Restorative Composite Resins

Col Kraig S. Vandewalle

USAF Dental Evaluation & Consultation Service

Official Disclaimer
The opinions expressed in this presentation are those of the author and do not necessarily reflect the official position of the US Air Force or the Department of Defense (DOD) Devices or materials appearing in this presentation are used as examples of currently available products/technologies and do not imply an endorsement by the author and/or the USAF/DOD

Overview
Direct restoratives
composition classification performance factors

Flowable Packables

Click here for briefing on composite resins (PDF)

Composite
Material with two or more distinct substances
metals, ceramics or polymers

Dental resin composite

soft organic-resin matrix
polymer

hard, inorganic-filler particles

ceramic

Most frequently used

esthetic-restorative material
Leinfelder 1993

History
1871 silicates
alumina-silica glass & phosphoric acid very soluble poor mechanical properties

1948 - acrylic resins

polymethylmethacrylate high polymerization shrinkage
Rueggeberg J Prosthet Dent 2002

History
(cont.)
1962 Bis-GMA
stronger resin

1969 filled composite resin

improved mechanical properties less shrinkage paste/paste system

1970s acid etching and microfills 1980s light curing and hybrids 1990s flowables and packables 2000s nanofills
Rueggeberg J Prosthet Dent 2002

Indications
Anterior restorations Posterior restorations
preventive resin conservative class 1 or 2

Contraindications
Large posterior restorations Bruxism Poor isolation

Advantages
Esthetics Conservation of tooth structure Adhesion to tooth structure Low thermal conductivity Alternative to amalgam

Disadvantages
Technique sensitivity Polymerization shrinkage
marginal leakage secondary caries postoperative sensitivity

Decreased wear resistance

Composition
Resin matrix
monomer initiator inhibitors pigments
O CH2=C-C-O-CH2CH-CH2O CH3 OH

Bis-GMA
CH3 -CCH3 O OCH2CHCH2O-C-C=CH2 OH CH3

Inorganic filler
glass quartz colloidal silica

Coupling Agent
Phillips Science of Dental Materials 2003

Monomers
Binds filler particles together Provides workability Typical monomers
Bisphenol A glycidyl methacrylate (Bis-GMA)
O CH2=C-C-O-CH2CH-CH2O CH3 OH CH3 -CCH3 O OCH2CHCH2O-C-C=CH2 OH CH3

Urethane dimethacrylate (UEDMA)

CH3 CH3 O O O O CH2=C-C-O-CH2CH2-O-C-NHCH2CH2CHCH2-C-CH2-NH-C- OCH2CH2O-C-C=CH2 CH3 CH3 CH3

Triethylene glycol dimethacrylate (TEGMA)

O O CH2=C-C-O-CH2CH2-OCH2CH2 OCH2CH2O-C-C=CH2 CH3 CH3

Monomers
Bis-GMA
extremely viscous
large benzene rings

lowered by adding TEGDMA

O CH2=C-C-O-CH2CH-CH2O CH3 OH

freely movable increases polymer conversion increases crosslinking increases shrinkage

CH3 -CCH3 OH O OCH2CHCH2O-C-C=CH2 CH3

Monomers
Shrinkage
27% marginal gap formation

Filler Particles
Crystalline quartz
larger particles not polishable

Silica glass
barium strontium lithium pyrolytic
sub-micron
Phillips Science of Dental Materials 2003

Filler Particles
Increase fillers, increase mechanical properties
Fracture Toughness

% Filler Volume
2 1.5 1

strength abrasion resistance esthetics handling

50 to 86 % by weight 35 to 71% by volume

0.5
0 0 28 37 48 53 62

Ferracane J Dent Res 1995

Coupling Agent
Chemical bond
filler particle - resin matrix
transfers stresses

Organosilane (bifunctional molecule)

siloxane end bonds to hydroxyl groups on filler methacrylate end polymerizes with resin
CH2 OH OH
Bonds with filler

Bis-GMA

CH3-C-C-O-CH2-CH2-CH2-Si-OH O Silane

Bonds with resin

Phillips Science of Dental Materials 2003

Inhibitors
Prevents spontaneous polymer formation
heat light

Extends shelf life Butylated Hydroxytoluene

Phillips Science of Dental Materials 2003

Pigments and UV Absorbers

Pigments
metal oxides
provide shading and opacity titanium and aluminum oxides

UV absorbers
prevent discoloration acts like a sunscreen
Benzophenone
Phillips Science of Dental Materials 2003

Visible-Light Activation
Camphorquinone
most common photoinitiator
absorbs blue light
400 - 500 nm range

Initiator reacts with amine activator Forms free radicals Initiates addition polymerization
O CH2=C-C-O-CH2CH-CH2O CH3 OH CH3 -CCH3 O OCH2CHCH2O-C-C=CH2 OH CH3

