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Inside Dentistry
September 2007
Volume 3, Issue 8

Polymerization Shrinkage—A Clinical Review

Deniz Cakir, DDS, MS; Robert Sergent, DMD; and John O. Burgess, DDS, MS

The greatest limitation in the use of composite resin as a posterior restorative material seems to be shrinkage during polymerization, which leads to po
marginal seal, marginal staining, and recurrent caries. Because no method guarantees a perfectly sealed restoration for adhesive restorative materials,
clinicians must address problems of polymerization shrinkage and resulting destructive shrinkage stress. Only a thorough understanding of the mecha
that cause shrinkage stress and the techniques that may reduce its effect will allow clinicians to gain a better use of resin composites. Because recurr
caries is one of the leading causes of restoration replacement, it is imperative that low-shrinkage composite resins be developed. The objectives of this
are to review the origin of polymerization shrinkage, the clinical factors affecting polymerization stress, and methods advocated to reduce shrinkage st
and the effectiveness of these methods.

ORIGIN OF STRESS
Composite resins have four primary components: an organic matrix, inorganic Gllers, a coupling agent that binds the Gller to the matrix, and the
initiator/accelerator system. In most composites, the organic matrix is a dimethacrylate, generally bisphenol-A glycidil dimethacrylate (bis-GMA) or ure
dimethacrylate (UDMA) blended with triethylene glycol dimethacrylate (TEGDMA). The matrix contains reactive carbon-carbon double bonds, which cro
to form a polymer network. Composite resin polymerizes by free radical polymerization generated when a photo-initiator, such as camphoroquinone, ab
light energy (photons) emitted from the curing light and initiates polymerization by reacting with a photoreducer, a tertiary amine forming free radicals
initiating crosslinking.1 Camphoroquinone has a maximum absorption at 468 nm and can be polymerized with LED curing lights. Some composite resin
other photoinitiators, such as 1-phenyl-1,2-propanedione (with a peak absorption of 410 nm), bisacylphosphine oxide, or triacylphosphine oxide (with p
absorptions of 320 nm to 390 nm), which fall outside the curing range of most LED curing lights.1 These photoinitiators are used to reduce the strong y
color produced by camphoroquinone.

The exothermic reaction created when the monomer converts to the polymer produces a volume reduction in the polymer with a resulting decrease in
molecular vibration and intermolecular distances.2 As the polymer is formed, the resin matrix changes from a paste or pregel state to a viscous solid
composite resin contracts by about 1.5% to 5%. The gel point is the point at which the resin changes from a viscous paste to an elastic solid. When the
point is reached, stress is transmitted from the composite resin to the surrounding tooth structures. When composite resin is a paste, or pregel state, n
stress is conducted to surrounding tooth structure. As curing begins, the material dows from unbound surfaces to accommodate for shrinkage. As the
composite resin becomes more rigid because of the increasing modulus of the composite, dow stops and the bonded composite resin transmits shrin
stresses generated to the surrounding tooth. This point is called the gel point and the stress generated may exceed the adhesive bond or the cohesive
strength of the tooth or the composite, producing a marginal defect.

When composite resin is bonded on all surfaces, shrinkage must be compensated by strain (dow) of the composite, tooth, or adhesive.4 If this stress is
greater than the cohesive strength of the composite, damage occurs within the composite.5 If the stress exceeds the tensile strength of enamel, the en
fractures. If the adhesive was placed improperly, then it will fail. These failures can be seen as a white line that appears during restoration Gnishing bec
the Gnishing debris collects in the defect and changes the index of refraction of light.6 Cracks or fractures are seen in teeth with bucco-lingually wide
restorations7 because the cavity walls are primarily enamel, which is brittle and too thin to withstand the forces generated by polymerization shrinkage

FACTORS IN SHRINKAGE
Polymerization shrinkage, stress, and modulus development are dependent on the conversion of the monomer to the polymer. Stress development is a
7-9
by the preparation geometry and substrate compliance7-9 (whether the composite resin and or tooth structure can dex). The C-factor is the ratio of bon
and unbonded surfaces in the restored tooth. Feilzer and colleagues8 used C-factor to describe the stress generated during polymerization shrinkage o
composite resin. When the ratio of bonded to unbonded surfaces increases, the stress placed on the tooth increases because the composite resin can
dow to relieve the shrinkage stresses.

