sidual monomer, and the fact that they have no
real adhesion or watertight seal to tooth struc-
ture. In 1955, Buonocore published his now
famous paper that suggested the acid treat-
ment of enamel to improve the adhesion of
direct acrylic fillings.3 Despite improvements,
the majority of observed clinical problems can
be directly attributed to or have been influ-
enced by the very high polymerization shrink-
age of methyl methacrylates. Unfilled methyl
methacrylate monomer has an unprecedented
shrinkage of ~25% during setting. The incor-
poration of fillers into the monomers lowers
overall shrinkage to about 7% (although the
monomer to polymer shrinkage remains the
same). This 7% shrinkage is still clinically
unacceptable, especially in the absence of a
sound marginal bond or seal.
In response to the compromised clinical
performance of methyl methacrylates, Bowen
began investigating the use of epoxy resins4
in dentistry. Epoxy resins draw their name
from the fact that they contain three member
epoxide rings where two ring members are
carbon atoms and one member is an oxygen
atom (Figure 2, see glycidyl methacrylate).
The epoxide functional groups are somewhat
unstable and prone to ring opening, which
allows polymerization with other molecules.
Moreover, ring opening polymerization al-
most always results in a lower polymeriza-
tion shrinkage than linear polymerization,
which occurs in methyl methacrylate. When
the epoxide base material is mixed with poly-
amine hardener, an autocuring polymeriza-
tion reaction is initiated. Epoxy resins held
early promise for dentistry because they cure
at room temperatures with little volumetric
shrinkage, can be loaded with inert fillers,
and show good adhesive properties to most
solid surfaces. Though they proved useful
for some indirect dental applications, epoxy
resins were ultimately abandoned because of
 CONTINUING EDUCATION 1 LOW-SHRINK COMPOSITE RESINS

questionable biological compatibility and be- incorporated, but most tend to increase overall
cause they set too slowly to be used for direct polymerization shrinkage. Thus, there must be
restorations. In 1956, Bowen synthesized an a delicate balance between the various amounts
important new monomer that was a reaction of each monomer.
product of bisphenol A and glycidyl methacry- As the clinical usage of direct esthetic restor-
late, which became known as bis-GMA and led ative materials advanced, the overall impor-
to the development of the modern composite tance of polymerization shrinkage and shrink-
resin. Bis-GMA ultimately proved highly useful age stresses was recognized. Bis-GMA itself
in dentistry due to its many clinical and techni- has a reported volumetric shrinkage of about
cal advantages over acrylics and epoxy resins. 5%.5 With the incremental addition of higher
As a result of the molecular length between shrinking dilution monomers, early macro-
the acrylate groups, it polymerized rapidly at and microfilled composites could have had
room temperature with moderately low over- a total volumetric shrinkage as high as 7.1%.6
all polymerization shrinkage. It could also be Improvements in more recent products have
induced to polymerize with ultraviolet (UV), successfully reduced this value; however, in-
photo, or chemical initiators. As a very large cluding both conventional hybrid and flowable
molecule, it has a low volatility and produces a composite resins, modern methacrylate-based
strong, rigid polymer when set. However, bis- composites still have polymerization shrink-
GMA has a fairly high viscosity, which limits age values ranging from about 1.78% to 5.7%.7
the incorporation of reinforcement fillers and Depending on the bond strength of the inter-
makes the unset composite paste thick and face between composite and tooth, a shrinkage
difficult to handle clinically. To overcome this, of this magnitude can readily lead to clinical
formulations made with bis-GMA usually must problems such as marginal gap formation and
be diluted with other dimethacrylate comono- leakage, debonding at the restoration/tooth
mers, which are smaller and of lower molecular interface, cuspal deflection, and microfrac-
weight. Examples include HEMA (hydroxy- tures of the tooth structure surrounding the
ethyl methacrylate), TEGDMA (triethylene outline form of the cavity.
gylycol dimethacrylate),
and EGDMA (ethylene
glycol dimethacrylate).
Unfortunately, these lower
molecular weight comono-
mers have higher volumet-
ric shrinkages than bis-
GMA. For example, the
most commonly used co-
monomer, TEGDMA, has a
polymerization shrinkage
of ~15%. Dilution mono-
mers can also be used to
modify the hydrophilicity
and handling properties
of the composite resin and Fig 3. Influence of filler loading on total polymerization shrinkage (as-
significantly increase the suming 10% shrinkage of the matrix monomers). The red arrows demon-
amount of filler that can be strate overall shrinkage before and after polymerization.

