Republic of Iraq

Ministry of Higher Education

And Scientific Research
AL_Farahidi University
Collage Of Dentistry

Application technique of dental composites

A Project Submitted to
The College of Dentistry, Al-Farahidi University, Department of
Conservative in Partial Fulfillment for the Bachelor of Dental
Surgery

By
Russell Riyad Hadi

Supervised by
Dr. Shelan Sadiq Jumaah
B.D.S., M.S.C

2024 A.D
 Certification of the Supervisor
I certify that this project entitled "Application technique of dental composites."
was prepared by the fifth-year students Russell Riyad Hadi
under my supervision at the College of Dentistry/ Al-Farahidi University in partial
fulfilment of the graduation requirements for the bachelor’s degree in Dentistry

Dr. Shelan Sadiq Jumaah

i
 Dedication
I dedicate this research work to my beloved parents, whose unwavering love,
encouragement, and sacrifices have been the cornerstone of my academic journey.
Their inspiration and steadfast support have propelled me through the challenges of
dentistry college, and I am forever grateful for their guidance.

I also dedicate this research to my esteemed professors and mentors, whose

wisdom, mentorship, and dedication to excellence have shaped my path in
dentistry. Their guidance has been instrumental in my academic and professional
growth, and I am deeply appreciative of their influence.

To my cherished colleagues and classmates, I extend my heartfelt dedication. Their

friendship, camaraderie, and unwavering support have made my time in dentistry
college not only enriching but also memorable. I am thankful for the
encouragement and shared experiences that have made this journey all the more
fulfilling.

Lastly, I dedicate this research to the patients who have entrusted me with their oral
health. Their trust and confidence have been humbling and motivating, and I am
committed to using my skills and knowledge to provide the best possible care to
them and future patients. This research stands as a testament to the power of
dedication, collaboration, and hard work, and it is my honor to share it with those
who have played a pivotal role in my academic and professional development."

ii
 Acknowledgement
I extend my sincere gratitude to all those who have contributed to the successful
completion of this research work.
First and foremost, I am deeply thankful to my research supervisor, Dr. Shelan
Sadiq Jumaah, for their invaluable guidance, encouragement, and unwavering
support throughout this project. Their expertise, patience, and dedication have
played a pivotal role in shaping the direction of this research, and I am truly
grateful for their mentorship.
I would also like to express my gratitude to the staff and faculty of the dentistry
college for their support and the resources they have provided, which have been
instrumental in enabling me to pursue this research. The academic environment and
facilities offered by the college have been crucial in facilitating my learning and
growth as a dental student.
My heartfelt thanks also go out to my colleagues and classmates for their
assistance, feedback, and unwavering encouragement. The discussions, debates,
and collaboration with my peers have not only challenged me to think critically and
creatively but have also significantly contributed to the success of this research.
Lastly, I want to express my deepest appreciation to my family and friends for their
unwavering love, encouragement, and steadfast support throughout my academic
journey. Their unwavering belief in me has been a constant source of motivation
and inspiration, and I am truly grateful for their presence in my life.
In conclusion, I would like to acknowledge the contributions of everyone who has
supported me in this research work. Your assistance, guidance, and encouragement
have been instrumental in its success, and I am honored to have worked with such
an exceptional group of individuals.

Russell Riyad Hadi

iii
 Table Of Content
Page
Content Title Number
Introduction 1
1.1: Resin composite restorations: 3
1.1.1 Definition: 3
1.1.2 History: 3
1.1.3 Aesthetics of Composites 4
1.1.4 Microleakage and Nanoleakage 4
1.2 Types of Composite Resins: 5

1.2.1 Macrofilled Composite Resins: 5

1.2.1.1 Advantage of Conventional Composite: 6

1.2.1.2 Disadvantages: 6

1.2.2 Microfilled Composite Resins: 6

1.2.2.1 Advantages: 6

1.2.2.2 Disadvantages: 6

1.2.3 Hybrid Composite Resins: 7

1.2.3.1 Advantages of Hybrid Composites: 8

1.2.3.2 Disadvantages of Hybrid Composites: 8

1.2.3.3 Two new generations of hybrid composite resins 8

are:
1.3 Properties of Composite Restorative Materials 10
1.3.1 Coefficient of Thermal Expansion 10

iv
1.3.2 Water Absorption 10
1.3.2.1 Factors Affecting Water Absorption of Composites 10
1.3.3 Wear Resistance 11
1.3.4 Surface Texture: 11

