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 J Appl Oral Sci

 v.21(1); Jan-Feb 2013

 PMC3881802

J Appl Oral Sci. 2013 Jan-Feb; 21(1): 68–73.

doi: 10.1590/1678-7757201302295
PMCID: PMC3881802
PMID: 23559115

Marginal adaptation of class V composite restorations submitted

to thermal and mechanical cycling
Denise Sá Maia CASSELLI,1 André Luis FARIA-E-SILVA,2 Henrique CASSELLI,3 andLuis Roberto
Marcondes MARTINS4

Author information Article notes Copyright and License information Disclaimer

This article has been cited by other articles in PMC.

Abstract
Go to:

INTRODUCTION
Despite the improvements of restorative material in recent decades, the marginal integrity of
restorations remains a challenge for dentistry. Poor marginal adaptation may produce
marginal discoloration, postoperative sensibility, and secondary caries21. These are the most
frequent reasons to replace or repair an adhesive restoration3,24. The marginal failure of
composite resin restorations is related mainly to the quality of bonding to the dental
structures2 and to stress generated on the restoration21.
Traditionally, the bonding to the dental tissue is obtained by etching the substrate using
phosphoric acid, followed by rinsing and applying an adhesive agent25. Later, simpler
adhesives were introduced with the development of self-etching primers/adhesives,
eliminating the previous conditioning, rinsing, and drying steps that were critical for the
adhesion protocol. However, it has been demonstrated that this simplification did not
improve the bonding performance7,25. Moreover, the substrate where the adhesive was
applied can also influence the performance of different adhesive systems25,28.
Furthermore, de-bonding followed by gap formation can be observed when the restoration is
submitted to stresses. The polymerization of composite resin results in a reduction in the
intermolecular distance between the monomers and consequential shrinkage16. Bonding the
composite resin to the cavity walls impairs the material deformation and generates shrinkage
stress on the bonding interfaces18,26. If stress exceeds the bond strength between the dental
substrate and the adhesive system, a contraction gap will be formed, jeopardizing the
restoration's longevity17,21.
In addition to stress shrinkage, the occlusal loads and alterations of the temperature of the
oral behavior produce stress on the restoration and can also compromise the marginal
sealing14,27. Clinical evaluations of restorations are very complicated because of ethical
reasons, and they are time-consuming and expensive. In vitro studies simulating oral
conditions have been performed in order to permit an estimation of the restoration longevity.
Thus, the aim of this study was to evaluate the effect of the substrate and adhesive system on
the marginal integrity of composite restorations submitted to thermal and mechanical
cycling. The null hypotheses were that the following have no effect on the marginal
adaptation of composite restorations: (I) the localization of the restoration margin (dentin or
enamel), (II) the adhesive system (etch-and-rinse or self-etching), and (III) thermal and
mechanical cycling.
Go to:

METHODOLOGY
One week after extraction, 40 sound bovine incisors were cleaned and examined under a
light microscope (Eclipse E 600; Nikon, Shinagawaku, Tokyo, Japan) in order to exclude
those with cracks. The teeth were stored in distilled water at 5ºC for less than one month
before the restorative procedure. Standard-shaped Class V cavities (3x3 mm, and 2 mm of
depth) were prepared using a #169L carbide bur (KG Sorensen Ind. Com. Ltda. - Barueri,
SP, Brazil) on the buccal surface. Each preparation was designed so that the incisal margin
was in the enamel and the gingival margin was in the dentin. Within these dimensions, the C-
factor [ratio between the bonded area (33 m2) and the free surface (9 mm2)] of the cavity was
3.7. The cavities were prepared with a water-cooled highspeed turbine using a standard
cavity preparation device. The turbine is attached to this device that permits the controlled
movement of the bur on the x, y and z axes. A new bur was used for each of the five
preparations.
The cavities were restored using a two-step etch-and-rinse [Single Bond 2 (SB)], or a
twostep self-etching [Clearfil SE Bond (CL)] adhesive (n=20). The classification,
composition and manufacturers of the adhesive systems used are described in Figure 1.
Figure 1
Classification, manufacturer and composition of the adhesive agents used in the study. *As
informed by the manufacturers. Bis-GMA: bisphenol-A glycidyl dimethacrylate; HEMA: 2-
hydroxyethyl methacrylate; DUDMA: diurethane dimethacrylate; CQ: camphorquinone;
DHEPT: dihydroxyethyl p-toluidine; 10-MDP: 10-methacryloyloxydecyl dihydrogen
phosphate

Adhesive Classification Manufacturer Composition*

Single Bond 2-step,etch-and- 3M ESPE, St. Paul, Bis-GMA, HEMA, DUDMA, polyalkenoic acid
2 rinse MN, USA copolymer, CQ, DHEPT, water, ethanol, silica