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 CONTINUING EDUCATION 1 LOW-SHRINK COMPOSITE RESINS

Strategies for Reducing

Polymerization Shrinkage
Reducing Monomer Percentage
Through the Addition of Inorganic
Fillers
Polymerization shrinkage is normally mea-
sured and reported as a volumetric change.
It occurs because the monomer molecules in
the liquid state are spaced at Van der Waals
distances, but during polymerization into the Fig 4.
solid state, covalent bonds are formed, reducing
interatomic distances. Solid fillers, conversely,
maintain a constant volumetric dimension dur-
ing the polymerization reaction. As such, one
of the earliest strategies was simply to reduce
the total amount of monomer content through
the addition of solid fillers. It is well understood
that the introduction of inorganic fillers can
improve clinical performance by increasing
durability and reducing wear of the mostly or-
ganic resin monomers, but more significantly, Fig 5.
as filler density increases, overall polymeriza-
tion shrinkage decreases because shrinkage is
Fig 4. Utilization of multiple-sized, irregularly
confined exclusively to the monomer phase. shaped filler particles. Smaller particles can
Figure 3 shows graphically how 50% and 70% fill interstices between larger particles. Fig 5.
filler additions can dramatically reduce shrink- Utilization of prepolymerized filler particles for
microfilled and nanofilled composite resins.
age as compared with a cured monomer resin
alone. Assuming a 10% volumetric shrinkage
for the monomer phase, the addition of a 50% the next section, the addition of non-bonded,
filler fraction results in a 50% reduction in micro-, or nanofillers may also help reduce
shrinkage for an overall shrinkage of 5%, while polymerization stresses.8,9 However, as the
a 70% filler fraction reduces it to 3%. quantity of micro- and nanofillers increases,
the overall viscosity of the final composite prod-
Utilizing Multiple-Sized Filler uct is dramatically increased and some of the
Particles physical properties may be adversely affected.
Total filler loading is also dependent on the Thus, their amounts must always be optimized.
“packing” properties of the solid fillers. To
achieve the greatest density or loading of ir- Utilizing Prepolymerized Filler
regularly shaped filler particles, an assortment Particles
of particle sizes and shapes is needed where Another common approach that has been ap-
progressively smaller sized particles can fill the plied to reducing shrinkage is the use of “prepo-
interstices between the larger particles (Figure lymerized fillers.” These specialized fillers are
4). This has fostered the growth of hybrid com- manufactured by adding inorganic micro- or
posites, which utilize multiple size fillers to nanofillers at very high concentrations to a res-
achieve this objective. As will be discussed in in monomer under conditions of high heat and

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 CONTINUING EDUCATION 1 LOW-SHRINK COMPOSITE RESINS

pressure. Once cured, the resultant blocks are
ground into macrosized filler particles, which
typically range in size from about 30 µm to 65
µm for most microfilled and nanofilled com-
posite resins10 (Figure 5). The restorative ma-
terial is made up by dissolving a heterogenous
mixture of these larger macrosized filler parti-
cles and individual microfillers in a quantity of
uncured monomer. This significantly reduces
the amount of uncured, free monomer that can
contract during polymerization, thus decreas-
ing overall shrinkage. Yet another benefit is the
reduction in the interparticle distances, which
increases frictional contact between particles
during polymerization of the resin monomer
(Figure 6).
Synthesis and Utilization of Low-
Shrinking Monomers
Changes in filler configuration offered only
limited reductions in polymerization shrink-
age. Researchers, therefore, next began to
examine ways to modify the matrix and
monomer chemistry. Of early interest were
non-shrinking or expanding monomer/poly-
mer systems. In 1975, Bailey proposed using
bicyclic monomers, where both of the rings
opened during polymerization.11 Thus, the
shrinkage for each Van der Waals distance
converted to a covalent bond was offset par-
tially or entirely by the opening of two cyclic
rings. This is capable of leading to no change
in set volume or possibly even slight expansion.
As was pointed out previously, “ring opening
polymerization” almost always results in less
setting shrinkage than simple “linear addition
polymerization.” Because they are chemically
compatible with methacrylate chemistry, the
group of “bicyclic” monomers that has re-
ceived the most attention is the spiro ortho-
carbonates (SOCs). The technical challenge
of using SOCs in clinical resin composites is
that they are mainly crystalline at room tem-
perature and somewhat unreactive. Since
some SOCs can copolymerize with methac-
rylates, Thompson and Bailey attempted to
overcome their limitations by grinding them
into fine particles and creating a slurry of the

Fig 6.
Fig 6. Large interparticle distances do not create any frictional contact during polymerization, allow-
ing greater shrinkage (upper two images). Large prepolymerized particles contact one another during
polymerization and help resist volumetric shrinkage (lower two images).

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 CONTINUING EDUCATION 1 LOW-SHRINK COMPOSITE RESINS

crystalline SOCs with the traditional liquid shrinkage may not be significantly lower than
bis-GMA monomers.12 However, the SOCs that possible with more conventional resin-
and the traditional monomers did not cure based composites. Also, Silorane chemistry
simultaneously, leading to a high percentage of is still new,* so no long-term clinical data is
unreacted crystalline SOC in the final polym- available as compared with methacrylates. It
erized resin. Additionally, they were only able also requires at least twice the polymeriza-
to achieve a slight reduction in the total polym- tion time as methacrylate resin for a 2-mm in-
erization shrinkage. Later work by Stansbury crement and has poor compatibility with the
and Bailey utilized SOCs with lowered melting methacrylate-based adhesives and composite
points and greater compatibility with standard products; therefore, it requires its own pro-
dental monomers. Unfortunately, they were prietary adhesive and related complementary
still unable to show anything other than mod- products. Most importantly, however, lowered
est improvements in polymerization shrink- polymerization shrinkage does not necessar-
age with copolymers as high as 33% SOC by ily translate into a lowered stress applied to
weight.13,14 the tooth or higher bond strengths, as will be
In 2007, an interesting new ring opening discussed in the section on polymerization
monomer was introduced called Silorane (3M stress below.
ESPE), which is named for the two chemical
subunits that make up the molecule: silox- *Editor’s note: Since the original publication of
anes and oxiranes. Siloxanes provide an in- this article, 3M has changed the chemistry of
organic backbone of alternating silicon and its low-shrink composites from Silorane ring
oxygen atoms (–Si-O-Si-O-) that has either opening composites to addition fragmenta-
a hydrogen or an organic side group attached tion monomer (AFM) and aromatic urethane
to the Si atoms. Siloxanes can be branched, dimethacrylate (AUDMA).
unbranched, or cyclic and are best known for
imparting hydrophobic properties. In Silorane, Reducing the Total Number of
the siloxane backbone is cyclic and the organic Covalent Bonds Formed
side groups are oxiranes. Oxiranes are three With only limited success in the use of ring
member rings consisting of two carbons and opening monomers, recent efforts to reduce
one oxygen, which is the simplest epoxide, and shrinkage have focused on yet another strate-
as pointed out previously are members of the gy. Since volumetric shrinkage has been linked
epoxy resin group. Polymers formed from oxi- to molecular sites where there is a conversion
ranes are known for low shrinkage and excel- of an electrostatic Van der Waals interaction
lent physical properties. Siloranes polymerize to a covalent bond, it stands to reason that re-
via cationic ring opening of the oxirane groups, ducing the total number of such conversions
leading to very minimal overall shrinkage. should effectively reduce the total volumetric
According to the manufacturer, the volumetric shrinkage. This can be accomplished by uti-
shrinkage obtainable with the silorane-based lizing monomer molecules with higher mo-
composite is approximately 0.9% when evalu- lecular weights, which also typically occupy
ated by the bonded disc method, also known as a larger volume of space. With fewer total
the Watt’s method. This is significant because monomer molecules to occupy the same po-
15