1.3.5 Radiopacity 12

1.3.6 Modulus of Elasticity: 12

1.3.7 Creep: 12

1.3.8 Configuration or “C-factor”: 12

1.3.9 Polymerization Shrinkage: 13

1.3.9.1 Factors Affecting Polymerization Shrinkage: 14

1.3.9.2 Polymerization shrinkage can be reduced by: 15
1.4 General Cavity Design Guidelines: 17

1.5 Incremental techniques for Direct Composite 18

Restoration:
1.5.1 Incremental techniques: 18

1.5.2 Horizontal Technique: 19

1.6 U-shaped Layering Technique: 20

1.7 Vertical Layering Technique: 20

1.8 Oblique layering technique: 20

1.9 Three-Site Technique: 21

1.10 Split-increment horizontal layering technique: 22

1.11 Successive cusp buildup technique: 24

1.12 Centripetal buildup technique: 26

v
1.13 Bulk Technique: 28

1.14 comparison between incremental filling and

bulk filling methods:
1.15 Snowplow Technique: 29

1.16 Preheated Composite: 30

1.17 Injection Molding Technique: 30

1.18 Sonic Fill Composite Technique: 31

1.19 Esthetic Techniques: 31

1.20 Effects of different placement techniques: 33

Conclusion 37

References 38

vi
 List of figures
Figure Page
Number Figure Title Number
1.1 Diagrammatic representation of different composites 5
1.2 Coefficient of thermal expansion can result in 10
dimensional change in restoration which can cause gap
between tooth and the restoration.
1.3 Abrasive wear in composite restoration causes exposure 11
of filler-particles which get removed from the surface of
composite restoration.
1.4 Polymerization shrinkage can result in gap between 13
restoration and the tooth surface.
1.5 In light cured composites, shrinkage occurs towards 13
source of light.
1.6 In chemical cured composites, shrinkage occurs towards 14
center of restoration.
1.7 Polymerization shrinkage can pull cusps together and can 16
result in fracture.
1.8 Incremental build-up of restoration results in decreased 16
polymerization shrinkage.
1.9 Incremental layering technique. 19
1.10 Horizontal Technique. 19
1.11 Vertical Layering Technique. 20
1.12 Oblique layering technique. 21

vii
1.13 Use of light transmitting wedges for better curing at 22
gingival margins.
1.14 Split incremental technique. 23
1.15 Split Horizontal Technique. 24
1.16 Successive cusp buildup technique. 25
1.17 Centripetal buildup technique. 26
1.18 A schematic drawing illustrating use of intracavity 27
extension tip.
1.19 completed restoration demonstrating various layers of 27
centripetal buildup technique.
1.20 comparison between incremental filling and bulk filling 29
methods.
1.21 Comparison of Clark Class II preparation (injection 30
Molding Technique) (left) vs the slot preparation (center)
vs the G.V. Black preparation (right).
1.22 Separate dentin and enamel buildup using an index 32

viii
 List of Table
Table
Page Number
Number Table Title
1.1 Resin-based composite classification 7
1.2 Clinical indications of resin-based composites 7

ix
 Introduction:
The application technique of dental composites is a fundamental aspect of modern
restorative dentistry, with a direct impact on the quality, longevity, and esthetic
appeal of dental restorations. Dental composites, also known as tooth-colored or
resin composites, have become the material of choice for a wide range of
restorative procedures, including direct fillings, veneers, and cosmetic
enhancements. Their ability to mimic the natural appearance of teeth, coupled with
advancements in material science and adhesive technology, has transformed the
landscape of restorative dentistry.

The application process of dental composites involves a series of intricate steps,

beginning with the careful preparation of the tooth structure to create an ideal
bonding surface. This is followed by the application of adhesive systems, which
play a crucial role in establishing a durable bond between the composite material
and the tooth. The subsequent layering and shaping of the composite resin require
precision and attention to detail to achieve proper contour, anatomy, and occlusal
harmony, ensuring functional and esthetic success.

In recent years, the field of restorative dentistry has witnessed significant

advancements in composite materials, adhesive systems, and placement techniques.
New generations of composites, such as nano-filled and micro-hybrid formulations,
have been developed to offer improved mechanical properties, enhanced polish
ability, and simplified handling characteristics. These advancements have expanded
the possibilities for achieving superior esthetics and long-term durability in dental
restorations.

1
Furthermore, the introduction of bulk-fill composites has revolutionized the
placement process by enabling the efficient restoration of cavities in deeper layers,
allowing for a simplified and expedited approach to composite placement. Bulk-fill
techniques, with their enhanced depth of cure and reduced polymerization
shrinkage, have streamlined the restorative workflow, offering practitioners greater
efficiency and predictability in achieving high-quality outcomes.

2
Chapter one: Review of literature
1.1: Resin composite restorations:
1.1.1 Definition:
Composites are a combination of two or more classes of materials. In dentistry, the
most common composite is a combination of a polymer and ceramic, where the
polymer is used to bind ceramic particles. The polymer functions as the matrix in
dental composites and the particles are reinforcing materials.1 (Ronald Sakaguchi et
al., 2019)
1.1.2 History:
During the first half of the 20th century, silicates were the only tooth colored
esthetic material available for cavity restoration. Proceeding to late 1940s and the
early 1950s acrylic resin similar to those used for custom impression trays and
dentures replaced silicates because of their tooth like appearance, insolubility in
oral fluids, ease of manipulation and low cost.2 (Adela Hervás García et al., 2005)
In 1956, Bowen investigated dimethacrylates (Bis-GMA) and silanized inorganic
filler, dimethacrylates was generally known as Bis-GMA or Bowen’s resin, was
made up from the combination of bisphenol-A and glycidyl methacrylate.3 (Richard
Trushkowsky et al., 2015) In the 1970s, microfilled composite were introduced and
were marketed at the end of 70s. it was composed of microfine filler particles of
pyrolytic silica (SiO2), in the range of 0.007 – 0.14 µm with a mean of 0.04 µm.4
(Dijken, H.W., 1987) Proceeding to the end of 20th century, condensable/packable
composites were introduced in 1990s. However, Due to a high failure rate in
clinical use, this type of composite has been phased out. During the Beginning of
21st century, Nanofill composites were introduced5 (Cangul et al., 2017)

3
1.1.3 Aesthetics of Composites
Composites have shown good aesthetics because of their property of
translucency. Composites are available in different opacities and shades so they
can be used in different places according to aesthetic requirements.6
1.1.4 Microleakage and Nanoleakage
Microleakage can lead to the penetration of acids, enzymes, ions, and bacterial
products through the gap resulting in marginal discoloration, post-treatment
sensitivity, secondary caries, and pulp defects.7 (Deviyanti et al., 2018)
Microleakage can occur due to:
– Polymerization shrinkage of composites
– Poor adhesion and wetting
– Thermal stresses
– Mechanical loading
Microleakage can result in bacterial leakage.