The greatest stress occurs when composite is bonded to Gve walls of a prepared cavity (C = 5) as in Class 1 or Class 5 restorations. The composite att
to shrink toward the bonded surface but will be restrained by the bonded areas on the opposing surface. The lowest C-factor values are obtained with c
cavities because the material has enough unbonded surfaces to dow, providing stress relief. A high C-factor creates a risk for debonding of the restora
Shallow and large designs reduce the C-factor; therefore, it is important to have a lower conGguration cavity. If a light-curing technique could produce a
difference in marginal adaptation, it could be most easily demonstrated in the Class 1 or Class 5 restoration.

The authors could not Gnd any clinical study that demonstrated that any curing method produced an improvement in marginal adaptation or marginal
discoloration compared with a standard incremental placement and curing technique. The ability of polymer to dow, and thereby relieve some portion o
stress, is documented. Most recent studies measuring the shrinkage of composite resins have reported about 2% to 3% polymerization shrinkage by vo
in highly Glled composite resin restorative material.10,11 Flowable composite resins have greater shrinkage, ranging from 4% to 5% per volume.
polymerization shrinkage produced in a given composite resin is related to the shade, opacity, and composition of the composite resin, the irradiance le
exposure times of the curing light used, any incompatibility between a photo-initiator system and the spectral output of the curing light, cavity preparat
geometry, and composite layer thickness.13,14

When composite resins are cured, light passes through the composite attenuates, which means that deeper layers of composite resin are less cured. A
factor that decreases the light intensity passing through the composite will lower the conversion rates of the composite resin. If inadequate levels of
conversion are achieved during polymerization, mechanical properties and wear resistance are reduced. With incomplete curing, leachable residual
monomers and initiators become greater biocompatibility issues, and color instability can also become a problem. The following is a list of factors tha
polymerization shrinkage stress:15,16
• curing-light guide placement (how far away from the surface it is);
• intensity and wavelength of the curing light;
• curing mode of the composite resin (light-cure or chemical-cure);
• dow of the composite—early compensation before development of signiGcant modulus of material;
• water sorption of the composite—a mechanism for compensating for shrinkage and giving improved marginal adaptation;
• composition composites with low Gller increases shrinkage (dowables vs restorative composites);
• shade and opacity of the composite resin; and
• type of composite resin—dowable vs highly Glled.

Different resins cure differently. Light-cured composite materials may be undercured through reduced irradiance levels, inadequate exposure times, or
incompatibility between a photo-initiator and the spectral output of the curing light. A curing unit may register 700 mW/cm2, but as light passes throug
composite it attenuates, diminishing rapidly from 248 mW/cm2 at 0.5-mm thickness to 25 mW/cm2 at 3-mm thickness of composite resin. Curing com
in 2-mm increments is recommended.

The depth of cure of the composite resin varies not only with the power density of the curing light and the amount of photo-initiator in the composite, b
with the type and shade of the composite, with darker, more opaque shades and microGlls requiring longer curing times. The further the light guide is fr
surface being cured, the lower the energy received by the composite and the longer that particular material must be cured. Light attenuates when pass
through tooth structure as well as the composite. Therefore, curing through the tooth reduces light intensity and it is not recommended as an effective
method for poly-merizing composite resin restorations.

CONTROLLING THE EFFECTS OF SHRINKAGE

Several articles have suggested that modifying curing light output may reduce polymerization shrinkage and improve marginal integrity. Three modes a
available. A continuous cure is used when the output is constant for a speciGed period of time. The step- or ramp-cure begins at low intensity and switc
higher intensity. The pulse-delay cure is a discontinuous curing procedure. With this technique, increments of composite resin are inserted and cured u
the continuous cure. The Gnal occlusal increment receives a brief low-intensity cure and, after a delay during which the resin is Gnished, the material is
fully polymerized to gain Gnal mechanical properties. Although it has been suggested that the curing mode and composite resin placement technique m
affect the marginal integrity of a composite resin restoration, in vitro results to date have been mixed, with some investigators showing improved resist
leakage while others have been unable to demonstrate eicacy with these techniques.

Originally, a vertical placement incremental technique would reduce the total shrinkage in a composite resin restoration. Since then, many variations of
incremental placement technique have been advocated. A gingivo-occlusal layering (horizontal)17,18 and wedge-shape layering (oblique) method is to p
and polymerize wedge-shaped composite increments from the occlusal surface;19 the successive cusp build-up technique20 is to apply the Grst compo
increment to a single dentin surface without contacting the opposing cavity walls, and to build up the restoration by placing a series of wedge-shaped
composite increments; with this technique each cusp is built up separately.