Clearfil SE 2-step,self-etch Kuraray, Osaka, Primer: 10- MDP, HEMA, hydrophilic

Bond Japan dimethacrylate, photo-initiator, water

Bonding agent: Bis-GMA, HEMA, 10-MDP, CQ,

DHEPT, colloidal silica
The cavities were randomly restored using one of the following adhesive protocols (SB or
CL). For the SB groups, a 35% phosphoric acid gel (3M Scotchbond Etchant, 3M ESPE, St.
Paul, MN , USA) was applied to the entire cavity for 15 sec. The acid was rinsed off with
water for 15 sec and the excess water was removed with a small damp cotton pellet. The SB
adhesive system was applied according to the manufacturer's instructions to all cavity walls,
which were checked for a shiny surface. The adhesive layer was thinned with a directed
lowpressure air stream and light-cured for 20 sec. For the CE groups, the self-etching primer
was applied to the cavities, left undisturbed for 20 sec and evaporated with an air-syringe.
The adhesive was then applied, spread gently with an air-syringe and light-cured for 20 sec.
The cavities were restored with a micro-hybrid composite resin (Filtek Z-250, 3M ESPE, St.
Paul, MN, USA), filled in one (bulk) increment of 2 mm and light-cured for 20 sec. The
light-curing procedures were performed with LED Radii-Cal (SDI, Bayswater, Victoria,
Australia) devices. The output of the light-curing unit was periodically checked using a
handheld radiometer (Model 100, Demetron Kerr, Orange, CA) and was determined to be
near 600 mW/cm2. All restored cavities were stored in distilled water at 37°C for 24 h and
polished with flexible aluminum oxide disks (Sof- Lex Pop-on®, 3M ESPE, St. Paul, MN,
USA) under a water spray. The disks were used in descending order of grit size (coarse,
medium, fine followed by extra-fine).
Impressions of restorations were taken using a polyvinyl siloxane impression material
(express, 3M ESPE, St. Paul, MN, USA) and replicas were done with epoxy resin (epoxide,
Buehler Ltd, Lake Bluff, IL). Replicas were mounted on aluminum stubs, gold sputter-coated
(SCD 050, Baltec, Vaduz, Liechtenstein) and examined by scanning electron microscopy
(SEM; JSM-5600LV, JEOL, Tokyo, Japan). The enamel and gingival margins were divided
into 3 regions each for SEM analysis. The margins were analyzed under SEM at 500x
magnification. The maximum length of the marginal gap of each region was recorded (T0).
After the first evaluation, the samples were submitted to the thermo-cycling procedure. The
designed number of cycles for thermal stress was 5000 cycles using a thermo-cycling
machine (MCT2; Instrumentos de Precisão Ltda, São Paulo, SP, Brazil). Each cycle
consisted of immersion of samples in water at 5±2ºC followed by 55±2ºC with a dwell time
of 2 min for each bath. The transfer time between baths was 15 sec. New impressions were
taken immediately after the thermo-cycling procedure and the replicas were evaluated under
SEM (T1).
Afterward, the samples were placed into resin cylinders through their root portions. This
procedure allowed the adaptation of the samples to a cyclic mechanical loading device
(eRIOS Representações e Comércio Ltda, São Paulo, SP, Brazil). A vertical load of 50 kN
was applied on the samples' incisal edges. With a frequency of 2 Hz, 100000 cycles of
loading were performed. The samples remained in distillated water at 37ºC during the
mechanical cycling. Replicas of the samples were rebuilt immediately after the mechanical
cycling and analyzed under SEM (T2). All impressions were performed immediately
following the cycling.
The Mann-Whitney test was used to compare the adhesive systems in each level of the
substrate. The Wilcoxon test was used to analyze the factor location of margin in each level
of the adhesive system. The repeated measures Friedman test was used to compare the time
of evaluation in each experimental condition. The level of significance of all analyses was
established at 5%.
Go to:

RESULTS
The results of the gap measurements for the adhesive and substrate factors are displayed
in Table 1. The SB presented higher values of gap widths than the CL when the margin of
restoration was located in the dentin. The opposite was observed for the evaluation of
margins in the enamel, where the SB showed a better marginal adaptation than the CL. The
SB presented a better performance in the margins in the enamel than in the dentin. There was
no difference between the locations of the margins for the gap measurement when the CL
was used. The comparison between the times of evaluation is presented in Table 2. The
widths of the gap measured in the baseline, after thermal and mechanical cycling were
statistically similar for all experimental conditions. Illustrative micrographs obtained of the
marginal integrity of restorations are shown in Figures 2 and and33.
Table 1
Medians of gap measurements (in µm)

Location of margins Adhesive p

SB CL

Dentin 5.8 1.4 <0.001*

Enamel 0.0 1.0 <0.001*

p
<0.001* 0.29

*Indicates statistical difference.

Table 2
Medians of gap measurements (in pm) within each time of evaluation

Location of margins Adhesive Time of evaluation p-value

T0 T1 T2

Dentin SB 4.73 6.27 5.73 0.794

CL 0.00 1.53 2.73 0.197

Enamel SB 0.00 0.00 0.00 1.000

CL 1.07 0.27 1.13 0.066

Figure 2
Intact margin in enamel obtained with Single Bond 2 after thermo-cycling (T1). E - Enamel; C -
Composite
Figure 3
Photomicrography obtained at T0 showing the presence of gap in the dentinal margin of a restoration
performed with Single Bond 2. D - dentin; C - Composite
Go to:

DISCUSSION
A proper marginal sealing is essential to improve the longevity of composite resin
restorations10,12,21. Class V cavities were chosen in this study because they remain a challenge
for restorative procedures. Thus, most of the clinical studies evaluating the performance of
an adhesive system use class V cavities. The C-factor of these cavities impairs the composite
resin flowing during the polymerization shrinkage, increasing the stress over the boding
interface10,23. Moreover, these cavities frequently present gingival margins in the dentin,
consisting of an additional challenge to obtain a proper marginal sealing23. However, in the
present study, differing from clinical situations, the cavities were filled with one increment of
composite. The bulk filling was chosen to standardize the restoration and to increase the
effects of stress shrinkage and, consequently, the challenge over the bonding interfaces.
In composite restorations, stresses submitted on the restoration can disrupt the bonding and
lead to the formation of gaps. Thus, a proper bond of an adhesive to the dental tissue
contributes to avoid marginal microleakage7,14. In the present study, the location of the
restoration margin influenced the gap formation only for the SB, while this adhesive
presented the best marginal adaptation to the enamel margins. Conversely, the CL presented
similar behavior in both the margin in the enamel and in the dentin. Thus, the first null
hypothesis was partially accepted.
Bonding to enamel is predictable and stable because of this substrate's high mineral content25.
In contrast with the enamel, dentin is a more heterogeneous substrate, consisting of
hydroxyapatite, collagen fibrils, and water. The acid conditioning of the dentin widens the
opening of the dentinal tubules, exposes a layer of mineral depleted collagen fibrils, and
increases the water content25. The presence of organic content and water impairs proper
bonding. Furthermore, the presence of solvents and hydrophilic components in the adhesive
layer of the SB can additionally compromise the adhesive's proper polymerization5,11, mainly
in the presence of dentinal wetness, contributing to a reduction of the bonding performance9.
These aspects can explain the inferior results of the SB when the margins were located in the
dentin.
On the other hand, the CL presents a hydrophobic adhesive that is applied on the etched
dentin by a self-etching primer. The absence of solvents and the more hydrophobic
characteristic of this adhesive layer contribute to form a more homogeneous and stable
bonding1,19. This explains the lowest gaps observed in the margin in the dentin when the CL
was used, compared with the SB. The opposite was observed in the margins in the enamel.
Thus, the second null hypothesis was rejected. The poorer performance of the CL on the
enamel margins when compared to the SB is possibly related to the relatively low acidity of
its self-etching primer. CL's self-etching primer contains the acidic monomer 10-MDP and
presents a pH level of approximately 2 (milder acid)15. Self-etching adhesives with relatively
high pH levels are unable to produce an acidic environment that will efficiently etch the
enamel13. In contrast, phosphoric acid used previously to the application of the SB is able to
efficiently etch the enamel. Thus, a more stable bonding to the dental substrate contributes to
maintaining the margin sealing.
An interesting outcome of the present study was that there was no difference in the gap
measurements between the times of evaluation, independently of the adhesive utilized and
the margin evaluated. Thus, the third null hypothesis was accepted. It was expected that the
thermal and mechanical cycling would increase the gap widths. The thermal cycling
promotes the shrinkage of samples when subjected to cold water, followed by expansion in
hot water. Thus, the differences in the coefficients of thermal expansion between the
composite resin and dental tissues results in stress on the bonding interface6,14. Similarly, the
load application on the sample promotes tooth deformation and generates stress on the
restoration margins29. These stresses are expected to increase the width of existent gaps or
develop other gaps. Increased gaps have been demonstrated after mechanical and/or thermal
cycling4,8,22. Contradictorily, this was not observed in the present study. One possible
explanation may reside in the water absorption from the samples during the cycling tests.
Thus, the hygroscopic expansion of the composite can partially compensate a possible gap
increase generated by the stresses27.
Laboratorial studies simulating clinical conditions are usually performed trying to predict the
restoration behavior. The present study used thermal and mechanical cycling in order to
promote stress on the restorations. Despite the absence of statistical differences between the
moments of evaluation (before and after cycling), the outcomes of this study must be
carefully evaluated. Clinically, there are other variables and different results can be observed.
Furthermore, the current study used bovine teeth as a bonding substrate to evaluate the
leakage of the adhesive restorations. The use of bovine teeth as a substitute for human teeth
is a controversial matter. However, Reis, et al.20 (2004) analysed the bond strength and the
enamel and dentinal morphology of possible substitutes for human teeth in bonding tests.
The values of the bond strengths obtained with bovine and human teeth are similar, either for
the enamel or the dentine. In addition, the morphology presented by these two substrates was
also similar.
Go to:

CONCLUSION
Within the limitations of the current study, the following conclusions can be drawn:
Single Bond 2 showed higher means of gaps in the dentin margins, while the location of
margins did not have an influence on the gap formation of the Clearfil SE Bond. Clearfil SE
Bond promoted a better margin sealing than the Single Bond when the margins in the dentin
were observed. In contrast, the Single Bond presented the best performance in the enamel
margins.
The thermal and mechanical cycling utilized did not alter the gap measurements.
Go to:

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 Articles from Journal of Applied Oral Science are provided here courtesy of Bauru School of
Dentistry

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 Endodontics
 Implantology
 Infection Control
 Magnification
 Materials
 Occlusion
 Oral Medicine
 Orthodontics
 Pain Management
 Pediatric Dentistry
 Periodontics
 Practice Management
 Prevention
 Prosthodontics
 Restorative Direct
 Restorative Indirect
Related Articles
 Treating the Esthetic and Occlusal Effects of Wear
Inside Dentistry, February 2019
 Class III Direct Restoration with Flowable Bulk-fill Composite
Inside Dentistry, January 2019
 Biomimetic Tooth Repair
Inside Dentistry, January 2019
 Facial Esthetics
Inside Dentistry, December 2018
 Predictable, Conservative Closure of Black Triangles
Inside Dentistry, December 2018

Inside Dentistry
June 2014
Volume 10, Issue 6
Factors for Successful Composite Restorations
Operator technique remains key even with today’s advanced materials
James F. Simon, DDS, MEd | Lloyd A. George, DDS, MEd, JD

Many steps go into the placement of a successful and long-lasting composite restoration. When a
restoration fails, understanding the cause of the failure is an important first step in preventing a
similar problem from occurring in the future.

It is easy for a dentist to put the blame for a failed restoration on the manufacturer of the material. In
some instances, the manufacturer is the one to blame, as materials are often sent to the market
based on laboratory testing without the proper clinical testing. Generally, this is not the case,
however. When faced with a failed restoration, the dentist must look at his/her technique and the
way the material is being used before placing all the blame for failure on the manufacturer.

Reasons for Failure

The principal reasons for failure are secondary caries, fracture, marginal deficiencies, wear, and
postoperative sensitivity.1 Many of these things can be controlled by the operator; however, the
patient also has a great deal to do with the long-term success of any restoration. In a recent
prospective cohort study,2 it was found that patient age, patient ethnicity, number of surfaces
restored, dentist sex, and dentist practice workload were significant predictors of early restoration
failure, whereas the restorative material used was not significant. Therefore, before assuming that
failure stems from a problem with a material, it is important to consider other relevant factors that
may contribute to the failure of a restoration.

Manufacturer’s Instruction
When analyzing a failure, one of the first questions one should ask is, “Were the manufacturers’
instructions read and followed for the product?” Many dentists assume that all bonding and
composites systems are the same, and if they are familiar with one, then they can use any system
on the market. With some bonding systems, the manufacturer’s instructions say to scrub the product
into the dentin for a certain period of time, whereas others say to leave it undisturbed for a different
period of time. Do you etch with phosphoric acid prior to use, and if so, for how long? Some
composites require more curing time or smaller layers, whereas others need less light and can be
bulk filled. Unless the instructions are read before use, the incorrect technique may lead to an
inferior restoration, which leads to both an unhappy patient and dentist.

Effectiveness of Moisture Control

Excellent moisture control of the operating field is extremely important for a successful restoration.
The use of a properly placed rubber dam during placement of the composite material is ideal.
Restorations that were placed with a rubber dam have showed significantly fewer material fractures
that needed replacement; this also had a significant effect on overall longevity.3 Wet bonding is
recommended for most adhesive systems; however, the optimal amount of wetness varies
depending upon the adhesive system (etch & rinse or self-etch) used and the primer (acetone or
ethanol) in the system. No system includes blood or saliva as part of the bonding technique.

Recently, alternative systems for isolation, including Isolite/Isodry (Isolite Systems) and the
Optragate (Ivoclar) have been introduced, and seem to work well. These systems can be a valuable
addition when placing technique-sensitive materials and should be considered when help is needed
placing hydrophobic resin materials and use of the rubber dam is not possible.