• Nanoleakage: It is passage of fluid/dissolved species in nanosized (10–9 m)

gaps. These nanosized porosities occur within the hybrid layer. These can occur
because of:
– Inadequate polymerization of primer before application of bonding agent.
– Incomplete resin infiltration.
– Polymerization shrinkage of maturing primer resin.
Nanoleakage can result in sensitivity during occlusal and thermal stresses.

4
1.2 Types of Composite Resins:
Though composites have been classified according to different characteristics, the
most commonly followed classification is based on the type, distribution and filler
phase of composites.8 (Table 1.1)
Composite resin can be divided into three types based on the size, amount and
composition of the inorganic filler (Figs 1.1 A to C):
1. Macrofilled composite resins.
2. Microfilled resins.
3. Hybrid composite resins.

Figs 1.1 A to C: Diagrammatic representation of different composites

1.2.1 Macrofilled Composite Resins:

Average particle size of macrofill composite resins is from 5-25 micron. Filler
content is approximately 75-80% by weight. It exhibits a rough surface texture
because of the relatively large size and extreme hardness of the filler particles. The
surface becomes more rough as the resin matrix being less hard, and wears at faster
rate. Due to roughness, discoloration and wearing of occlusal contact areas and
plaque accumulation take place quickly than other types of composites.

5
1.2.1.1 Advantage of Conventional Composite:
• Physical and mechanical performance is better than unfilled acrylic resins.
1.2.1.2 Disadvantages:
• Rough surface finish
• Poor polishability
• More wear
• More prone to staining.
1.2.2 Microfilled Composite Resins:
Microfilled composites were introduced in the early 1980s. Average particle size of
microfilled resins ranges from 0.04-0.1 micrometer. Filler content of microfilled
resins is 35-50% by weight. The small particle size results in smooth polished
surface which is resistant to plaque, debris and stains. But because of less filler
content, some of their physical properties are inferior. They have low modulus of
elasticity and high polishability, excellent translucency. However, they exhibit low
fracture toughness and increased marginal breakdown. They are indicated for the
restoration of anterior teeth and cervical abfraction lesions (Table 1.2).
1.2.2.1 Advantages:
1. Highly polishable.
2. Good esthetic.
1.2.2.2 Disadvantages:
1. Poor mechanical properties due to more matrix content
2. Poor color stability
3. Low wear resistance.
4. Less modulus of elasticity and tensile strength
5. More water absorption
6. High coefficient of thermal expansion

6
1.2.3 Hybrid Composite Resins:
In order to combine the advantages of conventional and microfilled composites,
hybrid composites were developed.

Table 1.1: Resin-based composite classification.

Table 1.2: Clinical indications of resin-based composites Hybrid composites are

named so because they are made up of polymer groups (organic phase) reinforced
by an inorganic phase. Hybrid composites are composed of glasses of different
compositions and sizes, with particle size diameter of less than 2 µm and
containing 0.04 µm sized fumed silica. Filler content in these composites is 75-80%
by volume. This mixture of fillers is responsible for their physical properties
similar to those of conventional composites with the advantage of smooth surface
texture.

7
1.2.3.1 Advantages of Hybrid Composites:
1. Availability in various colors.
2. Different degrees of opaqueness and translucency in different tones and
fluorescence.
3. Excellent polishing and texturing properties.
4. Good abrasion and wear resistance.
5.Similar coefficient of thermal expansion.
6.Ability to imitate the tooth structure.
7.Decreased polymerization shrinkage.
8.Less water absorption.

1.2.3.2 Disadvantages of Hybrid Composites:

1.Not appropriate for heavy stress-bearing areas.
2.Not highly polishable as microfilled because of presence of larger filler particles
in between smaller ones.
3.Loss of gloss occurs when exposed to toothbrushing with abrasive toothpaste.

1.2.3.3 Two new generations of hybrid composite resins are:

1. Nanofill and nanohybrids
2. Microhybrids.

1. Nanofill and nanohybrid composites:

Nanofill and nanohybrid composites have average particle size less than that of
microfilled composites. The introduction of these extremely small fillers and their
proper arrangement within the matrix results in physical properties equivalent to
the original hybrid composite resins.

8
Advantages
1.Highly polishable
2.Tooth-like translucency with excellent aesthetic
3.Optimal mechanical properties
4.Good handling characteristics.
5.Good color stability
6.Stain resistance
7.High wear resistance
8.Can be used for both anterior and posterior restorations and for splinting teeth
with fiber ribbons.

2. Microhybrid composites:
Microhybrid composites have evolved from traditional hybrid composites. Filler
content in microhybrids are 56 to 66% by volume.
The average particle size in these composites range from 0.4-0.8 µm. Incorporation
of smaller particles makes them better to polish and handle than their hybrid
counterparts. Because of presence of large filler content, microhybrid composites
have improved physical properties and wear resistance than microfilled composites.
Advantages:
1.Better polish and surface finish.
2.Easy handling.
3.Improved physical properties.
4.Good wear resistance.

9
1.3 Properties of Composite Restorative Materials
1.3.1 Coefficient of Thermal Expansion Coefficient of thermal expansion of
composites is approximately three times higher than normal tooth structure.
This results in more contraction and expansion than enamel and dentin when there
are temperature changes, it can result in loosening of the restoration. This can be
reduced by adding more filler content.

Figure 1.2: Coefficient of thermal expansion can result in dimensional change in

restoration which can cause a gap between tooth and the restoration.

1.3.2 Water Absorption Composites have a tendency to absorb water which can
lead to the swelling of resin matrix, filler debonding and thus restoration failure.
Composites with higher filler content exhibit lower water absorption and therefore
better properties than composites with lower filler content.

1.3.2.1 Factors Affecting Water Absorption of Composites

• More is the filler content less is the water sorption
• Lesser degree of polymerization causes more sorption Type and amount of
monomer and dilutent also affect water sorption. For example, UDMA based
composites show less sorption and solubility.