21
One early publication21 advocated a three-sided light-curing technique and incremental placement of the composite to decrease the polymerization str
generated in the tooth structure during composite resin curing. In this technique, a transparent matrix is used and a light-redecting wedge is placed
interproximally at the gingival margin of the preparation. Light-curing progressed by curing through the wedge to cure the initial gingival increment of
composite, then the buccal, and then the facial increment was placed and cured. Even though this technique has been used by many clinicians, Losche
reported that little light reaches the center of the preparation. The three-sided curing technique’s success is not due to the three-sided method, but to
decreased light transmission and poor composite resin polymerization. This brings into question all techniques where increments greater than 2 mm a
or the composite resin is cured through the tooth. In the centripetal build-up technique,28 developed for class II cavity restorations, an initial vertical com
increment is applied on the cervical margin against the metal matrix. Cavity Glling is then completed by horizontally layering. This technique allows
transformation of class II cavities into class I cavities.

Bulk placement and curing has been recommended to reduce stress at the cavosurface margins.23 Using transenamel polymerization, advocated by
Belvedere,24 the adhesive, a dowable composite, and a composite resin are placed into the preparation in bulk and then polymerized by curing through
tooth from the buccal and lingual. Polymerization is completed by curing from the occlusal. This method of curing composite resin was tested by meas
the leakage in Class I restorations. In two separate studies,25,26 composite resin was used to restore premolars using four different placement and curi
techniques. No difference in leakage was found from the bulk-Glling technique vs any of the incremental curing techniques, even the pulse-delay curing
technique. In these studies, the composite resin was placed incrementally using different types of increments—horizontal, diagonal, and with a slit in th
center of the composite that was Glled with a Gnal incremental of composite. There was no statistical difference among any group and the bulk Gll had
same leakage as the other placement methods. After the microleakage was measured, the hardness of the sectioned teeth was measured, beginning f
the occlusal and proceeding toward the pulp. The hardness of the bulk-Glled restorations was signiGcantly less than the incrementally cured restoration
which again demonstrates the limited depth of cure of composite resin.

Composite placed incrementally ensures more complete curing. Incompletely cured composite resins may release components into the oral cavity tha
be detrimental.27 The reason for the reduced shrinkage with the bulk-curing technique is obvious—uncured composite resin does not shrink as much a
completely cured resin. A signiGcant factor in the reduction of curing effectiveness with a bulk-Glling technique is that, as previously discussed, light
attenuates while penetrating through the tooth structure. As light passes through the tooth structure, it drops dramatically from 500 mW/cm2
mW/cm2 when curing through 2.5 mm of tooth.

Is incremental curing the answer to curing completely without stress? Many investigators have compared incremental curing with bulk polymerization
composite resin. Eakle and Ito28 compared four incremental insertion methods and noted that diagonal insertion was best. Crim and Chapman
that incremental placement of composite resin was no more effective than bulk placement in reducing leakage. Coli and Brannstrom30 reported that in
composite resin restorations with bulk insertion, the number of restorations with gaps was similar to a two-stage insertion. Versluis and colleagues
that incremental Glling techniques reduce cusp movement in teeth with a well-established bond. This brief and incomplete survey of the investigations
evaluating the bulk and incremental insertion of composite resin reveals that neither method consistently produces superior results. Some report less
with the incremental technique; others less with bulk placement.

In 1992, Goracci and co-workers32 slowly polymerized composite resin over a 4-minute period, while controlling the output of the curing unit with a rheo
They showed fewer gaps and marginal defects with this technique. The slow polymerization technique was veriGed, but required so much time to polym
composite resin that it was clinically ineffective. They did show that slow polymerization methods have merit.

Highlight by 3M ESPE (St. Paul, MN) was the Grst curing light with a step- or soft-cure, but was discontinued and replaced with the 3M ESPE Elipar® Tri
which has an exponential output mode in which the output slides from low to high. In two studies,33,34 no signiGcant difference could be found between
this technique and bulk-curing. Another technique is the pulse-delay, or the pulse-cure technique.35 This requires placing increments of composite resin
curing for 20 seconds. The Gnal enamel replacement increment is cured with a brief burst of energy for 2 to 3 seconds. A 3-minute delay is then allowe
enable the composite time to dow and shrink while the restoration is Gnished and polished. After Gnishing, the restoration is cured at high intensity to t
polymerize the material. Mechanical properties are maintained when these techniques are applied.

