COSMETIC AND ESTHETIC DENTISTRY |
JADA Continuing Education
THE NEW POSTERIOR RESINS AND
A SIMPLIFIED PLACEMENT TECHNIQUE
RONALD D. JACKSON, D.D.S. and
MICHAEL MORGAN, D.D.S.
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ABSTRACT
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Background. New heavy-body (packable) composites have been developed for use in posterior direct resin restorations. These materials are promoted as having better handling characteristics and higher physical properties than previous microhybrid composites.
Methods. The authors describe an incremental layering technique that takes advantage of the improved handling characteristics and proposed reduced shrinkage and greater depth of cure.
Clinical Implications. When this new technique is used with one-bottle adhesives and improved instrumentation, posterior heavy-body composites can be placed faster, easier and possibly more predictably than when medium-body resins and previous techniques are used.
The composite resins were first introduced in the 1960s with product names such as Adaptic (Johnson & Johnson) and Concise (3M Dental Products). They were chemically cured and their use was indicated for Class III, IV and V cavity preparations. The filler particles were large and the filler content was low. They were not polishable and tended to discolor over time. For these indications, they were durable, with some restorations lasting up to 10 years. However, high wear rates and marginal leakage made such composites unacceptable for long-term restoration of posterior occlusal surfaces.1
A major step in composite technology occurred in the 1970s with the introduction of light-cured composite resins such as Nuva-Fil (DENTSPLY/L.D. Caulk). (Although it is more accurate to call these composite resins light-initiated, the popular term light-cured will be used in this article.) Studies have demonstrated that light-cured composite resins are more wear-resistant and more color-stable than the self-cured composite resins.2,3 The improved wear resistance was the result of using smaller filler particles (mean diameter, 5 to 8 micrometers) and because less air was incorporated in placement of the restoration compared with hand-mixed autocured resins. Increased air causes inhibition of the polymerization process and creates voids that accelerate wear.4
In the early 1980s, resins specifically for posterior use appeared with the introduction of such products as P-10 (autocured; 3M Dental Products), followed by P-30 (light-cured; 3M Dental Products). They were also relatively wear-resistant because of reduced particle size and increased filler loading.5
By reducing the particle size even further, to 0.04 µm, manufacturers were able to introduce microfill products around this time. This new generation of composite resins had high polishability, high wear-resistance and good color stability. However, because of lower strength in flexion and tension, these composite resins were prohibited for Class II restorations.6 The sole exception has been Heliomolar (Ivoclar-Vivadent), which was developed in 1986 and remains popular for posterior restorations.
In the mid-1980s, significantly improved light-cured composite resins, such as Herculite (SDS Kerr), APH (which stands for all-purpose hybrid) (DENTSPLY/L.D. Caulk) and P-50 (3M Dental Products) became the standards for restorative resins. They were intended for universal use (that is, for both anterior and posterior restorations). They were called hybrids because they had a mixture of particle sizes (from 0.04 to 3 mm). The mean particle size was approximately 1 µm.
Further refinements in these materials led to the term micro-hybrid being used to describe resins with mean particle sizes in the 0.6- to 0.7-µm range. Generally, the particles in these composite resins also were more uniform in size. These materials (such as TPH, DENTSPLY/L.D. Caulk; Herculite XRV, SDS Kerr; Charisma, Heraeus/Kulzer; Tetric Ceram, Ivoclar-Vivadent; and Renamel Hybrid, Cosmedent) have excellent physical properties, are relatively nonsticky, and finish and polish well; however, they do not hold a high polish.7
Although successful techniques for posterior resin placement have been developed with these universal microhybrid materials, they present many challenges when clinicians attempt to place morphologically correct and functional Class II restorations.8–15 Many hybrid composites are difficult to manipulate because of inherent stickiness and slumping. Stickiness can result in voids and porosity as materials are manipulated. Slumping increases the difficulty of creating proper anatomical form during incremental placement of the material.
Another problematic physical property inherent to all composite resins is shrinkage during polymerization.16 Shrinkage can present numerous challenges during placement. It has commonly been assumed that resins shrink toward the light; however, recent investigators have disputed this.17,18 They propose that the material shrinks toward the fixed boundaries and there is not much difference in vector patterns between autocured and light-cured composite resins. Either way, the bonded interface is stressed. If the preparation is bulk-filled or if a single increment connects opposing walls in Class I or II posterior restorations, the resulting high C-factor ratio (that is, the ratio of the bonded to unbonded walls in a restoration) can further increase shrinkage stress.19 This, in turn, can lead to marginal gaps and microleakage at gingival margins. Such leakage can cause postoperative sensitivity and possibly lead to secondary caries.20
Dental practitioners generally accept that one of the most difficult challenges when placing a direct Class II composite resin restoration is the formation of a high-quality, predictable contact. Composite resins cannot be condensed like amalgam. Allowances must be made for this fact during matricing and placement.