10
1.3.3 Wear Resistance Composites are prone to wear under masticatory forces or
use of tooth brushing and abrasive food (Figure 1.3).
Wear resistance is a property of filler particles depending on their size and quantity.
The site of restorations in dental arch and occlusal contact relationship, size, shape
and content of filler particles affect the wear resistance of the composites.

Figure 1.3: Abrasive wear in composite restoration causes exposure of filler-

particles which get removed from the surface of composite restoration.

1.3.3.1 Factors Affecting Degradation/Wear of Composites:

• Lesser is the polymerization, more is the degradation.
• Microfilled composites show less of degradation.
• Hydrolytic degradation of strontium or barium glass fillers can result in pressure
built up at resin filler junctions. This may cause cracks and fracture of composite
restoration. Sudden temperature change can result in disruption in silane coating
and thus bond failure between matrix and filler.

1.3.4 Surface Texture:

The size and composition of filler particles determine the smoothness of the surface
of a restoration. Microfill composites offer the smoothest restorative surface. This

11
property is more significant if the restoration is in close approximation to gingival
tissues.

1.3.5 Radiopacity
Resins are inherently radiolucent. The presence of radiopaque fillers like barium
glass, strontium and zirconium makes the composite restoration radiopaque.

1.3.6 Modulus of Elasticity:

Modulus of elasticity of a material determines its rigidity or stiffness. Microfill
composites have greater flexibility than hybrid composite since they have lower
modulus of elasticity.
Solubility Composite materials do not show any clinically significant solubility in
oral fluids. Water solubility of composites ranges between 0.5-1.1 mg/cm2.

1.3.7 Creep:
Creep is progressive permanent deformation of material under occlusal loading.
The more the content of resin matrix, more is the creep. For example, microfilled
composites show more creep since they contain more of resin matrix.

1.3.8 Configuration or “C-factor”:

(C-factor) is the ratio of bonded surface of the restoration to the unbounded
surfaces. The higher the value of ’’C‟-factor, the greater is the polymerization
shrinkage.

12
1.3.9 Polymerization Shrinkage:
Composite materials shrink while curing which can result in formation of a gap
between resin-based composite and the preparation wall (Figure 1.4). It accounts
for 1.67-5.68% of the total volume.

Fig. 1.4: Polymerization shrinkage can result in gap between restoration and the
tooth surface.
• In light-cured composites, about 60% polymerization occurs within 60 seconds,
further 10% in next 48 hours; remaining resin does not polymerize. Since the
material nearest to the light sets first. Shrinkage in light cured composites occurs in
the direction of light (Fig. 1.5A and B).
• For chemical-cured composites shrinkage occurs slowly and uniformly towards
the center of restoration (Fig. 1.6).

Fig. 1.5 A and B: In light cured composites, shrinkage occurs towards source of
light.
13
Fig. 1.6 In chemically cured composites, shrinkage occurs towards center of
restoration.
Polymerization shrinkage can result in:
• Postoperative sensitivity
• Recurrent caries
• Failure of interfacial bonding
• Fracture of restoration and tooth (Fig. 1.7).

1.3.9.1 Factors Affecting Polymerization Shrinkage:

1. CONFIGURATION FACTOR
Class 1 and class V cavity exhibit greatest stress because the restoration is bonded
to five walls of the cavity. High C – factor results in debonding of the restoration.
Lowest stress is seen in class IV cavity because it has enough unbonded surfaces
providing stress relief. Hence it is important to have lower configuration cavity.

2. COMPOSITION OF RESIN COMPOSITES

A resin matrix with monomers of high molecular weight will result in lower
shrinkage values than those formulated with monomers of low molecular weight.
Molecular functionalities, molecular structure, molecular mass and size have major
influences upon the amount of shrinkage and also on monomer viscosity9.

14
3. MATERIAL PROPERTIES
There are three inherent properties of the resin composites that are crucial over the
magnitude of stress: i) volumetric shrinkage ii) material stiffness (elastic modulus)
and degree of conversion from double bonds to single bonds.
4. FILLER VOLUME FRACTION
Filler volume fraction is inversely proportional to volumetric shrinkage. As the
volume of filler content increases, the volume of resin matrix decreases and hence
volumetric shrinkage reduces proportionately10.
5. INTENSITY OF CURING LIGHT
The higher the light intensity, the greater the polymerization shrinkage. This is due
to the greater degree of conversion. The slower polymerization retards the gel
point, which provides time for stress relaxation11.
6.THICKNESS OF COMPOSITE RESIN
Incremental curing produces lesser polymerization shrinkage stress than bulk
curing12.

1.3.9.2 Polymerization shrinkage can be reduced by:

• Decreasing monomer level
• Increasing monomer molecular weight.
• Improving composite placement technique: Placing successive layers of wedge-
shaped composite (1-1.5 mm) decreases polymerization shrinkage (Fig. 11.9).
• Polymerization rate: “Soft-start” polymerization reduces polymerization
shrinkage.