In several studies,36-38 no clear beneGt to the soft-curing or the pulse-delay technique could be seen. The effectiveness of the soft-cure or ramp-cure
techniques in decreasing leakage and stress at the margins of Class 2 restorations is not clear and it has not been reproduced in clinical trials. Either th
evaluation methods in clinical trials are not reGned enough to detect these differences or the amount of shrinkage is compensated for by other factors
sorption39 or compliance of the tooth). Composites are able to compensate for volumetric shrinkage by dow before the resin reaches a solid state, alth
this compensation is limited;40 in this study the authors found only 20% of the shrinkage completed at the maximum dow. To accomplish improved ma
integrity, the composite resin must dow during its change from a viscous paste to an elastic solid to accommodate the resin shrinkage and to yield sea
margins. A composite resin that does not shrink is necessary to consistently improve marginal integrity, and continued work in this area is essential.

CONCLUSION
To summarize the main points of this article, the authors reiterate that among the factors affecting composite-resin shrinkage, cavity preparation size a
conGguration are signiGcant. Light intensity decreases rapidly as light passes through tooth or composite resin. Curing lights have large differences in
output, but light attenuation reduces the ability of curing lights to polymerize thick increments of resin; therefore, composite resin is most completely
polymerized in 2-mm increments. Even though different curing units have different curing modes, the composite selected affects shrinkage more than
method of curing. The clinical effectiveness of the soft-, ramp-, or pulse-delay cure is questionable. Continued development of composite resins with re
shrinkage is critically needed.

DISCLAIMER
Dr. Burgess has received grant/research support from 3M ESPE.

References
1. Stansbury JW. Curing dental resins and composites by photopolymerization. J Esthet Dent. 2000;12(6):300-308.

2. Ferracane JL. Developing a more complete understanding of stresses produced in dental composites during polymerization. Dent Mater. 2005;21(1)

3. Charton C, Colon P, Pla F. Shrinkage stress in light-cured composite resins: Induence of material and photoactivation mode. Dent Mater. 2006 Oct 5; [
ahead of print].

4. Davidson CL, Feilzer AJ. Polymerization shrinkage and polymerization shrinkage stress in polymer-based restoratives. J Dent. 1997;25(6): 435-440.

5. Stansbury JW, Trujillo-Lemon M, Lu H, et al. Conversion-dependent shrinkage stress and strain in dental resins and composites. Dent Mater.
67.

6. Pensak T. Clinical showcase. J Can Dent Assoc. 2004;70(2): 118-119.

7. Sarrett DC. Clinical challenges and the relevance of materials testing for posterior composite restorations. Dent Mater. 2005;(1):9-20.

8. Feilzer AJ, De Gee AJ, Davidson CL. Setting stress in composite resin in relation to conGguration of the restoration. J Dent Res. 1987;66(11): 1636-16

9. Rees JS, Jacobson PH. The polymerization shrinkage of composite resins. Dent Mater. 1989;5(1):41-44.

10. Puckett AD, Smith R. Method to measure the polymerization shrinkage of light-cured composites. J Prosthet Dent. 1992;68(1):56-58.

11. Norris C, Burgess JO. Polymerization shrinkage of seventeen composite resins [abstract]. J Dent Res. 2002;81:A-424.

12. Labella R, Lambrechts P, Van Meerbeek B, et al. Polymerization shrinkage and elasticity of dowable composites and Glled adhesives. Dent Mater
1999;15(2): 128-137.

13. Rueggeberg FA, Caughman WF, Curtis JW Jr. Effect of light intensity and exposure duration on cure of resin composite. Oper Dent. 1994;19: 26-32.

14. Alster D, Venhoven BA, Feilzer AJ, et al. Infuence of compliance of the substrate materials on polymerization contraction stress in thin resin compo
layers. Biomaterials. 1997;18(4):337-341.

15. Giachetti L, Scaminaci Russo D, Bambi C, et al. A review of polymerization shrinkage stress: current techniques for posterior direct resin restoration
Contemp Dent Pract. 2006;7(4):79-88.

16. Braga RR, Ferracane JL. Alternatives in polymerization contraction stress management. Crit Rev Oral Biol Med. 2004;15(3): 176-184.

17. SpreaGco RC, Gagliani M. Composite resin restorations on posterior teeth. In: Roulet JF, Degrange M. Adhesion: The Silent Revolution in Dentistry
Quintessence; 2000:253-276.