When all factors are taken into consideration, placing posterior Class II resins is much more demanding and technique-sensitive than placing amalgams. In addition, the adhesive process must be followed with precision and accuracy. Failure to do so can result in postoperative sensitivity, and even failure of the restoration.12
Finally, the time needed to place a high-quality posterior composite resin restoration can be considerably more than that needed to place an amalgam restoration. The increased time requires an increased fee, which is often resisted by patients and third-party payers who may not fully understand all of the benefits of an adhesive restoration beyond esthetics.
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NEW MATERIALS
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New terminology.
New composite resins specifically developed for posterior use have recently been introduced (Table 1
). Some manufacturers are marketing these products as condensable. (The dictionary defines condensable as able to be compacted or made denser by reducing volume.) Unlike amalgam, composite resins cannot be compacted (or condensed). However, it is not necessary for composite resins to demonstrate this property to be used expediently and successfully for posterior restorations.
The new resins can be described as packable (The dictionary defines packable as the ability to organize the composition of, in order to achieve a favorable or hoped-for result.) and stay where placed, regardless of the time required for sculpting before light-curing. In addition, these materials are easily manipulated because they are virtually nonsticky when clean, scratch-free instruments are used.
A great deal of confusion exists when differentiating the various classes of composite resins in the marketplace today. Some of this is due to the various adjectives, such as condensable, packable or compactable, used by manufacturers to market their new resin products. A better way to describe these new posterior composites might be to use the common terms used to describe impression materials. Just as those materials are available in light-body, medium-body and heavy-body forms, so too are contemporary composite resins.
Light-body composite resins are the flowable materials that have a low viscosity. Medium-body composites are composed of the microfill, hybrid and microhybrid universal resins currently used for anterior and posterior restorations. In general, they have a medium viscosity, which allows them to be placed and contoured with different degrees of ease or difficulty depending on cavity configuration. The stickiness and slumping of each of these products varies. The new packable posterior composite resins can be accurately termed heavy-body. The change in composition of heavy-body composite resins compared with their medium-body predecessors is the result of increasing the volume of filler particles, varying the size and type of the particles, altering the chemistry of the resin matrix or a combination of any of the above.21–23 Manufacturers are claiming that these changes result in less shrinkage during polymerization as well as in improvements in workability, depth of cure, wear resistance and color stability.
Because these materials do not slump, the entire occlusal increment can be placed and sculpted to the final anatomy at once, thereby greatly reducing the amount of final adjusting and finishing.
Characteristics.
The desirable properties and handling characteristics in a composite resin used to restore posterior teeth are different from those in a material used to restore anterior teeth.24 For posterior teeth, the material will have the following desirable qualities:
- – heavy body and can be pushed into the proximal box of the preparation;
- – will stay in place when patted against a burnished contact;
- – nonsticky;
- – does not slump;
- – has high compressive and flexural strength;
- – finishes well;
- – has a high depth of cure and less shrinkage than other composite materials.
Even though a dentin opacity and an enamel translucency are still required for esthetic reasons, the wide range of shades required to restore anterior teeth is generally not necessary to restore posterior teeth.
The manufacturers of the heavy-body composites currently in use claim that their products have all of the aforementioned desirable physical characteristics.21–23 Because these materials do not slump, the entire occlusal increment can be placed and sculpted to the final anatomy at once, thereby greatly reducing the amount of final adjusting and finishing.
Controversy exists over whether a single increment (that is, bulk placement) should be placed against opposing walls simultaneously before light-curing.25 The concern is that polymerization shrinkage may cause the cusps to bend toward each other.26,27 This stress can be detrimental to the tooth and the marginal integrity over time. Manufacturers claim that, for the most part, because of their high density, the heavy-body resins result in less volumetric shrinkage than standard restorative resins.21–23 This property, combined with a greater depth of cure (most manufacturers are claiming up to 5.0 millimeters21–23), enables the clinician in many instances to place and sculpt the entire dentin replacement in one increment. If the dentin replacement is greater than 5.0 mm (that is, in a cavity with a deep proximal box), a second increment is required. In these instances, the clinician needs to sculpt only the second increment to contour.