15
Fig. 1.7: Polymerization shrinkage can pull cusps together and can result in
fracture.

Fig. 1.8: Incremental build-up of restoration results in decreased polymerization

shrinkage.
Restoration placement techniques are universally recognized as a considerable
factor in the modification of shrinkage stress. By maneuvering specific restorative
techniques, stress resulting from constrained shrinkage may be scaled down. Per
contra, it is not clear which restorative technique should be used to demolish
shrinkage stress. Administering the composite in layers instead of using a bulk
technique is recommended to reduce shrinkage stress.13
Three main factors concur to reduce shrinkage stress: use of a small volume of
material, a lower cavity configuration factor, and minimal contact with the
opposing cavity walls during polymerization. It is widely accepted that incremental
filling decreases shrinkage stress as a result of reduced polymerization material
16
volume. Each increment is compensated by the next, and the consequence of
polymerization shrinkage is less damaging since only the volume reduction of the
last layer can damage the bond surface.14
1.4 General Cavity Design Guidelines:
(1) Cavity floor: it is not necessary to make flat floor with composite, so you will
not cut more in tooth structure and leave suitable amount of dentin, internal walls
should be rounded to avoid stress concentration, also cause pulling of the bond at
this area creating space, and stresses fall resulting in compression forces and
pressure on dentinal tubules, roundation is done by rounded end stone (TR).
(2) Cavo-surface margin (tooth restoration interface): must be well finished for
better adaptation to avoid white line of demarcation, walls must be flared to
increase amount of opened enamel rods for better bonding also ends appearance of
white lines. It is important to check stresses that falls on this area as direct
occlusion will affect bond and cause fracture, so finish and flare the cavo-surface
margin using finishing stone 45°.
(3) Cusp thickness: any undermined enamel in posterior teeth under direct force as
cusp, buccal and lingual walls of the proximal box, even if supported by composite
will fracture, should be removed by finishing stone.
But cervical enamel should not be removed, you should preserve it as it is the most
site for recurrent caries, also bonding to dentin or cementum is not strong as with
enamel.
• So before making the cavity do pre-wedging to preserve the cervical enamel, also
build up cervical area immediately for support.
• In case of class I, measure the thickness of mesial and distal marginal ridges, in
premolars minimum 1.6 mm, and in molars 2 mm, if less open its class II.
• Cusp thickness must be 2 mm to withstand occlusal forces, if less fracture will
occur, so do cuspal coverage, reduction to cusp 2 mm using straight fissure bur or
17
rounded bur, to convert forces from wedging action to be directed towards long
axis of the tooth.

1.5 Incremental techniques for Direct Composite Restoration:

When placing posterior composites, the use of small increments is recommended
by many authors for insertion and polymerization so that the after effect of
shrinkage stress can be reduced.
Considering anterior composite restorations, though the placement of successive
increments aids to knockdown the effects of polymerization shrinkage stress, errors
in layering techniques result in restorations which are too translucent or opaque.
So, to ensure esthetically pleasing results, layering concepts should be lucid,
standardized, and reproducible.
1.5.1 Incremental techniques:
Incremental techniques as15 (Aschheim et al., 2015) discussed are as follows:
2.4.1.1. Incremental Layering Technique (Fig 1.9)
This technique is advocated for use in medium to large posterior composite
restorations to avoid the limitation of depth of cure.
Incremental layering technique has many characteristics:
• This technique is based on polymerization of resin based composite layers of
less than 2 mm thickness.
• Helps to attain good marginal quality.
• It prevents deformation of the preparation wall.
• It ensures complete polymerization of the resin-based composite.
• Incremental layering of dentin and enamel composite creates layers with
high diffusion which allow optimal light transmission within the restoration,
thus increasing aesthetics.

18
 Fig. 1.9 Incremental layering technique

1.5.2 Horizontal Technique (Fig 1.10)

Occluso-gingival layering is done with this technique. Also, it is indicated for small
restorations only as it increases the C-Factor.

Fig. 1.10 Horizontal Technique.

19
1.6 U-shaped Layering Technique:
This Technique is being applied as follows:
• First increment in the form of U-Shape is placed at the base, both gingival and
occlusal.
• Over that place horizontal and oblique increments to pack the preparation.
• Then, curing is carried out from all the sides.

1.7 Vertical Layering Technique (Fig 1.11)

This Technique is being applied as follows:
• Place small increments in a vertical pattern starting from one wall, i.e. buccal or
lingual and carried to another wall.
• Start polymerization from behind the wall, i.e. if buccal increment is placed on
the lingual wall, it is cured from outside the lingual wall.
• Reduces gap at gingival wall which is formed due to polymerization shrinkage,
hence postoperative sensitivity and secondary caries.

Fig. 1.11 Vertical Layering Technique

1.8 Oblique layering technique:

The oblique technique is accomplished by placing a series of wedge-shaped
composite increments. Each increment is photocured twice, first through the cavity

20
walls and then from the occlusal surface, to direct the vectors of polymerization
toward the adhesive surface (Fig. 1.12). This technique reduces the C-factor and
prevents the distortion of cavity walls.16,17,18.

Fig. 1.12: Oblique layering technique.

1.9 Three-Site Technique:

In this technique, light curing of composite with the help of clear matrix along with
reflective wedges helps in achieving excellent results. Here, the composite is cured
by directing the curing light through the matrix and wedges, to prevent any void at
the gingival margin by preventing the polymerization vectors. Addition of wedge
shaped composite material in increment is done to further inhibit distortion of
cavity walls and reduce the C-factor. Here, polymerization is achieved by cavity
walls as well as through the occlusal sides.14

21
Fig. 1.13: Use of light transmitting wedges for better curing at gingival margins.

1.10 Split-increment horizontal layering technique:

When the conventional horizontal technique is utilized, each composite increment
that connects the cavity floor with the four surrounding walls produces the highest
and the most unfavorable C-factor ratio of 5 when it is photocured.16 Concern has
been expressed about placing individual increments against opposing walls
simultaneously before photocuring, as the resulting polymerization shrinkage stress
may cause the cusps to bend toward each other and deform as a result This stress
may cause postoperative sensitivity and can be detrimental to the tooth and the
marginal integrity over time.19 For the proposed technique, each horizontal
increment was split, before curing, into four triangle-shaped portions (Figure 1.14),
with each portion placed against only one cavity wall and part of the floor one
diagonal cut was filled completely with dentin shade composite and photocured. At
this point, the other diagonal cut was filled and photocured, one half at a time. The
same technique is followed until dentin-enamel junction and later enamel shade
composite followed by translucent shade are placed and shaped to establish
occlusal morphology. This sequence would prevent composite resin from
connecting two opposing cavity walls simultaneously, minimizing the negative
effects of polymerization shrinkage on the cavity walls and adhesive interfaces.