Polymerization Shrinkage
Typical resin composites applied in restorative dentistry exhibit volumetric shrinkage values from
less than 1% up to 6%, depending on the formulation and the curing conditions.4 The result of this
shrinkage can be the restorative material pulling away from the tooth, leaving a gap that eventually
lead to postoperative sensitivity, marginal staining, recurrent caries, and eventual loss of the
restoration.4 Different methods have been suggested to overcome this problem, including
incremental layering,5 placement of flowable composite as stress breaker,6 and different light
applications (pulse or ramp curing).7 The newest approach has been with the development of low-
shrinkage stress composites that can be bulk filled because of their reported reduction in shrinkage
stress. These seem to be very interesting for future consideration.

Light Curing
Each composite requires a certain amount of energy (joules) for complete curing. This may vary by
the manufacturer, by the type of composite material, and the shade of the composite. It is a function
of the power of the curing light (mW/cm2) and the amount of time that the light is delivered.
Unfortunately, the amount of delivered energy can vary due to the improper placement of the light
tip, movement of the light tip during curing, distance of the light tip from the resin, shade and type of
the resin material, condition of the light curing unit, or thickness of the resin. Even the most powerful
curing light will not cure a composite if it is not properly placed. Just because the top layer of the
composite is hard, that does not mean that the composite is cured at the bottom.

In general, not enough attention is given to proper placement of the curing light or the condition of
the light. The proper amount of irradiance is determined by the manufacturer and the shade of the
composite. Incomplete or insufficient curing adversely affects the resin’s physical properties, reduces
the bond strength to the tooth, decreases the biocompatibility of the restoration, increases marginal
wear and breakdown, and increases bacterial colonization of the restoration.8
Several surveys have shown that many QTH (quartz-tungsten-halogen) curing lights in dental offices
do not deliver enough light energy to completely cure composites.9

Size and Location of Restoration

The position of the tooth in the arch and the size of the cavity have been shown to be a factor in the
success of a restoration. One study found the risk of failure in the molar area to be twice as high as
for premolars,10 while another study placed the failure rate in lower molars as three times that of the
upper premolars.11 Multi-surfaced restorations are also more prone to failure than single surface
restorations. A study calculated that for every surface added to the restoration, a 40% increase in
the failure rate resulted.10

Proper Placement Technique

Many experts recommend incremental placement of the composite because of the decrease in the
“C” factor and the resultant decrease in the shrinkage stress.6 This has been the recommended
technique; however, with the introduction of the low shrinkage stress composite materials, bulk filling
has become more popular. Because of their low stress and good depth of cure, these composites
may be the future.

No matter which technique that is used, proper matrix placement is extremely important for the
restoration success. A restoration that has an open contact or a gingival overhang is not an
acceptable restoration. Food impaction from an open contact does not lead to good gingival health
and an open or rough margin may lead to bacterial growth and eventual recurrent decay. Sectional
matrix systems and separating rings may lead better contours, contacts, and marginal seal.

Proximal Box Placement

Bonding failures have been commonly attributed to the gingival margin of Class II composite
restorations.12In the proximal box of most Class II restorations, there is little or no enamel at the
margin for bonding. Gaps at the gingival margins have been attributed to the potential for poor
bonding at this margin.13 The discrepancy between etching depth and adhesive infiltration leads to a
large area of exposed collagen at the gingival margin.14
Another variable that may interfere with the bonding in the gingival area is water content. Increased
water content leads to reduced adhesive infiltration and lower monomer/polymer conversion of the
adhesive at the gingival margin as compared to the proximal wall.15 Sometimes, the placement of a
glass ionomer as the first layer for these deep margins may be considered because of some of the
favorable qualities of this material.16

Shade Matching
Correct color matching of the restoration and the tooth is an important aspect of the esthetic
restoration. Many things can complicate making the correct shade selection, such as the lighting
system in the operatory, the fact that teeth lighten when dehydrated, the color of the operatory or the
patient’s clothing, and the experience of the person doing the shade selection. Shade selection
requires knowledge of physics and the physiology of color; therefore, it is both an art and a science
requiring in depth knowledge, accurate clinical judgment, and perception on the part of the
dentist.17 Unfortunately, the limitations of shade guides are significant factors that compromise shade
matching procedures in dentistry and contribute to the dissatisfaction of clinicians, technicians, and
patients.18

Finishing and Polishing

High-quality finishing and polishing improve both the esthetics and the longevity of composite
restorations, whereas rough, poorly polished surfaces contribute to staining, plaque accumulation,
gingival irritation, recurrent caries, and discoloration of the restoration.19 There are many systems
available for the finishing and polishing process, including carbide or fine diamond burs, disks,
rubber or silicone points or wheels, bristle brushes, and polishing pastes. It is important to use each
correctly and in the proper sequence to achieve the best polish. Skipping steps may shorten the
appointment time, but also shortens the useful life of the restoration. Discoloration of composite
resins was found to be related to surface treatments as well as resin composition.20

Conclusion
There are many variables that go into the success or failure of a resin composite restoration.
Although it is easy to blame the manufacturer for a failure and ask them for a better material, an
improved material used incorrectly will not make for a better restoration. Every so often, it is
necessary to step back and review the way the material is being used to make sure that all the
basics are covered before looking for that better material. Manufacturers can—and should—be held
accountable if a material in the market does not perform as claimed; however, most manufacturers
endeavor to give the profession the best materials possible. As dental professionals, it is our
responsibility to follow best clinical practices and ensure that we are using these materials correctly
for the benefit of our patients and our practices.