it is the first time a commercially available di- tential space compared to smaller monomers,
rect composite has reported a shrinkage factor there is a reduction in the number of cova-
< 1. However, when using other generally ac- lent bonds formed per unit space. This will
cepted test methods, the actual polymerization ultimately reduce the total polymerization

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 CONTINUING EDUCATION 1 LOW-SHRINK COMPOSITE RESINS

Polymerization shrinkage and its associated stress

do not always parallel one another.
Polymerization stress is a local physical state,
not a basic material property.
shrinkage and shrinkage stress. to result from a complex interaction of cav-
An example of this strategy is found in ity geometry, volumetric shrinkage, degree of
Kalore™ (GC America Inc.), which was intro- conversion, reaction kinetics, and viscoelas-
duced in 2009. Kalore is 82% filled by weight tic properties of the restorative material.17 To
and has a reported volumetric shrinkage of ap- understand this, consider the dynamics of the
proximately 1.7% (by mercury dilatometer). It curing reaction, as follows.
replaces the bis-GMA monomer with DX-511, At the very initiation of polymerization, the
a new lower shrinking monomer chemically monomers are all in a fluid or “sol state,” and
related to urethane dimethacrylate (UDMA) the composite resin behaves like a viscous so-
that has been developed by Dupont. Thus, lution. During active polymerization, liquid
Kalore is able to retain full methacrylate com- monomers are gradually converted to solid
patibility. DX-511 has a much higher molecular polymer with an accompanying reduction
weight (895) than bis-GMA (513) and has both in volume. However, as long as there is still a
stiff and flexible segments in the monomer, sufficient quantity of unset, liquid monomer
the latter of which reduces the monomer vis- readily available, any polymerization shrink-
cosity, permitting lower amounts of diluent age of restorative composite within the dental
monomers to be used in the formulation. cavity can be partially offset by the flow of un-
set monomer, ie, as the set material contracts,
Clinical Significance the gap is immediately filled with unset fluid
Polymerization Shrinkage vs. material. This is referred to as the pre-gelation
Polymerization Stress phase. No significant stress builds up within
Based on the previous information presented, the restorative material itself and none is ap-
one might conclude that a reduction in the plied to the walls of the cavity. However, once
volumetric/polymerization shrinkage of the the majority of the liquid monomer is con-
restorative material would almost always be sumed by the polymerization reaction, the
accompanied by a reduction in the stress ap- “gel phase” is initiated. Continued shrinkage
plied to the tooth. However, polymerization can no longer be offset by free monomer, and
shrinkage and its associated stress do not stress begins building up internally within the
always parallel one another. Polymerization restorative material. If the restoration is adhe-
stress is a local physical state, not a basic mate- sively bonded to a wall or walls of the tooth, this
rial property. As such, its final value is depen- stress can also transfer from the restoration to
dent upon the system geometry and boundary the tooth. Depending on the magnitude of the
conditions.16 Some of the moderating factors stress, this may result in a deflection of the
are physicochemical, and some are clinical. cuspal walls, an adhesive failure of the bond
Polymerization stress development seems between tooth and restoration, or a cohesive

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 CONTINUING EDUCATION 1 LOW-SHRINK COMPOSITE RESINS

failure (fracture) within the adhesive layer, the lower number. Though C-Factor numerically
restorative material, or the tooth itself. All of uses simple integers representing cavity walls
these adverse event results may shorten the because it is an easy value for the clinician to
life of the restoration and the tooth. assess, an important assumption is that all
walls must be of relatively equal surface area.
Determinants of Polymerization A much more accurate and appropriate calcu-
Stress lation for C-Factor would be:
Cavity Geometry
One key factor in how much polymerization
Bonded Surface Area
stress will be transferred “to the tooth” by ––––––––––––––––––––––––––– = Configuration Factor = C-Factor
the restorative material is the cavity geom-
Nonbonded Surface Area
etry. More specifically, it is only at the sites
where the restoration interfaces with and is
One can readily understand the importance
adhesively bonded to the tooth that the stress
of using this second formula (which exchang-
can be transferred. Restoration surfaces that
es rational numbers for pure integers) when
have no contact with or are not bonded to the
examining a flowable resin-based liner for a
cavity walls can deflect during polymeriza-
Class I cavity. By taking the cavity walls as
tion, allowing for internal dissipation of stress
the basis for the calculated C-Factor, it would
forces (ie, confined only to the restorative ma-
have to be:
terial). If none of the restoration’s surface area
is bonded to the tooth, it can shrink and move
Bonded Walls (Buccal + Lingual + Mesial + Distal + Pulpal)
freely within the cavity confines. However, if –––––––––––––––––––––––––––––––––––––––––––––––– = 5 = C-Factor
a single cavity wall is bonded, stress will be
Nonbonded Walls (Occlusal)
applied to the tooth at that one site and is dis-
sipated at the others. If two walls are bonded,
A C-Factor of 5 is quite high and would nor-
stress is applied to the two sites, and so on.
mally lead to very high stresses on the tooth.
Since most direct esthetic restorations are
However, for a thin cavity liner applied to the
adhesively bonded, the exact cavity geometry
pulpal floor, the buccal, lingual, mesial, and
and number of bonded and nonbonded sur-
distal surfaces contribute relatively little to
faces becomes a key factor to polymerization
the total bonded surface area in comparison
stress. A convenient way to describe this is the
to the pulpal surface. Dropping the four neg-
ratio of the bonded walls to the nonbonded
ligible surfaces yields a C-Factor of 1, which
walls, which provides a quantifiable measure
is very low:
of where and how much stress can be applied
directly to the tooth and cavity. This ratio has
Bonded Walls (Pulpal)
been referred to as “Configuration Factor” or –––––––––––––––––––––––––––––––––––––––––––––––––– = 1 = C-Factor
“C-Factor” for short18:
Nonbonded Walls (Occlusal)