22
This would even reduce the C-factor ratio from 5, which is the highest and the most
unfavorable, to the second most favorable C-factor ratio of 0.5.

Figure 1.14: Split incremental technique (a) the two diagonal cuts split first uncured
horizontal increment of dentin shade into four triangle-shaped portions, this
followed by photocuring from buccal lingual and occlusal directions (b and c)
complete filling of one diagonal cut 1 with dentin shade composite and photocured,
later ½ of other diagonal cut 2 filled with dentin shade composite and photocured
and other ½ of cut 3 is similarly filled and cured. And the same procedure is
followed for the next horizontal incremental (d) enamel shade component followed
by translucent shade composite is placed and cured showing finished restoration.
Such small increment portions with a low C-factor ratio would relieve the
shrinkage stress by the free composite surface flowing at the diagonal cuts and not
at the bonded interfaces, minimizing the adverse effects of polymerization
shrinkage stresses.20

23
 Figure 1.15: Split Horizontal Technique.

1.11 Successive cusp buildup technique:

Here, individual cusps are restored one at a time up to the level of the occlusal
enamel. Small sloping increments are applied to each corner of the cavity [Figure
1.16] in turn and manipulation is kept to a minimum, to avoid folding voids into the
material. This method, while initially time-consuming, can greatly reduce finishing
time by precise attention to progressive reconstruction of natural morphology.

24
Figure 1.16: (a)Adhesive applied on prepared cavity (b) mesiolingual incremental
placed (c) distolingual incremental placed (d) mesiobuccal incremental placed (e)
centrobuccal incremental placed (f) distobuccal incremental placed showing
completed restoration.

25
1.12 Centripetal buildup technique:
The centripetal buildup technique offers a number of advantages when composite
resin posterior restorations are indicated. This technique employs thin metal matrix
bands and wooden wedges eliminating the need for transparent matrix bands,
which may not provide firm contact areas and anatomical proximal contours
[Figure 1.17] and are cumbersome to use for many practitioners. Further, recent
studies do not indicate any detriment of metal matrix bands in cervical gap
formation.21

Fig. 1.17: Centripetal buildup technique (showing proximal composite

semitransparent layer placed toward the matrix band using composite).
An important benefit of the procedure is offered by the centripetal buildup steps
first by creating a very thin proximal layer (Figure 1.17); the internal curing (Figure
1.18) of this layer is affected which can strengthen the composite and cut down
cervical gap that could form.22,23 Furthermore, even if such gap does develop, the
next consecutive layer which is condensed toward the gingival floor is likely to fill
gap since the continuity of space created is not occluded. Comparative
microleakage tests have yet to be conducted but the author's experience of more
than 6 years with this technique has demonstrated excellent marginal adaptation
radiographically. The formation of occlusal surface ring is another significant
addition of the proposed technique. By building a continuous layer to cusp slopes,
26
an occlusal reference surface is created, avoiding overfilling and minimizing the
subsequent need for rotary burs. These finishing procedures are known to be
detrimental to outer surface of composite.24 Finally, the centripetal buildup
technique is very conservative with preservation of sound tooth structure; it is not
time-consuming, and it is easy to implement. Once the second step of the procedure
is completed and peripheral composite envelope is created, the cavity is managed
as a simple Class I cavity. The systemic use of enamel and dentin shades achieves
predictable and pleasing esthetic results. The centripetal buildup technique has been
exercised profitably where small to medium posterior restoration is indicated.
However, when directly restoring extensive stress-bearing occlusal surfaces,
especially in molars, silver amalgam when manipulated meticulously is still the
material of choice to achieve a long-lasting dental restoration.

Fig. 1.18: A schematic drawing illustrating use of intracavity extension tip.

Fig. 1.19: completed restoration demonstrating various layers of centripetal buildup

technique.

27
1.13 Bulk Technique:
This technique is not practiced as frequently as the incremental techniques of
composite restoration technique, due to its various disadvantages which would
ultimately result in the failure of the restoration. However, some practitioners
recommend bulk fill technique to reduce stress at the Cavo surface margins.
The main characteristic of these materials is their insertion in single-increment
applications of 4 to 5 mm. Low-viscosity bulk-fill resin composites were the first
materials developed. These flowable materials are indicated as a restorative base
and require a 2-mm thick covering layer with a regular/conventional resin
composite. Subsequently, paste like “full-body” bulk-fill restorative resin
composites were introduced. These materials contain a higher percentage of
inorganic filler, which allows their use in high-masticatory load-bearing areas
without the need of coverage.25 (Durão et al., 2020)
Disadvantages like greater polymerization shrinkage makes it a non-viable option,
nevertheless the primary advantage is that the bulk material avoids the formation of
incremental voids.