References
1. Goldstein GR. The longevity of direct and indirect posterior restorations is uncertain and may be
affected by a number of dentist-, patient-, and material-related factors. J Evid Based Dent Pract.
2010;10(1):30-31. doi: 10.1016/j.jebdp.2009.11.015.
2. McCracken MS, Gordan VV, Litaker MS, et al; National Dental Practice-Based Research Network
Collaborative Group. A 24-month evaluation of amalgam and resin-based composite restorations:
Findings from The National Dental Practice-Based Research Network. J Am Dent Assoc.
2013;144(6):583-593.
3. Heintze SD, Rousson V. Clinical effectiveness of direct class II restorations - a meta-analysis. J
Adhes Dent. 2012;14(5):407-431. doi: 10.3290/j.jad.a28390.
4. Mantri SP, Mantri SS. Management of shrinkage stresses in direct restorative light-cured
composites: a review. J Esthet Restor Dent. 2013;25(5):305-313. doi: 10.1111/jerd.12047. Epub
2013 Aug 9.
5. Park J, Chang J, Ferracane J, Lee IB. How should composite be layered to reduce shrinkage
stress: incremental or bulk filling? Dent Mater. 2008;24(11):1501-1505. doi:
10.1016/j.dental.2008.03.013.
6. Alomari QD, Reinhardt JW, Boyer DB. Effect of liners on cusp deflection and gap formation in
composite restorations. Oper Dent. 2001;26(4):406-411.
7. Feilzer AJ, Dooren LH, de Gee AJ, Davidson CL. Influence of light intensity on polymerization
shrinkage and integrity of restoration-cavity interface. Eur J Oral Sci. 1995;103(5):322-326.
8. Price RB, Strassler HE, Price HL, Seth S, Lee CJ. The effectiveness of using a patient simulator
to teach light-curing skills. J Am Dent Assoc. 2014;145(1):32-43. doi: 10.14219/jada.2013.17.
9. Martin FE. A survey of the efficiency of visible light curing units. J Dent. 1998;26(3):239-243.
10. Opdam NJ, Bronkhorst EM, Roeters JM, Loomans BA. Longevity and reasons for failure of
sandwich and total-etch posterior composite resin restorations. J Adhes Dent. 2007;9(5):469-475.
 11. Da Rosa Rodolpho PA, Donassollo TA, Cenci MS, et al. 22-Year clinical evaluation of the
performance of two posterior composites with different filler characteristics. Dent Mater.
2011;27(10):955-963. doi: 10.1016/j.dental.2011.06.001.
12. Bouillaguet S, Ciucchi B, Jacoby T, et al. Bonding characteristics to dentin walls of class II
cavities, in vitro. Dent Mater. 2001;17(4):316-321.
13. Roulet JF. Benefits and disadvantages of tooth-coloured alternatives to amalgam. J Dent.
1997;25(6):459-473.
14. Bohaty BS, Ye Q, Misra A, et al. Posterior composite restoration update: focus on factors
influencing form and function. Clin Cosmet Investig Dent. 2013;5:33-42. doi:
10.2147/CCIDE.S42044.
15. Wang Y, Spencer P. Interfacial chemistry of class II composite restoration: structure analysis. J
Biomed Mater Res A. 2005;75(3):580-587.
16. Hagge MS, Lindemuth JS, Mason JF, Simon JF. Effect of four intermediate layer treatments on
microleakage of Class II composite restorations. Gen Dent. 2001;49(5):489-95; quiz 496-497.
17. Judd DB, Wyszecki G. Color in Business, Science, and Industry. 3rd ed. New York: Wiley-
Interscience;
1975:26-40.
18. Rodrigues S, Shetty SR, Prithviraj DR. An evaluation of shade differences between natural
anterior teeth in different age groups and gender using commercially available shade guides. J
Indian Prosthodont Soc. 2012;12(4):222-30. doi: 10.1007/s13191-012-0134-9.
19. Lopes GC, Vieira LC, Araujo E. Direct composite resin restorations: a review of some clinical
procedures to achieve predictable results in posterior teeth. J Esthet Restor Dent. 2004;16(1):19-31;
discussion 32.
20. Gönülol N, Yilmaz F. The effects of finishing and polishing techniques on surface roughness and
color stability of nanocomposites. J Dent. 2012;40(suppl 2):e64-e70. doi:
10.1016/j.jdent.2012.07.005.

ABOUT THE AUTHORS

James F. Simon, DDS, Med
Professor & Director, Esthetic Dentistry
University of Tennessee Health Science Center
Memphis, Tennessee
Lloyd A. George, DDS, MED, JD
Professor & Associate Dean of Clinical Affairs
University of Tennessee Health Science Center
Memphis, Tennessee
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 Pediatric Dentistry
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 Prevention
 Prosthodontics
 Restorative Direct
 Restorative Indirect
Related Articles
 Treating the Esthetic and Occlusal Effects of Wear
Inside Dentistry, February 2019
 Class III Direct Restoration with Flowable Bulk-fill Composite
Inside Dentistry, January 2019
 Biomimetic Tooth Repair
Inside Dentistry, January 2019
 Facial Esthetics
Inside Dentistry, December 2018
 Predictable, Conservative Closure of Black Triangles
Inside Dentistry, December 2018

Inside Dentistry
June 2014
Volume 10, Issue 6

Factors for Successful Composite Restorations

Operator technique remains key even with today’s advanced materials
James F. Simon, DDS, MEd | Lloyd A. George, DDS, MEd, JD

Many steps go into the placement of a successful and long-lasting composite restoration. When a
restoration fails, understanding the cause of the failure is an important first step in preventing a
similar problem from occurring in the future.

It is easy for a dentist to put the blame for a failed restoration on the manufacturer of the material. In
some instances, the manufacturer is the one to blame, as materials are often sent to the market
based on laboratory testing without the proper clinical testing. Generally, this is not the case,
however. When faced with a failed restoration, the dentist must look at his/her technique and the
way the material is being used before placing all the blame for failure on the manufacturer.

Reasons for Failure

The principal reasons for failure are secondary caries, fracture, marginal deficiencies, wear, and
postoperative sensitivity.1 Many of these things can be controlled by the operator; however, the
patient also has a great deal to do with the long-term success of any restoration. In a recent
prospective cohort study,2 it was found that patient age, patient ethnicity, number of surfaces
restored, dentist sex, and dentist practice workload were significant predictors of early restoration
failure, whereas the restorative material used was not significant. Therefore, before assuming that
failure stems from a problem with a material, it is important to consider other relevant factors that
may contribute to the failure of a restoration.

Manufacturer’s Instruction
When analyzing a failure, one of the first questions one should ask is, “Were the manufacturers’
instructions read and followed for the product?” Many dentists assume that all bonding and
composites systems are the same, and if they are familiar with one, then they can use any system
on the market. With some bonding systems, the manufacturer’s instructions say to scrub the product
into the dentin for a certain period of time, whereas others say to leave it undisturbed for a different
period of time. Do you etch with phosphoric acid prior to use, and if so, for how long? Some
composites require more curing time or smaller layers, whereas others need less light and can be
bulk filled. Unless the instructions are read before use, the incorrect technique may lead to an
inferior restoration, which leads to both an unhappy patient and dentist.