Bis-GMA

Polymerization
Initiation
production of reactive free radicals
typically with light for restorative materials

Propagation
hundreds of monomer units polymer network 50 60% degree of conversion

Termination
Craig Restorative Dental Materials 2002

C=C

C=C

C=C

C=C

C=C

C=C

C=C

C=C
C=C C=C

C=C C=C C=C C=C

C=C polymerization C=C C=C

C=C

C=C C=C
C=C C=C C=C C=C
Ferracane

C=C C=C

C=C C=C

C=C

C=C

Classification System
Historical Chronological Based on particle size
traditional microfilled small particle hybrid
Phillips Science of Dental Materials 2003

Traditional (Macrofilled)
Developed in the 1970s Crystalline quartz
produced by grinding or milling large - 8 to 12 microns

Difficult to polish
large particles prone to pluck

Poor wear resistance Fracture resistant Examples: Adaptic, Concise Suitable for Class 3, 4 and 5
Phillips Science of Dental Materials 2003

Microfills
Better esthetics and polishability Tiny particles
0.04 micron colloidal silica increases viscosity
Ground polymer with colloidal silica (50 u) Polymer matrix with colloidal silica

To increase filler loading

filler added to resin heat cured ground to large particles remixed with more resin and filler

Phillips Science of Dental Materials 2003

Microfills
Lower filler content
inferior properties
increased fracture potential lacks coupling agent lacks radiopacity

Linear clinical wear pattern Suitable for Class 3, 5

exceptions with reinforced microfills
Class 1 or 2
Click here for table of microfills

Small Particle
1 - 5 micron heavy-metal glasses Fracture resistant Polishable to semi-gloss Suitable for Class 1 to 5 Example: Prisma-Fil
Silane-coated silica or glass (1-5 u) Polymer matrix

Phillips Science of Dental Materials 2003

Hybrids
Popular as all-purpose
AKA universal hybrid, microhybrids, microfilled hybrids

0.6 to 1 micron average particle size

distribution of particle sizes
maximizes filler loading
Silane-coated silica or glass

microfills added
improve handling reduce stickiness

Polymer matrix with colloidal silica

Phillips Science of Dental Materials 2003

Hybrids
Strong Good esthetics
polishable

Suitable
Class 1 to 5

Multiple available

Click here for table of hybrids

Table of Properties
Property Compressive strength (MPa) Tensile strength (MPa) Elastic Modulus (GPa) Coefficient of Thermal Expansion (10-6/C) Knoop Hardness Traditional Microfilled Small Particle 350-400 Hybrid 250-300 250-300 300-350

50-65 8-15 25-35 55

30-50 3-6 50-60 5-30

75-90 15-20 19-26 50-60

70-90 7-12 30-40 50-60

Phillips Science of Dental Materials 2003

Newer Classification System

Based on particle size
megafill
0.5 - 2 millimeters

Most new systems

minifillers

macrofill
10 - 100 microns

Newest trend
nanofillers trimodal loading
prepolymerized

midifill
1 - 10 microns

minifill
0.1 - 1 microns

microfill
0.01 - 0.1 microns

nanofill
0.005-0.01 microns Bayne JADA 1994

Midi -filler 2 um (beachball) Mini -filler 0.6 um (canteloupe) Microfiller .04 um (marble) Nanofiller .02 um (pea)

Relative Particle Sizes

(not to scale)

Nanofill vs. Nanohybrid

Nanofills
nanometer-sized particles throughout matrix

Nanohybrids
nanometer-sized particles combined with more conventional filler technology

Swift J Esthet Restor Dent 2005

Nanofilled Composite
Filtek Supreme (3M ESPE) Filler particles
filled: 78% wgt nanomers
0.02 0.07 microns

nanocluster
act as single unit
0.6 1.4 microns
Click here for technical profile Click here for DECS evaluation

Performance Factors
Material factors
biocompatibility polymerization shrinkage wear resistance polish mechanisms placement types mechanical & physical properties

Biocompatibility
Tolerated by pulp
with good seal

Rare allergic reactions

HEMA

Cytotoxicity
short lived
not a chronic source

Degree of cure important

decrease free monomer
Phillips Science of Dental Materials 2003

Systemic
Estrogenic effects seen in cell cultures
impurities in Bis-GMA-based resins
Bis-phenol A in sealants
Olea EHP 1996 click here for abstract

however, insignificant short-term risk

literature review
Soderholm JADA 1999 click here for abstract

Polymerization Shrinkage
Significant role in restoration failure
gap formation
secondary caries formation marginal leakage post-operative sensitivity