1.14 comparison between incremental filling and bulk filling

methods:
incremental filling technique increased the deformation of the restored tooth and
could actually produce higher polymerization stresses at the restoration interface
compared with bulk filling, particularly when many small increments and
consecutive light activations are used26,27. Additionally, multiple increments
showed to induce greater cuspal movement than a bulk increment in cuspal
deflection measurements of premolars.28 Loguercio et al.29 reported that some
evaluated effects of polymerization shrinkage such as gap width, adhesive bond
strength, and the cohesive strength of the resin composite were not reduced by the
28
filling technique under the different C-factor cavities. Lee et al.30 observed that
cusp deflection increased with increasing cavity dimension and C-factor; thus, the
use of an incremental filling technique or an indirect composite inlay restoration
could reduce the cuspal strain. Conversely, Park et al.31 found that bulk-filling
technique yielded significantly more cuspal deflection than the incremental filling
techniques, concluding that cuspal deflection resulting from polymerization
shrinkage can be reduced by incremental filling techniques to obtain optimal
outcomes in clinical situations.
Despite the controversy over the advantages of incremental buildup of resin
composites, this technique has been broadly recommended for direct resin
composite restorations to assure sufficient polymerization in deep cavities with the
traditional materials.32

Fig. 1.20: comparison between incremental filling and bulk filling methods.

1.15 Snowplow Technique:

The snowplow technique involves the placement of a layer of flowable composite
on the pulpal floor and the gingival margin of the proximal box of a posterior
composite resin restoration. However, the layer of flowable composite is not cured
prior to placement of a denser-filled composite resin restorative material. In this
way, the flowable is pushed into a very thin layer, and the excess is pushed out of
29
the preparation. Reportedly, this will leave a very thin film of the high shrinking
flowable composite in a location that may contain porosities if a denser-filled
composite was used by itself. The flowable and the initial heavier filled composite
layer are light cured as one increment.33 (Presicci et al., 2012)
1.16 Preheated Composite:
Preheating a high-viscosity and packable composite resin up to 68°C before placing
it in the cavity and light-curing it has been demonstrated that it will decrease its
viscosity and thickness, increasing its flow and adaptation with the cavity walls. In
addition, preheating increases the polymerization rate and microhardness of
composite resin, improving its physico mechanical properties. The effect of heat,
due to a preheated composite resin, on the increase in pulpal temperature is
minimal (approximately 2°C), which can be tolerated by the pulp.34 (Darabi et al.,
2020)
1.17 Injection Molding Technique: (Fig 1.21)
This technique involves the use of a redesigned cavity preparation, a translucent
matrix system, and the proper combination of paste and flowable composites to
create strong and esthetic restorations which reduces the potential for voids and
fault lines while maintaining the structural integrity of the tooth.35 (Clark., 2010)

Fig 1.21: Comparison of Clark Class II preparation (injection Molding Technique)

(left) vs the slot preparation (center) vs the G.V. Black preparation (right).

30
 1.18 Sonic Fill Composite Technique:
Very recently, Kerr and KaVo, launched the SonicFill™ system for posterior
restorations. The system consists of a hand piece activated sonically and a special
composite formulation, which contains about 83.5% of fillers by weight. Upon
activation, the sonic energy lowers the viscosity of the composite and extrudes the
composite that has initially a thick consistency. The viscosity change of the
composite will ensure a perfect adaptation to the cavity walls and avoids the
stickiness of the composite to the instrument. It is not necessary to condense the
composite because the high frequency vibration yields intimate adaptation to the
cavity walls without voids inclusion.36 (Fahad et al., 2014)

1.19 Esthetic Techniques:

a) Stratified Layering Technique
The stratified layering technique was schemed and oriented to the development of
functional and anatomic restoration applying the “esthetic” composite resin
restorative materials that include shades of dentin and enamel as well as various
translucencies and intensive colors.37,38,39 This technique is designed to engrave
various degrees of chroma present within a tooth. It involves placing dentin shades
of composite resin with a higher chroma in the middle of the preparation and
placing a lower chroma resin close to the cusp walls. The stratified layering
technique is accomplished by placing initial dentin layers of composite shades or
chromas that are two or three degrees higher than the selected basic shade or
chroma. Subtle variations in dentin color can be achieved by changing the thickness
of each chroma layer in specific areas of the restoration. The enamel layer is placed
following the contours established by the dentin layers and it varies in thickness
depending on the desired effect. The enamel layer can be remodeled by placing

31
 various shades of opalescent or intensive enamels on distinct areas of the
restoration. Further effects can be produced using resin-intensive colors or stains.
b) Separate dentine and enamel buildup
This variation can be used when restoring a carious tooth with an intact occlusal
surface. After dam placement, a preoperative impression is taken of the occlusal.
Once layered “dentine” restoration is complete, the impression material is used to
aid precise adaptation of the final “enamel” increment(s). With careful control of
the amount of composite used, this technique may completely exclude the finishing
stage (Figure 1.22).40

Fig. 1.22: Separate dentin and enamel buildup using an index (a) Preoperative view
of Class I Dental Caries (DC) (b) preoperative impression of occlusal surface
(using silicon putty) (c) cavity preparation completed (d) incremental restoration
using dentin shade up to amelodentinal junction (e) completed restoration (obtained
32
 by applying final increment of enamel shade composite and silicon index over the
unset material, minimal excess removed before curing, requiring no for occlusal
adjustment).
c) Dual-shade layering technique:
Basic practitioners are recommended to establish confidence in layering techniques
by beginning with two material shades as this simplified technique is reported to
deliver an acceptable color match in a large number of clinical situations.
Following etching and adhesive application, an opaque dentine material is applied,
shaped, and light cured. Most dentine restorative materials are in the shade group A
and selection of the correct chroma is a key to success. Palatal, proximal, and labial
enamel increments are then layered, freehand over the opacious central core at
approximately half the thickness of residual enamel.41
D) Polychromatic Layering Technique:
In this technique, different shades of composite material, opalescent are added as
needed by the dentist. The main goal in this technique is to achieve the best
aesthetic results which should mimic/resemble the natural tooth. Herein, the most
widely accepted stratification technique was proposed by Lorenzo Vanini.42

1.20 Effects of different placement techniques:

1. Marginal Adaptation:
• (de Wet FA et al., 1991) compared three placement techniques (Bulk pack,
Horizontal layering and Vertical layering) and the results showed polymerization
shrinkage with all three techniques, with the poorest the bulk pack technique where
large marginal discrepancies were visible. No significant differences were detected
between the horizontal and vertical placement techniques.