Effectiveness of Moisture Control

Excellent moisture control of the operating field is extremely important for a successful restoration.
The use of a properly placed rubber dam during placement of the composite material is ideal.
Restorations that were placed with a rubber dam have showed significantly fewer material fractures
that needed replacement; this also had a significant effect on overall longevity.3 Wet bonding is
recommended for most adhesive systems; however, the optimal amount of wetness varies
depending upon the adhesive system (etch & rinse or self-etch) used and the primer (acetone or
ethanol) in the system. No system includes blood or saliva as part of the bonding technique.

Recently, alternative systems for isolation, including Isolite/Isodry (Isolite Systems) and the
Optragate (Ivoclar) have been introduced, and seem to work well. These systems can be a valuable
addition when placing technique-sensitive materials and should be considered when help is needed
placing hydrophobic resin materials and use of the rubber dam is not possible.

Polymerization Shrinkage
Typical resin composites applied in restorative dentistry exhibit volumetric shrinkage values from
less than 1% up to 6%, depending on the formulation and the curing conditions.4 The result of this
shrinkage can be the restorative material pulling away from the tooth, leaving a gap that eventually
lead to postoperative sensitivity, marginal staining, recurrent caries, and eventual loss of the
restoration.4 Different methods have been suggested to overcome this problem, including
incremental layering,5 placement of flowable composite as stress breaker,6 and different light
applications (pulse or ramp curing).7 The newest approach has been with the development of low-
shrinkage stress composites that can be bulk filled because of their reported reduction in shrinkage
stress. These seem to be very interesting for future consideration.

Light Curing
Each composite requires a certain amount of energy (joules) for complete curing. This may vary by
the manufacturer, by the type of composite material, and the shade of the composite. It is a function
of the power of the curing light (mW/cm2) and the amount of time that the light is delivered.
Unfortunately, the amount of delivered energy can vary due to the improper placement of the light
tip, movement of the light tip during curing, distance of the light tip from the resin, shade and type of
the resin material, condition of the light curing unit, or thickness of the resin. Even the most powerful
curing light will not cure a composite if it is not properly placed. Just because the top layer of the
composite is hard, that does not mean that the composite is cured at the bottom.

In general, not enough attention is given to proper placement of the curing light or the condition of
the light. The proper amount of irradiance is determined by the manufacturer and the shade of the
composite. Incomplete or insufficient curing adversely affects the resin’s physical properties, reduces
the bond strength to the tooth, decreases the biocompatibility of the restoration, increases marginal
wear and breakdown, and increases bacterial colonization of the restoration.8
Several surveys have shown that many QTH (quartz-tungsten-halogen) curing lights in dental offices
do not deliver enough light energy to completely cure composites.9

Size and Location of Restoration

The position of the tooth in the arch and the size of the cavity have been shown to be a factor in the
success of a restoration. One study found the risk of failure in the molar area to be twice as high as
for premolars,10 while another study placed the failure rate in lower molars as three times that of the
upper premolars.11 Multi-surfaced restorations are also more prone to failure than single surface
restorations. A study calculated that for every surface added to the restoration, a 40% increase in
the failure rate resulted.10

Proper Placement Technique

Many experts recommend incremental placement of the composite because of the decrease in the
“C” factor and the resultant decrease in the shrinkage stress.6 This has been the recommended
technique; however, with the introduction of the low shrinkage stress composite materials, bulk filling
has become more popular. Because of their low stress and good depth of cure, these composites
may be the future.

No matter which technique that is used, proper matrix placement is extremely important for the
restoration success. A restoration that has an open contact or a gingival overhang is not an
acceptable restoration. Food impaction from an open contact does not lead to good gingival health
and an open or rough margin may lead to bacterial growth and eventual recurrent decay. Sectional
matrix systems and separating rings may lead better contours, contacts, and marginal seal.

Proximal Box Placement

Bonding failures have been commonly attributed to the gingival margin of Class II composite
restorations.12In the proximal box of most Class II restorations, there is little or no enamel at the
margin for bonding. Gaps at the gingival margins have been attributed to the potential for poor
bonding at this margin.13 The discrepancy between etching depth and adhesive infiltration leads to a
large area of exposed collagen at the gingival margin.14
Another variable that may interfere with the bonding in the gingival area is water content. Increased
water content leads to reduced adhesive infiltration and lower monomer/polymer conversion of the
adhesive at the gingival margin as compared to the proximal wall.15 Sometimes, the placement of a
glass ionomer as the first layer for these deep margins may be considered because of some of the
favorable qualities of this material.16

Shade Matching
Correct color matching of the restoration and the tooth is an important aspect of the esthetic
restoration. Many things can complicate making the correct shade selection, such as the lighting
system in the operatory, the fact that teeth lighten when dehydrated, the color of the operatory or the
patient’s clothing, and the experience of the person doing the shade selection. Shade selection
requires knowledge of physics and the physiology of color; therefore, it is both an art and a science
requiring in depth knowledge, accurate clinical judgment, and perception on the part of the
dentist.17 Unfortunately, the limitations of shade guides are significant factors that compromise shade
matching procedures in dentistry and contribute to the dissatisfaction of clinicians, technicians, and
patients.18

Finishing and Polishing

High-quality finishing and polishing improve both the esthetics and the longevity of composite
restorations, whereas rough, poorly polished surfaces contribute to staining, plaque accumulation,
gingival irritation, recurrent caries, and discoloration of the restoration.19 There are many systems
available for the finishing and polishing process, including carbide or fine diamond burs, disks,
rubber or silicone points or wheels, bristle brushes, and polishing pastes. It is important to use each
correctly and in the proper sequence to achieve the best polish. Skipping steps may shorten the
appointment time, but also shortens the useful life of the restoration. Discoloration of composite
resins was found to be related to surface treatments as well as resin composition.20

Conclusion
There are many variables that go into the success or failure of a resin composite restoration.
Although it is easy to blame the manufacturer for a failure and ask them for a better material, an
improved material used incorrectly will not make for a better restoration. Every so often, it is
necessary to step back and review the way the material is being used to make sure that all the
basics are covered before looking for that better material. Manufacturers can—and should—be held
accountable if a material in the market does not perform as claimed; however, most manufacturers
endeavor to give the profession the best materials possible. As dental professionals, it is our
responsibility to follow best clinical practices and ensure that we are using these materials correctly
for the benefit of our patients and our practices.

