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Introduction
Posterior resin composite restorations have established an
important place in clinical practice and have continued to gain
popularity. Resin composite use has almost superseded the
previous posterior restorative material, namely, silver
amalgam1. Compared with other posterior restorative
materials, tooth coloured resin composites are preferred by
patients as a result of their increased desire for aesthetic
restoration. In addition, patients have questioned the
biocompatibility of the mercury in amalgam2. The advances of
minimal intervention dentistry to conserve tooth structure
have led to modified cavity preparations in association with
improved bonding. Any restorative material has a limited
working life and replacing any restoration will cause further
loss of tooth structure3. Many factors affect longevity and
success of a restoration, such as the material, patient and
dentist factors, and cavity type. Since resin composites were
introduced, there has been an ongoing challenge to improve
their clinical performance, particularly for use in posterior
teeth. This has seen the introduction of hybrid, packable, Nano-
filled, low shrinkage and bulk-fill composites, but still the
clinical effectiveness of posterior composite is questioned by
many. Patient factors such as caries risk and occlusal stress can
influence the long-term clinical success of a restoration .

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Overview
Esthetic direct restoration materials include composite resin,
glass ionomer cement, resin modified GIC, compomers .
Composite resin defined according to Skinners as a “A highly
cross linked polymeric material reinforced by a dispersion of
amorphous silica, glass crystalline or organic resin filler
particles and/or short fibers bonded to the matrix by a coupling
agent" .while According to Baum & Phillps , they are defined as
"three dimensional combination of at least two chemically
different materials with distinct interface" 4 , and According to
McCobe "A composite material is product which consists of at
least two distinct phases normally formed by blending together
components having different structures and properties" . The
choice of the type restoration is influenced by certain factors
such as:

1. Financial feasibility.

2. Time involvement.

3. Physical properties of the restorative material.

4. Difficulty of placement.

5. Longevity of restoration.

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Tooth preparation
Posterior resin restorations have been indicated for various
types of tooth preparations. In particular, resins are utilized to
maximize aesthetics and minimize the loss of tooth structure
during preparation. Due to the location of the caries and thus
the need to restore proximal surfaces in class II restorations, a
number of tooth preparation designs have been advocated. So
these tooth preparation designs is used to reduce the loss of
sound tooth structure .

1) The “tunnel” technique, as reported by Hunt5 and

Knight6 , has been used to remove proximal caries while leaving
the marginal ridge intact. Although potentially promising ,the
lack of long-term clinical studies limits wide adoption of this
technique. The ability to access and restore a proximal
carious lesion directly represents the most
conservative proximal restorative technique available. This
technique is relatively successful in preserving intact tooth
structure .The ability to access proximal carious lesions directly
is usually limited .

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2) The aforementioned tooth preparation designs successfully
limit the removal of sound tooth structure and take advantage
of appropriate etching techniques in bonding to intact enamel
and dentin. However, depending upon the location and extent
of the caries, traditional preparation designs, which involve
access through the carious marginal ridge and the removal of
infected occlusal enamel and dentin , may be required.

Considerable attention has been devoted to the relationship

between cavity type, cavity size, number of surfaces restored,
and the risk of restoration failure. As the number of restored
surfaces increases, the risk of restoration failure also
increases7. Along with preparation design and extent of tissue
removal, the position of the tooth in the mouth directly
influences the overall clinical performance and longevity of the
restoration.

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 Polymerization :
Three main factors concur to reduce shrinkage stress :

1) use of a small volume of material .

2) a lower cavity configuration factor .

3) minimal contact with the opposing cavity walls during

polymerization.

It is widely accepted that incremental filling decreases

shrinkage stress as a result of reduced polymerization material
volume .

INCREMENTAL TECHNIQUES FOR DIRECT COMPOSITE

RESTORATION :
When placing posterior composites, the use of small
increments is recommended for insertion and polymerization
so that the after effect of shrinkage stress can be reduced .

1) Horizontal layering technique

The horizontal placement technique utilizes composite resin

layers, each <2.0 mm thick . This technique has been reported
to increase the C-factor, and thereupon increases the shrinkage
stresses between the opposing cavity walls8 .

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 2) Oblique layering technique

The oblique technique is accomplished by placing a series of

wedge-shaped composite increments. Each increment is
photocured twice, first through the cavity walls and then from
the occlusal surface, to direct the vectors of polymerization
toward the adhesive surface. This technique reduces the C-
factor and prevents the distortion of cavity walls9 .

3) Vertical layering technique

Place small increments in vertical pattern starting from one

wall, i.e., buccal or lingual and carried to another wall. Start
polymerization from behind the wall, i.e., if buccal increment is
placed on the lingual wall, it is cured from outside of the lingual
wall. This reduces gap at gingival wall which is formed due to
polymerization shrinkage, hence postoperative sensitivity and
secondary caries .

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 4) Centripetal buildup technique

The centripetal buildup technique offers a number of

advantages when composite resin posterior restorations are
indicated. This technique employs thin metal matrix bands and
wooden wedges eliminating the need for transparent matrix
bands, which may not provide firm contact areas and
anatomical proximal contours and are cumbersome to use for
many practitioners 10 .