Bonded Cavity Walls This explains why using a higher shrinking

-––––––––––––––––––––––––––– = Configuration Factor = C-Factor
Nonbonded Cavity Walls
Cavities with a high C-Factor would tend to
have higher potential stress than those with a
flowable composite resin liner can actually
help buffer against shrinkage stress and re-
duce postoperative sensitivity.
It is important for a clinician to consider the
C-Factor of a dental cavity because those with

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 CONTINUING EDUCATION 1
Although incremental placement with light-cured
composites may be necessary for light penetration
and maximum depth of cure, it includes the possibility
of trapping voids or contamination between layers
and increased chair time.
higher C-Factors tend to have more stress-
related, postoperative sequelae. This can
explain why a small Class I direct compos-
ite restoration that is nowhere near the pulp
can trigger significant post-restorative pain.
Based on the formula above, a normal depth
Class I cavity has a C-Factor of 5, which is the
highest possible.
Incremental Layering Vs. Bulk Placement
To help reduce the effects of shrinkage stresses
caused by cavity configuration, incremental
layering instead of bulk placement of the di-
rect restoration has been broadly advocated
and accepted by clinical dentistry.19 Layering
has also been recommended to improve
bond strength20 and reduce interfacial mi-
croleakage,21 cuspal deflection,22 and even
postoperative sensitivity.23 Although the use
of some type of incremental placement with
light-cured composites may be necessary for
adequate light penetration and to achieve
maximum depth of cure, its disadvantages
include the possibility of trapping voids or
contamination between layers and increased
chair time.24 Different incremental placement
techniques have been proposed with the ra-
tionale that oblique increments applied first
to the cuspal inclines would help reduce the
C-Factor and the stress applied to buccal and
lingual cusps by horizontal increments that
bridge them together during curing. To date,
the literature has not shown conclusively
11 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 2 www.compendiumlive.com
LOW-SHRINK COMPOSITE RESINS
that incremental layering definitively helps
reduce the effects of shrinkage stress versus
bulk placement. For example, a study by Abbas
showed that using multiple increments caused
greater cuspal deflection in premolars than a
single bulk increment,25 while a more recent
but similar study by Lee showed just the op-
posite.26 In two other studies that used finite
element analysis (FEA) to study different in-
cremental filling techniques, the results were
also dichotomous. Versluis concluded that in-
cremental filling increased the deformation
of the restored tooth and led to a more highly
stressed tooth–composite structure,27 while
an FEA study by Kuijs concluded that using a
chemically cured composite did result in low-
ered stress, but when considering light-cured
composites, none of the layering techniques
was significantly different from each other or
bulk filling.28
The trend of contradictory studies is also
found for the issue of oblique versus hori-
zontal layering techniques. One study of the
microtensile bond strengths to the dentin in
deep Class I cavities found multiple horizontal
layers to be the most promising way to get a
good bond to the cavity floor.29 A later study
by Nui showed that oblique layering produced
higher bond strengths.30 Park et al also consid-
ered bulk filling versus horizontal and oblique
layering. Their study utilized aluminum molds
instead of natural teeth to exclude significant
specimen variance. It found that bulk-filling
 CONTINUING EDUCATION 1
It has been shown that slowing down the rate
at which the polymer network is formed allows
more of the unset material to flow and compensates
for the volumetric change.
techniques with light-cured composite yield-
ed significantly more cuspal deflection than
the incremental filling techniques, but found
no significant differences between the hori-
zontal and oblique incremental methods.31
Thus, it is rather difficult to draw definitive
conclusions as to whether incremental lay-
ering is actually beneficial or which clinical
layering technique is superior. This ambigu-
ity has prompted manufacturers to develop
and offer direct composites that are intended
mainly for bulk-filling or modified bulk-filling
placement techniques. (Early commercially
available products for this approach include
SureFil SDR® flow, DENTSPLY Caulk, and
Venus® Bulk Fill, Heraeus Kulzer). The actual
technique being recommended is a modified
bulk-fill procedure where a horizontal layer
of up to 4 mm of low-modulus flowable com-
posite is used to fill the bulk of cavity but is
capped by a 2-mm layer of more traditional,
universal composite. The term “bulk-fill base”
has been used to describe this procedure. Of
course, should the cavity become very deep,
more than one increment of the low-modulus
base may still be required to assure adequate
depth of cure.
Degree of Conversion and Reaction
Kinetics
It would seem intuitive and it has been con-
firmed in the literature that a direct rela-
tionship exists between the degree of con-
version and the volumetric shrinkage of a
12 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 2 www.compendiumlive.com
LOW-SHRINK COMPOSITE RESINS
methacrylate-based composite.32,33 For a
specific composite, lowering the degree of
conversion will also lead to a lower shrinkage
strain and interfacial stress.34 Unfortunately,
lowering the degree of conversion generally
has a negative impact on the physical proper-
ties of the set material; therefore, this is not a
practical way to reduce stress. However, it is
practical and possible to reduce polymeriza-
tion stresses by altering the rate/kinetics of
the polymerization reaction. The rate of cure