18. Tjan AH, Bergh BH, Lidner C. Effect of various incremental techniques on the marginal adaptation of class II composite resin restorations.
1992;67(1):62-66.

19. Weaver WS, Blank LW, Pelleu GB Jr. A visible light activated resin cured through tooth structure. Gen Dent. 1988;36(3):236-237.

20. Liebenberg WH. Successive cusp build-up: an improved placement technique for posterior direct resin restorations. J Can Dent Assoc. 1996;62(6):5
507.

21. Lutz F, Krejci I, Luescher B, et al. Improved proximal margin adaptation of Class II composite resin restorations by use of light-redecting wedges.
Quintessence Int. 1986;17(10):659-664.

22. Losche GM. Marginal adaptation of Class II composite resin Gllings: guided polymerization vs reduced light intensity. J Adhes Dent. 1999;1(1):31-39
23. Bichacho N. The centripetal build-up for composite resin posterior restorations. Pract Periodontics Aesthet Dent. 1994; 6(3):17-23.

24. Belvedere PC. Contemporary posterior direct composites using state-of-the-art techniques. Dent Clin North Am. 2001;45(1):49-70.

25. Smith M, Burgess JO, Xu X. Microleakage of Class I composite resin restorations cured with three methods [abstract]. J Dent Res. 2001;80:197.

26. Manuel P, Ripps A, Burgess JO, et al. Microleakage of Class I composite resin restorations cured with four methods [abstract]. J Dent Res.

27. Schmalz G, Preiss A, Arenholt-Bindslev D. Bisphenol-A content of resin monomers and related degradation products. Clin Oral Investig. 1999;3(3): 1

28. Eakle WS, Ito RK. Effect of insertion technique on microleakage in mesio-occlusodistal composite resin restorations. Quintessence Int. 1990;21(5):
374.

29. Crim GA, Chapman KW. Effect of placement techniques on microleakage of a dentin-bonded composite resin. Quintessence Int. 1986;17(1):21-24.

30. Coli P, Brannstrom M. The marginal adaptation of four different bonding agents in Class II composite resin restorations applied in bulk or in two
increments. Quintessence Int. 1993;24(8):583-591.

31. Versluis A, Douglas WH, Cross M, et al. Does an incremental Glling technique reduce polymerization shrinkage stresses? J Dent Res. 1996;75(3):871

32. Goracci G, Mori G, de Martinis L. Curing light intensity and marginal leakage of resin composite restorations. Quintessence Int. 1996;27:355-362.

33. Walker RS, Burgess JO. Microleakage of Class V restorations with different visible-light curing methods. J Dent Res. 1999;78:155.

34. Walker R, Burgess JO. Microleakage of Class V restorations with different curing methods. J Dent Res. 2000;79:45.

35. Kanca J 3rd, Suh BI. Pulse activation: reducing resin-based composite contraction stresses at the enamel cavosurface margins. Am J
Dent. 1999;12(3):107-112.

36. Bernardo MF, Martin MD, Johnson GH, et al. Clinical evaluation of composite restorations polymerized by two different methods. Two year results
[abstract]. J Dent Res. 2002;81: A-81.

37. Brackett WW, Covey DA, St. Germain HA Jr. One-year clinical performance of a self-etching adhesive in class V resin composites cured by two meth
Oper Dent. 2002;27(3):218-222.

38. Oberlander H, Friedl KH, Schmalz G, et al. Clinical performance of polyacid-modiGed resin restorations using “softstart-polymerization.” Clin Oral Inv
1999;3(2): 55-61.

39. Feilzer AJ, de Gee AJ, Davidson CL. Relaxation of polymerization contraction shear stress by hygroscopic expansion. J Dent Res. 1990;69(1):36-39.

40. Feilzer AJ, Dauvillier BS. Effect of TEGDMA/BisGMA ratio on stress development and viscoelastic properties of experimental two-paste composites
Dent Res. 2003;82(10):824-828.

Deniz Cakir, DDS, MS

Instructor
Department of Prosthodontics
University of Alabama at Birmingham
School of Dentistry
Birmingham, Alabama

Robert Sergent, DMD

Chairman
Comprehensive Dentistry Department
Louisiana State University
School of Dentistry
New Orleans, Louisiana

John O. Burgess, DDS, MS

Assistant Dean for Clinical Research
Department of Prosthodontics
University of Alabama at Birmingham
School of Dentistry
Birmingham, Alabama
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