5) Split-increment horizontal layering technique

Concern has been expressed about placing individual

increments against opposing walls simultaneously before
photocuring, as the resulting polymerization shrinkage stress
may cause the cusps to bend toward each other and deform as
a result This stress may cause postoperative sensitivity and can
be detrimental to the tooth and the marginal integrity over
time11. For the proposed technique, each horizontal increment
was split, before curing, into four triangle-shaped portions ,
with each portion placed against only one cavity wall and part
of the floor one diagonal cut was filled completely with dentin
shade composite and photocured. At this point, the other

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 diagonal cut was filled and photocured, one half at a time. The
same technique is followed until dentin-enamel junction and
later enamel shade composite followed by translucent shade
are placed and shaped to establish occlusal morphology .

6) Successive cusp buildup technique

Here, individual cusps are restored one at a time up to the level

of the occlusal enamel. Small sloping increments are applied to
each corner of the cavity in turn and manipulation is kept to a
minimum, to avoid folding voids into the material. This method,
while initially time-consuming, can greatly reduce finishing time
by precise attention to progressive reconstruction of natural
morphology 12 .

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 7) Separate dentine and enamel buildup

Here, sloping increments are again applied to cavity walls and

cured in turn, but only to the level of the amelodentinal
junction . Final enamel increments are then applied. Prudent
control of the final layer will again reduce the finishing stage.
Some operators (if agreeable to the patient) place composite
pit and fissure stain before placement of the final layer. An
alternative method of achieving a more natural appearance is
to use a dark (e.g., A4) shade of composite for the bulk of the
restoration and a translucent or light shade for the “enamel”
increment 13 .

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The cavity configuration or C-factor:
is defined as the ratio of the bonded to the unbonded surface
area. During light-induced polymerization of resin composite,
the shrinkage forces in high C-factor cavities cannot be relieved
by resin flow, resulting in the debonding of one or more
walls14. Using different adhesive systems, it has been found
that the C-factor of the cavity negatively affect the microtensile
bond strength to dentin.

Composite restoration failure :
Resin restorations that are placed in areas of high
function are more prone to exhibit excessive wear
and/or marginal fracture despite the advances in the
current materials. Clinicians must exercise caution
when placing large resin-based composite restorations
in areas of high function. The longevity of posterior resin
restorations placed in patients who have a history of
grinding may be particularly limited15. While resin
composition, tooth preparation design, and matrix
systems may influence the lifetime of posterior
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composite restorations, the primary factor in the clinical
failure of moderate to large composite restorations is
secondary caries at the margins of the restorations 16 .
An increase in secondary caries at the margins of
composite restorations suggests that the seal at the
composite tooth interface is not adequate to resist
the physical, chemical, and mechanical stresses that are
present in the mouth. The failure of moderate to large
composite restorations has been linked to the
degradation of the bond at the tooth surface composite
material interface and an increase in the concentration
of the cariogenic bacterium (Streptococcus mutans) at
the perimeter of these materials. Degradation of the
bond at the interface between the tooth and composite
has been associated with the failure of adhesives to
form an impervious seal with the dentin . Failure of
the adhesive/dentin bond leads to open pores at the
composite–tooth interface and bacterial enzymes, oral
fluids, and even bacteria can penetrate these open
pores.

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References :
1) van Dijken JW, Pallesen U. Randomized 3-year clinical
evaluation .

2) Brunthaler A, Konig F, Lucas T, Sperr W, Schedle A. Longevity

of direct resin composite restorations in posterior teeth. Clin
Oral Invest 2003;7:63–70 .

3) van Dijken JW, Pallesen U. A randomized 10-year

prospective follow-up of Class II nanohybrid and conventional
hybrid resin composite restorations. J Adhes Dent
2014;16:585–592.

4) Anusavice ed. Phillip’s Science of Dental Materials, Ed 11,

Philadelphia, Saunders, 2003.

5) Hunt PR. A modified class II cavity preparation for glass

ionomerrestorative materials. Quintessence Int Dent Dig
1984;15(10):1011–1018.

6) Knight GM. The tunnel restoration – nine years of clinical

experienceusing capsulated glass ionomer cements. Case
report. Aust Dent J 1992;37(4):245–251.

7) 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 .

8) 12. Spreafico RC, Gagliani M. Composite resin restorations

on posterior teeth. In: Roulet JF, Degrange M,
editors. Adhesion: The Silent Revolution in Dentistry. Chicago:
Quintessence Publishing; 2000. pp. 253–76.

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9) Giachetti L, Scaminaci Russo D, Bambi C, Grandini R. A
review of polymerization shrinkage stress: Current techniques
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10) Coli P, Brännström M. The marginal adaptation of four

different bonding agents in Class II composite resin restorations
applied in bulk or in two increments. Quintessence
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11) Opdam NJ, Roeters FJ, Feilzer AJ, Verdonschot EH. Marginal
integrity and postoperative sensitivity in Class 2 resin
composite restorations in vivo. J Dent. 1998;26:555–62 .

12) Mackenzie L, Shortall AC, Burke FJ. Direct Posterior

composites: A practical guide. Dent update. 2009;36:71.

13) Javaheri DS. Placement technique for direct posterior

composite restorations. Pract Proced Aesthet
Dent. 2001;13:195–200 .

14) Feilzer AJ, De Gee AJ, Davidson CL. Setting stress in

composite resin relation to configuration of the
restoration. JDent Res. 1987;66:1636–1639.

15) Kampouropoulos D, Paximada C, Loukidis M,

Kakaboura A. The influ-ence of matrix type on the proximal
contact in Class II resin composite restorations ,oper dent j
2010;35(4):454–462.

16) mjor IA, Dahl JE, Moorhead JE. Age of restorations at

replacementin permanent teeth in general dental
practice. Acta Odontol Scand 2000;58(3):97–10.

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