33
• (Aulfat Ahmed Albahari1et al., 2020) concluded that the marginal adaptation were
not affected by the various tested application techniques in a comparison study
between incremental techniques and bulkfill techniques.
• (Cem Peskersoy et al., 2022) Bulk-fill composite resins placed either with sonic-
activated or sonic-vibrated instrument demonstrated better adaptability, less gap
formation and higher bond strength than both the bulk fill flowable composite and
conventional incremental techniques.
• (Dr. Ramciya KV et al., 2020) in a study comparing marginal adaptability of
fiber-reinforced and nanohybrid composite resin placed using layering and bulk
placement technique demonstrated that marginal adaptation of fiber reinforced
composite in layering technique found to be maximum whereas marginal
adaptation of nanohybrid composite in bulk filling technique found to be minimum
among the groups.

2.Marginal leakage:
• (Mohammed K Fahmi et al., 2019) in a comparison study using a high viscosity
bulk-fill composite with incremental and bulk-fill technique separately showed that
bulk-fill composites used with an incremental layering technique sealed
significantly better than the other groups followed by bulk-fill composite in the
bulk technique.
• (Anupriya Bugalia et al., 2011) in a study comparing four different placement
techniques (Split horizontal, centripetal, oblique, and bulk techniques)
demonstrated that microleakage was significantly decreased in groups where
composite resin was placed in increments when compared with bulk placement
technique while among the incremental techniques, split horizontal incremental
technique showed least microleakage followed by centripetal incremental technique
and oblique placement technique at the occlusal margin of restorations.
34
• (Marjaneh Ghavamnasiri et al., 2007) in a study aimed to evaluate the
microleakage at gingival margins below the cementoenamel junction (CEJ) of
Class II composite restorations using centripetal and incremental techniques
demonstrated that there was no significant difference in microleakage between
experimental groups.
• (Presicci, 2012) assessed microleakage and voids formation using micro
computed tomography. The tested 4 groups include cured flowable +incremental
technique, cured flowable +bulkfill, uncured flowable +incremental technique,
uncured flowable +bulkfill technique. The results revealed that the use of the
snowplow technique significantly reduced microleakage when the composite was
placed incrementally and the greatest amount of microleakage occurred when the
flowable composite was cured and the restorative composite was cured
incrementally.

3. Fracture Resistance:
• (E D Bonilla et al., 2020) in their study compared the effect of centripetal and
bulk techniques on fracture resistance of MOD restorations with various resin
composites and demonstrated that there was no significant effect of the two
placement techniques on the fracture resistance of Class II resin composite
restorations.
• (Horieh Moosavi et al., 2012) in their study compared the effect of centripetal and
bulk techniques on fracture resistance in composite restorations demonstrated that
placement techniques did not have a significant effect on the fracture resistance
(P=0.58).

35
4. Cuspal Deflection:
• (S. Jafarpour et al., 2012) compared the bulk and horizontal layering techniques
from the aspect of cuspal deflection and demonstrated that all insertion techniques
using conventional composite caused cuspal deformation with the deviation of
combined buccal and lingual cuspal deflection being higher with the bulk technique
when the cavity depth is at 4mm in depth while it’s higher in horizontal technique
when the depth is at 6mm in depth.
• (G Abbas et al., 2003) in their study, demonstrated that total mean cuspal
deflection measurements obtained with incremental technique were significantly
increased compared with bulk technique.
• (ME Kim et al., 2011) compared the cuspal deflection in premolars with bulk and
incremental techniques and reported lower cuspal deflection in the bulk cure
compared with the incremental cure and linked the results to the incomplete cure of
the composites.

5. Post Operative Sensitivity:

• (Patrícia Valéria Manozzo Kunz et al., 2022) in their systematic review and meta-
analysis evaluated the clinical performance of class I and II with composite
restorations using bulk and incremental techniques from the post operative
sensitivity aspect and demonstrated that the clinical performance of class I and II
restorations in posterior teeth is similar when placed with the incremental and bulk-
filling techniques.
• (Chane TARDEM et al., 2019) in their randomized clinical trial about the clinical
time and postoperative sensitivity after use of bulk-fill and incremental filling
composites demonstrated that neither the bulk nor the incremental techniques have
affected the risk of postoperative sensitivity.

36
Conclusion
Composite resin is one of the most crucial topics that gathers the attention of
dentists and scientists worldwide who are working toward developing composite
resin in the context of composition, bonding technique, curing technique, and
placement technique. While taking the studies discussed above into consideration,
we can demonstrate that: Bulk-fill composite resins placed either with sonic-
activated or sonic-vibrated instruments showed a superiority above bulk and
incremental techniques when comparing the marginal adaptation with the
incremental techniques showing better marginal adaptation when being compared
with bulk-fill technique. However, some studies had demonstrated that there is no
siginficant difference of placement technique when evaluating the marginal
adaptation. Snow-plow technique has shown the least microleakage when being
evaluated with the incremental technique, meanwhile the incremental technique
demonstrated the same result when being compared with centripetal technique with
the bulk technique being the most technique posing microleakage. The studies had
demonstrated that different placement techniques have no significant effect on the
fracture resistance. Cuspal deflection has been shown to be less in bulkfill
technique in comparison to incremental technique. However, some studies
demonstrated that the cavity depth could affect the cuspal deflection. In terms of
Post operative sensitivity, there was no signifcant difference between placement
techniques. However, the evolution of new techniques and new materials requires
more studies with the existing methods and materials.

37
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