The clinician replaces the enamel with a more translucent shade of resin than what was used to replace the dentin, and sculpts it to contour with pits, fissures, marginal ridges, triangular ridges and secondary fissures as needed to mimic the natural occlusal anatomy. More than esthetics is involved, because proper occlusal morphology affects function significantly. The last increment of resin is placed with minimal excess flash at the occlusal margins. A slight excess helps to ensure a gap-free restoration. Because the flash is minimal, the restoration may be finished quickly (Figures 1 and 2).
Adhesives.
In addition to the new heavy-body composites, the introduction of one-bottle adhesives has made it easier to place posterior restorations. One-bottle adhesives are light-cured and combine the primer and bond resin for enamel and dentin bonding. They are used in conjunction with the wet-bonding technique.28 Some products also include a small amount of filler particles. Diffusion of the resin into the demineralized collagen fibers of the dentin results in a hybrid layer of resin-reinforced dentin.29 The importance of the hybrid layer in adhesive dentistry has been consistently proven.28,30 A primary advantage of one-bottle adhesives over multicomponent adhesives is a decrease in the number of steps—and therefore the time—needed to achieve adhesion.31 Instead of having a separate application of primer and bonding resin, the two steps are combined in a single application that is faster and easier and can be more predictable.
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INSTRUMENTATION
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As mentioned above, one of the primary difficulties clinicians face when placing direct Class II composite resin restorations is achieving a predictable, high-quality interproximal contact. Traditional, relatively thick metal matrices used for amalgam placement often do not yield good results. Various preformed clear plastic or polyester (Mylar) bands also have yielded unpredictable results for some clinicians. New matrices and contact-forming instruments have been developed to compensate, not only for the thickness of the matrix band, but also for the shrinkage and lack of body of the composite resin (Tables 2 and 3). The Palodent System (Darway Inc.) and Composi-Tight System (Garrison Dental Solutions) consist of sectional matrices and bitine or G-shaped rings that engage the undercuts to stabilize the bands. Pressure from the rings and wedges helps separate adjacent teeth to achieve interproximal contact.
The Ho Band (Young Dental) is a dead-soft 0.001-inch-thick matrix used with a Tofflemire holder. With proper wedging and burnishing, the matrix thickness and composite shrinkage can be compensated for.
The Microband (Dental Innovations) is a new micromachined matrix band developed specifically for Class II posterior composite resin restorations. The contact area of a normal 0.0015-inch-thick matrix band has been thinned to 0.0006 inches (12 µm).32 A wedge is used to adapt the band to the gingival margin of the proximal box. Enough wedging force is needed to retain the wedge; however, excessive wedging to separate the teeth is not required. The thin contact area is burnished against the adjacent tooth in the ideal location and proper size. Because the band is so thin, the heavy-body composite resin is placed virtually in contact with the adjacent tooth. The manufacturer also supplies these bands as sectional matrices called Microstrips (Dental Innovations).
Contact-forming instruments are sometimes useful for Class II composite resin restorations. Most of the instruments operate by distending or stretching the matrix band while the proximal composite is light-cured. Although these instruments are not necessary in all situations, they are particularly helpful when restoring malaligned teeth or rotated teeth or when a wider-than-normal intertooth distance exists. When a contact-forming instrument is needed, we believe that the Contact Pro 2 B (C.E.J. Dental) provides a consistent contact of the correct size and location.
The combination of the new materials, matrices and contact-forming instruments has made it possible to achieve predictable, high-quality contacts in Class II direct composite resin restorations. In addition, the results are achieved faster, easier and more predictably than they were before.
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PLACEMENT TECHNIQUE
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We suggest the following sequence of procedures when placing direct Class II restorations with a heavy-body composite resin.
Clinical factors.
Evaluate the clinical factors to determine if placement of a Class II direct resin is appropriate. These restorations generally are appropriate for smaller cavities where the isthmus width is one-third or less the buccolingual width of the tooth and the restoration is not subject to heavy occlusal forces.33
Shade.
Before placing the rubber dam, the clinician should use an adjacent nonrestored tooth as a guide for selecting the base restoration shade. Currently, a limited number of shades are available for the heavy-body composites.
Isolation.
Administer the anesthetic to the patient and place the rubber dam. The use of a rubber dam is mandatory for adhesive posterior restorations, since isolation by other means usually is not adequate.34 Use waxed floss to ligate the teeth to be restored (Figure 3).