References
1. Goldstein GR. The longevity of direct and indirect posterior restorations is uncertain and may be
affected by a number of dentist-, patient-, and material-related factors. J Evid Based Dent Pract.
2010;10(1):30-31. doi: 10.1016/j.jebdp.2009.11.015.
2. McCracken MS, Gordan VV, Litaker MS, et al; National Dental Practice-Based Research Network
Collaborative Group. A 24-month evaluation of amalgam and resin-based composite restorations:
Findings from The National Dental Practice-Based Research Network. J Am Dent Assoc.
2013;144(6):583-593.
3. Heintze SD, Rousson V. Clinical effectiveness of direct class II restorations - a meta-analysis. J
Adhes Dent. 2012;14(5):407-431. doi: 10.3290/j.jad.a28390.
4. Mantri SP, Mantri SS. Management of shrinkage stresses in direct restorative light-cured
composites: a review. J Esthet Restor Dent. 2013;25(5):305-313. doi: 10.1111/jerd.12047. Epub
2013 Aug 9.
5. Park J, Chang J, Ferracane J, Lee IB. How should composite be layered to reduce shrinkage
stress: incremental or bulk filling? Dent Mater. 2008;24(11):1501-1505. doi:
10.1016/j.dental.2008.03.013.
6. Alomari QD, Reinhardt JW, Boyer DB. Effect of liners on cusp deflection and gap formation in
composite restorations. Oper Dent. 2001;26(4):406-411.
7. Feilzer AJ, Dooren LH, de Gee AJ, Davidson CL. Influence of light intensity on polymerization
shrinkage and integrity of restoration-cavity interface. Eur J Oral Sci. 1995;103(5):322-326.
8. Price RB, Strassler HE, Price HL, Seth S, Lee CJ. The effectiveness of using a patient simulator
to teach light-curing skills. J Am Dent Assoc. 2014;145(1):32-43. doi: 10.14219/jada.2013.17.
9. Martin FE. A survey of the efficiency of visible light curing units. J Dent. 1998;26(3):239-243.
10. Opdam NJ, Bronkhorst EM, Roeters JM, Loomans BA. Longevity and reasons for failure of
sandwich and total-etch posterior composite resin restorations. J Adhes Dent. 2007;9(5):469-475.
11. Da Rosa Rodolpho PA, Donassollo TA, Cenci MS, et al. 22-Year clinical evaluation of the
performance of two posterior composites with different filler characteristics. Dent Mater.
2011;27(10):955-963. doi: 10.1016/j.dental.2011.06.001.
12. Bouillaguet S, Ciucchi B, Jacoby T, et al. Bonding characteristics to dentin walls of class II
cavities, in vitro. Dent Mater. 2001;17(4):316-321.
13. Roulet JF. Benefits and disadvantages of tooth-coloured alternatives to amalgam. J Dent.
1997;25(6):459-473.
14. Bohaty BS, Ye Q, Misra A, et al. Posterior composite restoration update: focus on factors
influencing form and function. Clin Cosmet Investig Dent. 2013;5:33-42. doi:
10.2147/CCIDE.S42044.
15. Wang Y, Spencer P. Interfacial chemistry of class II composite restoration: structure analysis. J
Biomed Mater Res A. 2005;75(3):580-587.
16. Hagge MS, Lindemuth JS, Mason JF, Simon JF. Effect of four intermediate layer treatments on
microleakage of Class II composite restorations. Gen Dent. 2001;49(5):489-95; quiz 496-497.
17. Judd DB, Wyszecki G. Color in Business, Science, and Industry. 3rd ed. New York: Wiley-
Interscience;
1975:26-40.
18. Rodrigues S, Shetty SR, Prithviraj DR. An evaluation of shade differences between natural
anterior teeth in different age groups and gender using commercially available shade guides. J
Indian Prosthodont Soc. 2012;12(4):222-30. doi: 10.1007/s13191-012-0134-9.
19. Lopes GC, Vieira LC, Araujo E. Direct composite resin restorations: a review of some clinical
procedures to achieve predictable results in posterior teeth. J Esthet Restor Dent. 2004;16(1):19-31;
discussion 32.
20. Gönülol N, Yilmaz F. The effects of finishing and polishing techniques on surface roughness and
color stability of nanocomposites. J Dent. 2012;40(suppl 2):e64-e70. doi:
10.1016/j.jdent.2012.07.005.

Factors for Successful Composite Restorations

Operator technique remains key even with today’s advanced materials
James F. Simon, DDS, MEd | Lloyd A. George, DDS, MEd, JD

Many steps go into the placement of a successful and long-lasting composite restoration. When a
restoration fails, understanding the cause of the failure is an important first step in preventing a
similar problem from occurring in the future.

It is easy for a dentist to put the blame for a failed restoration on the manufacturer of the material. In
some instances, the manufacturer is the one to blame, as materials are often sent to the market
based on laboratory testing without the proper clinical testing. Generally, this is not the case,
however. When faced with a failed restoration, the dentist must look at his/her technique and the
way the material is being used before placing all the blame for failure on the manufacturer.

Reasons for Failure

The principal reasons for failure are secondary caries, fracture, marginal deficiencies, wear, and
postoperative sensitivity.1 Many of these things can be controlled by the operator; however, the
patient also has a great deal to do with the long-term success of any restoration. In a recent
prospective cohort study,2 it was found that patient age, patient ethnicity, number of surfaces
restored, dentist sex, and dentist practice workload were significant predictors of early restoration
failure, whereas the restorative material used was not significant. Therefore, before assuming that
failure stems from a problem with a material, it is important to consider other relevant factors that
may contribute to the failure of a restoration.

Manufacturer’s Instruction
When analyzing a failure, one of the first questions one should ask is, “Were the manufacturers’
instructions read and followed for the product?” Many dentists assume that all bonding and
composites systems are the same, and if they are familiar with one, then they can use any system
on the market. With some bonding systems, the manufacturer’s instructions say to scrub the product
into the dentin for a certain period of time, whereas others say to leave it undisturbed for a different
period of time. Do you etch with phosphoric acid prior to use, and if so, for how long? Some
composites require more curing time or smaller layers, whereas others need less light and can be
bulk filled. Unless the instructions are read before use, the incorrect technique may lead to an
inferior restoration, which leads to both an unhappy patient and dentist.