is actually the degree of conversion per unit
time (DC/s). It has been shown that slowing
down the rate at which the polymer network
is formed allows more of the unset material
to flow and compensates for the volumetric
change and even allows for a molecular level
rearrangement to occur in the developing
polymer. This reduces or delays the buildup
of internal and interfacial stresses.35
One of the earliest methods recognized to
reduce polymerization kinetics was the use
of self-curing composite materials rather
than photoinitiated versions. Because the
polymerization reaction occurs much more
slowly with self-curing composites, it pro-
vides an extended “pre-gelation stage,” which
translates into higher flow and lower stress
levels.36,37 However, auto-curing composites
often have a lower degree of conversion and
lowered physical properties when compared
with light-cured composites. Thus, there is
some controversy as to whether the stress
reductions are actually due to an altered rate
 CONTINUING EDUCATION 1
of cure or the lowered degree of conversion.
Auto-cure composites also require higher
amounts of tertiary amine co-initiators than
light-cured composites to catalyze the setting
reaction. This combined with the lesser de-
gree of conversion leads to more unreacted
monomer and greater color instability. This
has discouraged a more general use of auto-
cure composites.
The polymerization kinetics for light-cured
composites can be favorably reduced with-
out impacting final conversion by varying the
concentration of photoinitiators or a com-
mon polymerization inhibitor, butylated hy-
droxytoluene (BHT), which is used to help
prevent premature setting and extend the
shelf-life of the product.38 Since the curing
rate of light-cured composites is proportional
to the square root of the power density (PD =
mW/cm2 ), modulation of the power density
delivered in the early stages of the photo-ac-
tivation period or by the use of a low power
density for extended exposure times has also
been advocated to decrease stress without af-
fecting the final degree of conversion. This
early work by Bouschlicher and Reuggeberg39
led to a number of advanced curing lights that
offer “soft start,” “ramped,” stepped, and low
power modes designed to reduce the power
density at the beginning of the polymeriza-
tion reaction and increase it over time. While
these modified curing modes have received
widespread acceptance from manufacturers
and practitioners, there are conflicting stud-
ies as to their overall benefits. Some studies
have reported they were effective in reducing
the contraction stress rate or improving the
strength of the bonded interface,40 while oth-
ers determined the predominant reason for
decreased shrinkage stress with “soft start” or
“pulse curing” was due to a modest decrease
in the final conversion percentage.41 Fleming
reported that soft-start polymerization did
not significantly reduce marginal leakage or
cuspal deflection nor increase the degree of
13 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 2 www.compendiumlive.com
LOW-SHRINK COMPOSITE RESINS
conversion.42 Chan showed no differences in
postoperative sensitivity or decreased signs
of marginal stress after a 24-month clinical
trial.43 A recent paper may have proposed a
plausible explanation for these discrepancies.
According to Ilie, soft-start polymerization
may produce a valid benefit when the cavi-
ties are 2-mm deep or less, but when cavities
reached depths of 6 mm or higher there was
a significant drop in degree of conversion.44
Emergence of Lower Shrinkage Stress
Monomer Chemistry
As discussed earlier, the development of low-
volumetric shrinkage monomers such as
Silorane or DX-511 has not necessarily led to
a comparable reduction in shrinkage stresses.
This has, in turn, stimulated developments
in “lower contraction stress” monomers. One
such monomer is found in the aforementioned
SureFil SDR flow, which uses an oligomeric
resin monomer made of a dimethacrylate,
a polyisocyanate, and a reactive monomer
with photoresponsive moiety derived from a
photoinitiator. The resultant monomer has a
higher molecular weight of 849 g/mol when
compared with bis-GMA (513 g/mol). This
offers the previously discussed advantage
of reduced polymerization shrinkage due
to fewer covalent bonds per unit of volume.
However, according to the manufacturer, the
high molecular weight and the conformational
flexibility around the centered polymeriza-
tion modulator imparts an optimized flexibil-
ity and network structure to the cured resin,
which allows it to dissipate more energy (and
store less) during polymerization.
Another novel low-shrinkage/stress mono-
mer is TCD-DI-HEA (bis-(acryloyloxymethyl)
tricyclo[5.2.1.02,6]decane) (which is found,
for example, in Venus Diamond® Nanohybrid
Composite [Heraeus Kulzer]). The TCD
monomer utilizes several strategies to help
reduce volumetric shrinkage and shrinkage
stress. First, it possesses a very rigid backbone
 CONTINUING EDUCATION 1
similar to bis-GMA, which helps reduce mo-
lecular vibrations due to Brownian motion. It
also lacks the polar hydroxyl groups found in
bis-GMA. Both of these properties help reduce
the intermolecular distances between mono-
mer molecules in the uncured state. Therefore,
the change between the uncured and cured
states is minimized, which would help impart
lower volumetric shrinkage behavior to the
TCD. However, the monomer also possesses
highly elastic urethane side chains, which al-
lows the molecule to internally absorb stress
and better compensate for the already reduced
volumetric shrinkage. Numerous studies have
demonstrated that TCD is highly effective in
reducing both volumetric shrinkage and the
resultant shrinkage stress.45,46
Viscoelastic Effects
As previously discussed, increasing the total
amount of inorganic filler has been used in
restorative composites to help increase frac-