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Figure 3. Preoperative view of existing amalgam to be replaced in upper first molar. Rubber dam isolation has been achieved and the tooth ligated.
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Old restoration.
Remove the old amalgam restoration. The dentist should use slow-speed round burs to remove all caries. (Only the removal of diseased tooth structure is necessary.) Extension for prevention is not necessary and may be contraindicated.35 All internal line angles should be rounded.36 The proximal walls of the box as well as the gingival margin can have a slight bevel to better expose the enamel rods for etching (Figure 4).
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Figure 4. Extensive caries was found under the amalgam, necessitating some enamel removal for access. The completed preparation has rounded internal line angles.
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Matrix.
Place a matrix (Microband) using a Tofflemire holder with the shiny side against the adjacent tooth contact. The dentist places a wedge to tightly adapt the gingival margin. Burnish the contact area.
Perioprobe.
Use a perio-probe to measure the depth of the preparation in both the occlusal and proximal areas. Most manufacturers of heavy-body resins recommend bulk filling in increments no larger than 5 mm. In the placement technique shown (Figures 1
and 2), the maximum bulk of composite cured at once is approximately 3.0 to 3.5 mm. Until more clinical studies are conducted, it may not be prudent (and it is not usually necessary) to bulk-cure 5 mm of material (Figure 5).
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Figure 5. The depth of the cavity measures about 5.0 millimeters with a periodontal probe. The matrix band (Microband, Dental Innovations) has been placed, wedged and burnished.
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Etching and bonding.
The tooth is etched and a dentin/enamel bonding agent of choice is applied according to the manufacturer’s directions; the bonding agent is then cured.
Light-body composite resin.
Apply a 0.5- to 1.0-mm layer of flowable light-body composite resin in the proximal box at the gingival margin and across the entire pulpal floor and light-cure the resin. The flowable resin is an intermediate restorative material placed between the dentin hybrid layer and the heavy-body composite. Many researchers believe that flowable composite resins may partially compensate for the stress caused by polymerization shrinkage because of their low modulus elastomeric properties.37,38
Heavy-body restorative.
Place the heavy-body restorative material in 3.0- to 3.5-mm increments. The dentist builds the composite resin to contour and light-cures. The occlusal margin of the material should be just shy of the dentoenamel junction. This should leave approximately 1.0 to 1.5 mm of space for placement of the translucent enamel shade. (Because these composite resins do not slump, the primary anatomy can be easily sculpted at one time over the entire surface.) If the teeth are malaligned or if achieving proper contact seems doubtful, the dentist should use the contact-forming instrument before curing (Figure 6). After curing, tints can be placed to mimic a natural appearance if desired (Figure 7).
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Figure 6. After etching, adhesive placement and placement of a light-body (flowable) composite resin, the entire dentin is replaced in one increment with the use of heavy-body resin (Surefil, DENTSPLY/L.D. Caulk). The material is sculpted to contour and light-cured.
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Medium-body restorative.
Apply the translucent enamel shade of medium-body composite resin and contour. A medium-body restorative is necessary because most of the currently available heavy-body resins do not have a translucent enamel shade. To achieve a less opaque and more esthetic restoration, the clinician needs to place a translucent layer over the opaque dentin shade of material. We suggest that the clinician use the medium-body enamel shade from the same manufacturer of the heavy-body restorative material. Because this increment is essentially bonded to enamel and is only about 1-mm thick, it can be placed and sculpted over the entire surface at the same time. The clinician then extends the material over the occlusal margins so that there is a slight amount of flash (Figure 8).
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Figure 8. The enamel is replaced with a single increment of translucent medium-body composite resin (Esthet-X, DENTSPLY/L.D. Caulk).
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Finishing.
After curing is complete, the clinician uses a hemostat to remove the wedge and matrix. A number 12 blade on a scalpel handle is used to remove any interproximal gingival excess. Check the contact using waxed floss. If the contact is too tight, narrow fine-diamond finishing strips can be used to adjust.
The dentist then uses aluminum oxide finishing discs to remove flash at the proximal boxes, to contour occlusal embrasures, and to create proper marginal ridge contour.
The rubber dam is removed and the occlusion is checked with articulating paper; the occlusion and marginal excess are then adjusted with carbide finishing burs. It is best to use the bur in a high-speed hand-piece without water and use short light strokes while the assistant blows air on the tooth for good visibility. Minimal finishing should be necessary if the composite resin was sculpted to the correct contour. Excessive finishing can jeopardize marginal integrity and resin longevity (Figure 9).39,40 Final finishing and polishing are achieved with impregnated rubber instruments used in a slow-speed handpiece.