Effectiveness of Moisture Control

Excellent moisture control of the operating field is extremely important for a successful restoration.
The use of a properly placed rubber dam during placement of the composite material is ideal.
Restorations that were placed with a rubber dam have showed significantly fewer material fractures
that needed replacement; this also had a significant effect on overall longevity.3 Wet bonding is
recommended for most adhesive systems; however, the optimal amount of wetness varies
depending upon the adhesive system (etch & rinse or self-etch) used and the primer (acetone or
ethanol) in the system. No system includes blood or saliva as part of the bonding technique.

Recently, alternative systems for isolation, including Isolite/Isodry (Isolite Systems) and the
Optragate (Ivoclar) have been introduced, and seem to work well. These systems can be a valuable
addition when placing technique-sensitive materials and should be considered when help is needed
placing hydrophobic resin materials and use of the rubber dam is not possible.

Polymerization Shrinkage
Typical resin composites applied in restorative dentistry exhibit volumetric shrinkage values from
less than 1% up to 6%, depending on the formulation and the curing conditions.4 The result of this
shrinkage can be the restorative material pulling away from the tooth, leaving a gap that eventually
lead to postoperative sensitivity, marginal staining, recurrent caries, and eventual loss of the
restoration.4 Different methods have been suggested to overcome this problem, including
incremental layering,5 placement of flowable composite as stress breaker,6 and different light
applications (pulse or ramp curing).7 The newest approach has been with the development of low-
shrinkage stress composites that can be bulk filled because of their reported reduction in shrinkage
stress. These seem to be very interesting for future consideration.

Light Curing
Each composite requires a certain amount of energy (joules) for complete curing. This may vary by
the manufacturer, by the type of composite material, and the shade of the composite. It is a function
of the power of the curing light (mW/cm2) and the amount of time that the light is delivered.
Unfortunately, the amount of delivered energy can vary due to the improper placement of the light
tip, movement of the light tip during curing, distance of the light tip from the resin, shade and type of
the resin material, condition of the light curing unit, or thickness of the resin. Even the most powerful
curing light will not cure a composite if it is not properly placed. Just because the top layer of the
composite is hard, that does not mean that the composite is cured at the bottom.

In general, not enough attention is given to proper placement of the curing light or the condition of
the light. The proper amount of irradiance is determined by the manufacturer and the shade of the
composite. Incomplete or insufficient curing adversely affects the resin’s physical properties, reduces
the bond strength to the tooth, decreases the biocompatibility of the restoration, increases marginal
wear and breakdown, and increases bacterial colonization of the restoration.8
Several surveys have shown that many QTH (quartz-tungsten-halogen) curing lights in dental offices
do not deliver enough light energy to completely cure composites.9

Size and Location of Restoration

The position of the tooth in the arch and the size of the cavity have been shown to be a factor in the
success of a restoration. One study found the risk of failure in the molar area to be twice as high as
for premolars,10 while another study placed the failure rate in lower molars as three times that of the
upper premolars.11 Multi-surfaced restorations are also more prone to failure than single surface
restorations. A study calculated that for every surface added to the restoration, a 40% increase in
the failure rate resulted.10

Proper Placement Technique

Many experts recommend incremental placement of the composite because of the decrease in the
“C” factor and the resultant decrease in the shrinkage stress.6 This has been the recommended
technique; however, with the introduction of the low shrinkage stress composite materials, bulk filling
has become more popular. Because of their low stress and good depth of cure, these composites
may be the future.

No matter which technique that is used, proper matrix placement is extremely important for the
restoration success. A restoration that has an open contact or a gingival overhang is not an
acceptable restoration. Food impaction from an open contact does not lead to good gingival health
and an open or rough margin may lead to bacterial growth and eventual recurrent decay. Sectional
matrix systems and separating rings may lead better contours, contacts, and marginal seal.

Proximal Box Placement

Bonding failures have been commonly attributed to the gingival margin of Class II composite
restorations.12In the proximal box of most Class II restorations, there is little or no enamel at the
margin for bonding. Gaps at the gingival margins have been attributed to the potential for poor
bonding at this margin.13 The discrepancy between etching depth and adhesive infiltration leads to a
large area of exposed collagen at the gingival margin.14
Another variable that may interfere with the bonding in the gingival area is water content. Increased
water content leads to reduced adhesive infiltration and lower monomer/polymer conversion of the
adhesive at the gingival margin as compared to the proximal wall.15 Sometimes, the placement of a
glass ionomer as the first layer for these deep margins may be considered because of some of the
favorable qualities of this material.16
Shade Matching
Correct color matching of the restoration and the tooth is an important aspect of the esthetic
restoration. Many things can complicate making the correct shade selection, such as the lighting
system in the operatory, the fact that teeth lighten when dehydrated, the color of the operatory or the
patient’s clothing, and the experience of the person doing the shade selection. Shade selection
requires knowledge of physics and the physiology of color; therefore, it is both an art and a science
requiring in depth knowledge, accurate clinical judgment, and perception on the part of the
dentist.17 Unfortunately, the limitations of shade guides are significant factors that compromise shade
matching procedures in dentistry and contribute to the dissatisfaction of clinicians, technicians, and
patients.18

Finishing and Polishing

High-quality finishing and polishing improve both the esthetics and the longevity of composite
restorations, whereas rough, poorly polished surfaces contribute to staining, plaque accumulation,
gingival irritation, recurrent caries, and discoloration of the restoration.19 There are many systems
available for the finishing and polishing process, including carbide or fine diamond burs, disks,
rubber or silicone points or wheels, bristle brushes, and polishing pastes. It is important to use each
correctly and in the proper sequence to achieve the best polish. Skipping steps may shorten the
appointment time, but also shortens the useful life of the restoration. Discoloration of composite
resins was found to be related to surface treatments as well as resin composition.20

Conclusion
There are many variables that go into the success or failure of a resin composite restoration.
Although it is easy to blame the manufacturer for a failure and ask them for a better material, an
improved material used incorrectly will not make for a better restoration. Every so often, it is
necessary to step back and review the way the material is being used to make sure that all the
basics are covered before looking for that better material. Manufacturers can—and should—be held
accountable if a material in the market does not perform as claimed; however, most manufacturers
endeavor to give the profession the best materials possible. As dental professionals, it is our
responsibility to follow best clinical practices and ensure that we are using these materials correctly
for the benefit of our patients and our practices.

References
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