ture toughness and resistance to wear and to
reduce their overall polymerization shrinkage.
It has also been shown that there is a strong
correlation between filler volume and the
elastic modulus or stiffness of the restorative
material.47 Unfortunately, the increased stiff-
ness of the more heavily filled materials has
been found to play a major role in determining
the amount of polymerization stress that is
ultimately produced in the system.48 On the
basis of that study it appears that using low-
er modulus or less heavily filled composites
where clinically appropriate might be prefer-
able, because they tend to produce lower lev-
els of polymerization stress. While it may not
be ideal to use a low-filled composite under
posterior occlusal loading, it can be especially
useful when restoring nonstress-bearing sur-
faces such as Class III or Class V lesions.49 One
useful formulation modification for higher
filled hybrids is the inclusion of nonbonded
microfiller particles, which are thought to pro-
duce significant decreases in polymerization
14 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 2 www.compendiumlive.com
LOW-SHRINK COMPOSITE RESINS
stress by acting as localized stress-relieving
sites within the composite.50
Conclusions
Though much has already been accomplished
to better understand and manage the shrink-
age behavior and resultant stresses inherent in
direct placed composite restorations, this con-
tinues to be a challenge. Fully comprehending
all of the factors involved and their complex
interactions has, to date, proven to be very dif-
ficult. For some concepts there are conflicting
studies. Further research is needed to provide
clinical guidance in materials and techniques
for various direct restorative configurations.
Resin manufacturers have already done
much to significantly lower volumetric shrink-
age and are now beginning to make progress
in reducing the resultant stresses to the tooth
that can cause many adverse clinical sequel-
ae. Nontraditional monomers and innova-
tive clinical techniques offer the promise of
minimizing shrinkage and stresses to far less
significant levels.
ACKNOWLEDGMENTS
The author wishes to acknowledge the assis-
tance of Zach Turner of Blue Motion Studios,
LLC for the creation of the drawings for this
article.
ABOUT THE AUTHOR
Mark L. Pitel, DMD
Associate Clinical Professor of Operative Dentistry, Director of
Predoctoral and CDE Esthetic Studies, Columbia University
College of Dental Medicine, New York, New York
Queries to the author regarding this course may be submitted
to authorqueries@aegiscomm.com.
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15. Watts DC, Cash AJ. Determination of polym-
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16. Tantbirojn D, Versluis A, Pintado MR, et al. Tooth
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17. Pfeifer CS, Ferracane JL, Sakaguchi RL, Braga
RR. Factors affecting photopolymerization stress
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18. Carvalho RM, Pereira JC, Yoshiyama M, Pashley
DH. A review of polymerization contraction: the
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19. Donly KJ, Jensen ME. Posterior composite
polymerization shrinkage in primary teeth: an in
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15 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 2 www.compendiumlive.com
LOW-SHRINK COMPOSITE RESINS
20. He Z, Shimada Y, Sadr A, et al. The effects of
cavity size and filling method on the bonding to
Class I cavities. J Adhes Dent. 2008;10(6):447-453.
21. Tjan AHL, Bergh BH, Lidner C. Effect of various
incremental techniques on the marginal adaptation
of class II composite resin restorations. J Prosthet
Dent. 1992;67(1):62-66.
22. Kim ME, Park SH. Comparison of premolar cus-
pal deflection in bulk or in incremental composite
restoration methods. Oper Dent. 2011;36(3):326-334.
23. Ward DH. Treating patients with CARE (comfort-
able aesthetic restorations): reducing postoperative
sensitivity in direct posterior composite restorations.
Dent Today. 2004;23(8):60, 62, 64-65.
24. Campodonico CE, Tantbirojn D, Olin PS, Versluis
A. Cuspal deflection and depth of cure in resin-
based composite restorations filled by using bulk,
incremental and transtooth-illumination techniques.
J Am Dent Assoc. 2011;142(10):1176-1182.
25. Abbas G, Fleming GJ, Harrington E, et al. Cuspal
movement and microleakage in premolar teeth
restored with a packable composite cured in bulk or
in increments. J Dent. 2003;31(6):437-444.
26. Lee MR, Cho BH, Son HH, et al. Influence of cav-
ity dimension and restoration methods on the cusp
deflection of premolars in composite restoration.
Dent Mater. 2007;23(3):288-295.
27. Versluis A, Douglas WH, Cross M, Sakaguchi
RL. Does an incremental filling technique reduce
polymerization shrinkage stresses? J Dent Res.
1996;75(3):871-878.
28. Kuijs RH, Fennis WM, Kreulen CM, et al. Does
layering minimize shrinkage stresses in composite
restorations? J Dent Res. 2003;82(12):967-971.
29. Nikolaenko SA, Lohbauer U, Roggendorf M, et
al. Influence of c-factor and layering technique on
microtensile bond strength to dentin. Dent Mater.
2004;20(6):579-585.
30. Niu Y, Ma X, Fan M, Zhu S. Effects of layering
techniques on the micro-tensile bond strength to
dentin in resin composite restorations. Dent Mater.
2009;25(1):129-134.
31. Park J, Chang J, Ferracane J, Lee IB. How
should composite be layered to reduce shrink-
age stress: incremental or bulk filling? Dent Mater.
2008;24(11):1501-1505.
32. Venhoven BA, de Gee AJ, Davidson CL. Polym-
erization contraction and conversion of light-curing
BisGMA-based methacrylate resins. Biomaterials.
1993;14(11):871-875.
33. Silikas N, Eliades G, Watts DC. Light intensity ef-
fects on resin-composite degree of conversion and
shrinkage strain. Dent Mater. 2000;16(4):292-296.
34. Ferracane J, Greener EH. The effect of resin for-