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Figure 9. The occlusion is adjusted after removal of the rubber dam. The restoration is finished and polished.
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Dickinson and Leinfelder 41 conducted a study that used earlier-generation adhesives, composite resins and placement techniques; the results showed that etching and resealing improved short-term wear of the restoration. However, no studies have shown the efficacy of etching and resealing with currently used materials and techniques. Some clinicians have promoted the use of etching and resealing as a possible way to seal damaged enamel margins. Although no studies have shown extended longevity of the restoration or clinical efficacy with this additional step, it can do no harm (Figure 10; see page 381).
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DISCUSSION
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The benefits—both esthetic and functional—of anterior direct composite resin restorations are readily apparent to both the dentist and patient. The same cannot always be said for posterior direct composite resin restorations. However, many benefits do exist.
Direct resins are by their nature conservative. Only the existing restoration (if any) and diseased tooth structure are removed. The remaining healthy tooth structure remains intact. Extension for prevention or retention is no longer necessary. The restoration is made to fit the requirements of the tooth, instead of the tooth being made to fit the requirements of the restoration.
Conservation of healthy tooth structure is a significant benefit to patients. Because people are living longer and keeping their teeth, it is more important than ever to conserve tooth structure if future treatment becomes necessary. Should part of the remaining tooth structure become fractured or diseased at a later time, the tooth usually can be restored without preparing the entire tooth again. Better materials and techniques can be expected in the future. By conserving as much tooth structure as possible now, patients will have improved options available when—and if—they ever need to undergo treatment again.
Tooth reinforcement is another benefit of posterior bonded composite resin restorations. Proper adhesive techniques, combined with proper composite resin placement, strengthen the remaining healthy tooth structure.42–44 This property, along with a coefficient of thermal expansion of resins that is closer to that of tooth structure than the thermal expansion of metals is to that of teeth, should reduce the potential for cusp fracture.
When done properly, adhesively sealed enamel margins have consistently shown resistance to microleakage.45 Although a complete seal of dentin margins has been shown to occur on an inconsistent basis, microleakage is still significantly reduced in these restorations when compared with nonadhesive restorations.46 Furthermore, thoroughly hybridized dentin can reduce postoperative sensitivity and, should marginal breakdown eventually occur, possibly provide a barrier to bacteria-caused pulpal inflammation and secondary caries over the long term.47
Although they have been in use for only a short time compared with amalgam restorations, composite resin restorations have demonstrated similar clinical longevity.48–50 This is in spite of the fact that the earlier composite resins and adhesives as well as the placement techniques are considered historical by today’s standards. Even better results can be predicted for currently used materials.
Finally, the most obvious benefit of posterior composite resins is esthetics. In fact, much of the current trend toward the use of posterior composite resins has been driven by patient demands for increased esthetics in all areas of the mouth.
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CONCLUSION
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We have proposed a simplified placement technique for Class II direct resin restorations that involves the use of new posterior heavy-body resins. We should note that because the posterior heavy-body resins have been available for only about 1
years, information about clinical performance is lacking. These materials do not have a definitive track record. Clinical trials are under way with some of them, but little information has been published.51 At least one report somewhat contradicts some of the manufacturers’ claims.52
On the other hand, because some of these materials do not differ significantly from their medium-body predecessors, it may be possible to extrapolate predicted clinical performance. If clinical trials demonstrate physical properties and performance that are as good as—or better than—those of current universal medium-body composite resins, then these new heavy-body composite resins will likely dominate the posterior resin market.
In our opinion, the better handling characteristics that allow a shorter, simplified placement technique will be the reason dentists will use these new heavy-body resins. Finally, because dentists who use amalgam will find the transition to this composite resin placement technique easier, the downward trend in amalgam use will undoubtedly accelerate.
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FOOTNOTES
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Dr. Jackson has served, on a limited basis, as a paid consultant to SDS Kerr, DENTSPLY/L.D. Caulk and Ivoclar-Vivadent, but does not receive any royalties on the sale of any product mentioned in this article.
Dr. Jackson is in private practice, P.O. Box 1060, 204 E. Federal St., Middleburg, Va. 20118. Address reprint requests to Dr. Jackson.
Dr. Morgan is in private practice in Chicago.
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Crit. Rev. Oral. Biol. Med.,
May 1, 2004;
15(3):
176 - 184.
[Abstract]
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ABSTRACT
NEW MATERIALS