Counteract
lower shrinkage composites incremental placement

Composite Wear
Less wear
small particle size
less abrasion

heavier filled
less attrition

non-contact areas
3 - 5 times less

less surface area anterior location

premolars vs. molars
Hilton Oper Dentistry: A Contemporary Approach 2001

Composite Wear
Reduced wear with smaller particles
less plucking leaving voids

Higher filler loads for enhanced properties

correlations between wear and fracture toughness and flexure strength

Higher cure of resin matrix to resist scratching and gouging by abrasives

Hilton Oper Dentistry: A Contemporary Approach 2001

Polish Mechanisms
Acquired polish
clinician induced

Inherent polish
ultimate surface

Microfills
high acquired, high inherent
similar resin matrix and fillers wear more evenly

Hybrids
high acquired, acceptable inherent
Adept Report 1992

Polish Mechanisms
Small Particle Hybrid Microfilled Composite

Acquired Polish
Time
Linear wear pattern

Inherent Polish
Adept Report 1992

Shaded vs. Anatomic Placement

Shaded
shade selected from middle third of tooth shade guide gives recipe for multiple shades

Anatomic
highly chromatic dentin matched to existing dentin colorless enamel replaces existing enamel
Click here for details

Shaded Dentists Match Shade

Anatomic Ceramists Create Shade

Trans Enamel
A1 Enamel A1 Dentin

Trans Enamel Enamel Value

A3/A4 Dentin Enamel Value

Placement Types
Composite Brands
Shaded
4 Seasons (Ivoclar Vivadent) Esthet-X (Dentsply) Filtek Supreme (3M ESPE) Point 4 (Kerr) Venus (Heraeus Kulzer) Renamel (Cosmedent) Gradia Direct (GC)

Anatomic
4 Seasons (Ivoclar Vivadent) Vitalescence (Ultradent) Miris (Coltene/Whaledent)

Jackson PPAD 2003

Composite Selection
Anterior/stress (Class 4)
hybrid
mini- or midi-fill

hybrid/microfill veneer combo

Anterior/non-stress (Class 3 or 5)
hybrid
mini-fill

microfill

Composite Selection
Posterior
hybrid
mini- or midi-fill

reinforced microfill

Selecting a Brand
Contents of kit
shades bonding agent unit-dose compules vs syringes

Indications
anterior, posterior, both?

Cost of kit
refills
Click here for synopsis of restorative composite resins

Government Price
($/gm of refill resin)
8.49 7.58 6.3 6.5 8.53 8.79 8.9 9 9.44 9.95 10.15 10.21 11.37

G ra ons di a Po G st ra di H a er cu A n t lit e XR Pr V od ig y Po in t4 Z1 00 Vi Ven ta us le sc en ce Es th et X Z2 50 Pr em i Su se pr em e

Prices current as of Jan 05

Se as

Selecting a Brand
Results of lab and clinical studies Compositional characteristics
% filler content average filler particle size

Click here for synopsis of restorative composite resins

Radiopacity
(mm of aluminum)
3 2 1 0

ISO Requirement

Ve nu s Su pr em e 4 Se as on s En am Vi el ta les ce nc Gr e ad ia Po st

Source: USAF DECS Project 03-024

De nt in Gr ad ia An t

Surface Hardness
(24 hrs)
Source: USAF DECS Project 03-37

KHN

40 30 20 10 0

Z2 50 Su pr em Vi ta e le sc en ce

Horizontal lines connect nonsignificant differences (p<0.05); N=5

Po in t4 4 Se as on s Pr em is G e ra di a Po st G ra di a An t

Ve nu s Es th et -X

Flexural Strength
(24 hrs)
Source: USAF DECS Project 03-037

160 140 120 100 80 60 40 20 0 Supreme 4 Seasons Venus Gradia Ant Premise Gradia Post

Horizontal lines connect nonsignificant differences (p<0.05); N=5

Volumetric Shrinkage
Source: USAF DECS Project 03-037

5 4 3

2 1 0

Z1 00

Pr em is e 4 Se as on s

R en ew

A 11 0

ct

Ve nu

D ire

ra di

Horizontal lines connect nonsignificant differences (p<0.05); N=5

Es th

et -X

Fl

ow

Composite Variants
Packable Flowable

Packable Composites
Marketed for posterior use
increase in viscosity
better proximal contacts? handle like amalgam?