mulation on the degree of conversion and mechani-
cal properties of dental restorative resins. J Biomed
Mater Res. 1986;20(1):121-131.
 CONTINUING EDUCATION 1
35. Braga RR, Ferracane JL. Contraction stress re-
lated to degree of conversion and reaction kinetics.
J Dent Res. 2002;81(2):114-118.
36. Krejci I, Lutz F. Marginal adaptation of Class V
restorations using different restorative techniques. J
Dent. 1991;19(1):24-32.
37. Feilzer AJ, de Gee AJ, Davidson CL. Setting
stresses in composites for two different curing
modes. Dent Mater. 1993;9(1):2-5.
38. Payne MD, Ferracane JL, Sakaguchi RL. Moni-
toring curing of composites with varied BHT levels
using DMA and PhotoDSC [abstract]. J Dent Res.
2001;80(spec iss). Abstract 250.
39. Bouschlicher MR, Rueggeberg FA. Effect of
ramped light intensity on polymerization force and
conversion in a photoactivated composite. J Esthet
Dent. 2000;12(6):328-339.
40. Cunha LG, Alonso RC, Pfeifer CS, et al. Modu-
lated photoactivation methods: Influence on con-
traction stress, degree of conversion and push-out
bond strength of composite restoratives. J Dent.
2007;35(4):318-324.
41. Lu H, Stansbury JW, Bowman CN. Impact of cur-
ing protocol on conversion and shrinkage stress. J
Dent Res. 2005;84(9):822-826.
42. Fleming GJ, Cara RR, Palin WM, Burke FJ. Cuspal
movement and microleakage in premolar teeth
restored with resin-based filling materials cured us-
ing a ‘soft-start’ polymerisation protocol. Dent Mater.
16 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 2 www.compendiumlive.com
LOW-SHRINK COMPOSITE RESINS
2007;23(5):637-643.
43. Chan DC, Browning WD, Frazier KB, Brackett
MG. Clinical evaluation of the soft-start (pulse-de-
lay) polymerization technique in Class I and II com-
posite restorations. Oper Dent. 2008;33(3):265-271.
44. Ilie N, Jelen E, Hickel R. Is the soft-start polym-
erization concept still relevant for modern curing
units? Clin Oral Investig. 2011;15(1):21-29.
45. Marchesi G, Breschi L, Antoniolli F, et al. Con-
traction stress of low-shrinkage composite materials
assessed with different testing systems. Dent Mater.
2010;26(10):947-953.
46. Cadenaro M, Codan B, Navarra CO, et al. Con-
traction stress, elastic modulus, and degree of
conversion of three flowable composites. Eur J Oral
Sci. 2011;119(3):241-245.
47. Braem M, Van Doren VE, Lambrechts P, Vanherle
G. Determination of Young’s modulus of dental
composites: a phenomenological model. J Mater Sci.
1987;22:2037-2042.
48. Condon JR, Ferracane JL. Assessing the effect
of composite formulation on polymerization stress.
J Am Dent Assoc. 2000;131(4):497-503.
49. Tyas MJ. The Class V lesion: aetiology and resto-
ration. Aust Dent J. 1995;40(3):167-170.
50. Condon JR, Ferracane JL. Reduction of com-
posite contraction stress through non-bonded
microfiller particles. Dent Mater. 1998;14(4):256-260.
 CONTINUING EDUCATION 1 QUIZ
Low-Shrink Composite Resins: A Review of Their History,
Strategies for Managing Shrinkage, and Clinical Significance
TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/LSCOMPOSITERESINS
ENTER PROMO CODE: CCEDREVIEW
1. The extent to which monomers can be
transformed into a polymer is called the:
A. polymerization product.
B. polymerization coefficient.
C. transformational index.
D. degree of conversion.
2. When the benzoyl peroxide-tertiary amine
initiator reaction was discovered, it allowed
methyl methacrylate-based materials to:
A. have a stable final color or shade.
B. be certified by the FDA.
C. cure at room or oral temperatures.
D. incorporate a small amount of fluoride in
the final compound.
3. While unfilled methyl methacrylate monomer
has a shrinkage of ~25% during setting,
incorporating fillers into the monomers
lowers overall shrinkage to about:
A. 1%.
B. 3%.
C. 7%.
D. 15%.
4. For epoxy resins, which type of
polymerization almost always results
in a lower polymerization shrinkage?
A. Linear
B. Alternating
C. Endothermic
D. Ring opening
5. Bis-GMA itself has a reported volumetric
shrinkage of about:
A. 1%.
B. 3%.
C. 5%.
D. 7.1%.
Course is valid from 3/1/2019 to 3/31/2022. Participants must
attain a score of 70% on each quiz to receive credit. Partici-
pants receiving a failing grade on any exam will be notified and
permitted to take one re-examination. Participants will receive
an annual report documenting their accumulated credits, and
are urged to contact their own state registry boards for special
CE requirements.
17 COMPENDIUM EBOOK SERIES February 2021
2 Hours CE Credit
Mark L. Pitel, DMD
6. As filler density increases, overall
polymerization shrinkage decreases because
shrinkage is:
 A. confined exclusively to the monomer
phase.
B. d ependent on the chemical interaction with
the filler.
C. a multiple of filler content.
D. related to how much heat energy is
transferred to the filler.
7. To achieve the greatest density or loading of
irregularly shaped particles:
A. an assortment of particles is needed.
B.the grain of the particles needs to fit
parallel.
C. t he grain of the particles needs to fit
perpendicular.
D. the pH of the monomer must be >7.
8. The technical challenge of using spiro
orthocarbonates (SOCs) in clinical resin
composites is that they:
A. do not produce a consistent shade when
cured.
B. are unable to bond to enamel.
C. are unable to bond to dentin.
D. are mainly crystalline at room temperature.
9. Polymerization stress development seems
to result from a complex interaction that
includes:
A. cavity geometry.
B. volumetric shrinkage.
C. reaction kinetics.
D. All of the above
10. The curing rate of light-cured composites is
proportional to the:
A. size of the photoinitiator molecule.
B. square root of the power density.
C. cube of the wavelength.
D. inverse of the wavelength.
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www.ada.org/cerp. Provider ID# 209722.
| Volume 42 Number 2 www.compendiumlive.com
 CLINICAL CASE PRACTICAL, FLOWABLE TECHNIQUE