Subtle alteration of filler

shape size particle distribution

Similar resin chemistry and filler volume

Click here for table of packable composites

Packable Composites
Mechanical properties
similar to hybrids
1.8 1.6 1.4 1.2 1 0.8 0.6 ALERT Solitare SureFil Heliomolar Z100

Fracture Toughness

0.4
0.2 0

Choi J Esthet Dent 2000 Click here for abstract

Proximal Contact Studies

Packables similar to hybrids
diameter and tightness

Best contacts
sectional matrix system

Peumans Dent Mater 2001 -click here for abstract Klein Am J Dent 2002

Packable Composite Resin

Depth of Cure
% Hardness Ratio

100 80 60 40

96.9

96.2

91.2

85.1 71.5 70.3 2 mm 5 mm 41.4 22.4

70.2 55.4

20 0 Pyr-D Prodigy SureFil Alert 0 Solitaire 0 Pyr-E

Choi J Esthet Dent 2000 Click here for abstract

Packable Vs. Hybrid Composites

Mechanical properties similar Wear properties similar Curing depths similar Similar proximal contacts Drier, denser feel
Click here for more details Choi J Esthet Dent 2000 Peumans Dent Mater 2001

Flowable Composites
Marketed
Weight Percent

class 1, 3, 5 liner

Percent Filler Loading

80 70 60 50 40 30 20 10 0 Aeliteflo FloRestore Revolution Ultraseal+ Prodigy

Particle size similar to hybrid composites Reduced filler content

reduces viscosity
Bayne JADA 1998 Click here for abstract

Liners Under Direct Composites

Increased flow Increased shrinkage Improved marginal integrity?
laboratory studies equivocal
most studies show no benefit
Braga JADA 2003 click here for abstract

Reduced post-operative sensitivity?

no clinical evidence of reduction
Perdigao Quint Int 2004 click here for abstract

Polymerization Shrinkage
%
5 4 3 2 1 0

Ae

e t li

o Fl

lu o v e R

n o i t

e av

ow l F

-it ri t Te c

ow l F

rt e Al

Fi e r u S

00 1 Z li e H

ar l o m o

Tolidis JDR 1999

Radiopacity
Reduced radiopacity?
product specific may be more difficult to distinguish on radiograph
Gray value

250 200
Tetric Flow Flow-it Enamel Revolution FloRestore UltraSeal+

150
100 50 0

Murchison Quint Int 1999 Click here for abstract

Flowable Composite
Mechanical properties
inferior to hybrids
Fracture Toughness
Prodigy Ultraseal + Revolution
FloRestore Aeliteflo 0 0.5 1
MPa

Flexure Strength

1.5

2.5 0 50 100
MPa

150

200

Bayne JADA 1998 Click here for abstract

Flowable Composites
Clinical applications
preventive resin restorations small Class 5 provisional repair composite repair liners??

Regular Material Usage*

Civilian Practitioners Flowable Composite 81% Hybrid Composite 69% Amalgam 67% All-Purpose Composite 53% Microfill Composite 52% Resin-modified Glass ionomer 45% Packable Composite 33% Compomer 7% Other 1%
*Multiple responses DPR 2005

Review of Clinical Studies

(Failure Rates in Posterior Permanent Teeth)
% Annual Failure

8 6 4 2 0

Amalgam

Direct Comp

Comp Inlays

Ceramic CAD/CAM Inlays Inlays

Gold Inlays & Onlays

GI

Longitudinal

Cross-Sectional
Hickel J Adhes Dent 2001

Review of Clinical Studies

(Failure Rates in Posterior Permanent Teeth)
% Annual Failure

15
Standard Deviation

10
Longitudinal and Cross-Sectional Data

5 0
ct Co m Co p m po m Co er m p In Ce la ra ys m ic In la ys CA D/ CA M Ca st G ol d al ga m I Tu nn AR T G el

Am

Di re

Manhart Oper Dent 2004 Click here for abstract

Purchasing Considerations
Federal Service Universal hybrid systems are suitable for both anterior and posterior restorations
may not need to stock packable systems
additional expense to maintain no improvement in mechanical properties no improvement in proximal-contact formation no increase in depth of cure

Click here for more details

Purchasing Considerations
Federal Service Most cases often only need one shade type Complex cases may need multiple shades applied in layers
larger Class 4, direct veneers, diastema closures

Wide diversity of kits available

simple kits with only a few shades complete kits with multiple shades in various opacities; bonding agents, dispenser guns, shade guides
Click here for synopsis of restorative composite resins

Purchasing Considerations
Federal Service Simple universal hybrid kit in compact case for routine individual use in operatories or suites
many systems available
e.g., Prodigy (Kerr)

More complete universal hybrid kit for general use by entire facility or training program
several systems available
e.g., 4 Seasons (Ivoclar Vivadent)
Click here for synopsis of restorative composite resins

Future Composites
Low-shrinking monomers
expanding spiroorthocarbonates epoxy-based resins liquid crystal

Self-adhesive?

Click here for details

Acknowledgments
Dr. Dave Charlton Dr. Jack Ferracane Dr. Tom Hilton

Questions/Comments
Col Kraig Vandewalle
DSN 792-7670
ksvandewalle@nidbr.med.navy.mil