A Practical, Flowable Technique

for Restoring a Worn Dentition
Giancarlo Romero, DDS, MS

KEY TAKEAWAYS

• Adhesive dentistry using
a range of products from
BISCO is an alternative to
conventional, full-mouth
rehabilitation involving root
canal treatment for restorative
• The use of selective etching
and a universal bonding
agent can eliminate post-
cementation sensitivity,
a common problem in
restorative dentistry.
• Reducing the provisional
service period minimizes
complications with recurrent
caries, fractures, and loose
temporaries.

T
indications.

he restoration of a worn dentition can be a compli-

cated, lengthy procedure. Often, patients present with
collapsed vertical dimension of occlusion (VDO) and/
or minimal tooth structure, leading clinicians to pre-
scribe root canal treatment on multiple canals to gain
resistance form prior to restoring. This case demonstrates a flowable
technique, in which a laboratory wax-up was transferred at the esti-
mated VDO with the use of translucent silicon matrices fabricated
from the cast. Each tooth was restored with flowable composite; the
patient can be fully treated in one or two sessions. This technique,
ABOUT THE AUTHOR
featuring the use of various BISCO products (bisco.com), allows Giancarlo Romero, DDS, MS
the clinician to reestablish the proper VDO, occlusion, and esthet- Clinical Assistant Professor, Graduate
ics before completing the case with final ceramic materials. The key Prosthodontics, University of Texas
advantage is not having acrylic temporaries in the mouth for months Health Science Center, Houston, Texas;
Private Practice, Houston, Texas
when the case requires temporomandibular disorder resolution. Center, San Antonio, Texas
Another advantage is the use of segmental impression-taking versus
a full-arch impression due to the occlusion being dialed in and there
being no need for full-mouth temporaries. This approach also eases
the financial burden for the patient over time. Finally, this protocol
preserves marginal peripheral enamel for excellent bond strength
in these areas when compared to adhesion to dentin.

Before After

Before. Initial presentation illustrating excessive wear and reduced VDO.

18 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 2 www.compendiumlive.com

 CLINICAL CASE PRACTICAL, FLOWABLE TECHNIQUE

Fig 1. Fig 2.

Fig 3. Fig 4.

Fig 5. Fig 6.

Fig 1. Occlusal and lingual erosive lesions were present in the maxillary arch. The patient reported being a
heavy soda drinker. Fig 2. Occlusal and facial erosive lesions were present in the mandibular arch. The bi-
cuspids showed transparency to the pulp chamber. The patient was not symptomatic to cold or hot. Fig 3.
After fabrication of a diagnostic wax-up on an articulator at the estimated VDO following the principles
of phonetics and esthetics, the technique treats one tooth at time or alternating teeth, as shown. Adja-
cent teeth were isolated with Teflon tape. Selective etch with phosphoric acid (Select HV® Etch, BISCO), if
required, and bonding agent (All-Bond Universal®, BISCO) were applied and cured. Fig 4. With the aid of
a clear silicon matrix fabricated from the wax-up, flowable composite (Aeliteflo™, BISCO) was applied. The
composite will fill all empty space occupied by the wax-up and then be light-cured through a clear matrix.
Fig 5. Build-up with flowable composite on teeth Nos. 22 through 27, transferring wax-up to the clinical
situation. Fig 6. In one or two appointments, the full wax-up is transferred in a reversible fashion. The VDO
then gets restored, and no temporaries are needed. Final occlusion can now be dialed in.

19 COMPENDIUM EBOOK SERIES February 2021 | Volume 42 Number 2 www.compendiumlive.com

 CLINICAL CASE PRACTICAL, FLOWABLE TECHNIQUE

F i g 7. Fig 8. Fig 9.

Fig 7. Occlusal view illustrating the ideal transfer of

the proposed wax-up. Fig 8. After the patient ad-
justed to the new VDO and final preparations were
done with the flowable mock-up acting as a prepa-
ration guide since it was the final contour of the final
restorations, lithium-disilicate restorations (e.max®,
Ivoclar Vivadent, ivoclarvivadent.com) were fabri-
cated, as shown. The restorations were treated with
hydrofluoric acid etch (Porcelain Etchant, BISCO),
ultrasound in alcohol for 5 minutes, and application
of silane (Porcelain Primer, BISCO).

Fig 10.

Fig 9. (upper right corner of page) A segmental

impression was done in the mandibular arch. This is
less challenging than trying to do a full-mouth im-
pression with an active tongue. Note the preserva-
tion of marginal peripheral enamel. Final mandibular
anterior veneer preparations and a final impression
would follow (not shown). Fig 10. Final maxillary full-
coverage all-ceramic crowns bonded in place using
selective etching, universal bond, and dual-cure
resin cement (eCEMENT® dual-cured, BISCO). Fig 11.

Fig 11. Final man-

dibular veneers
bonded in place
using selective
etching, universal
bond, and light-
cured resin cement
(eCEMENT® light-
cured, BISCO).
Fig 12. Final resto-
rations bonded and
final rehabilitation.
Fig 12.

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