An alternative method to reduce polymerization shrinkage in direct posterior composite restorations

BACKGROUND: Polymerization shrinkage is one of dental clinicians' main concerns when placing direct, posterior, resin-based composite restorations. Evolving improvements associated with resin-based composite materials, dental adhesives, filling techniques and light curing have improved their predictability, but shrinkage problems remain. METHODS: The authors propose restoring enamel and dentin as two different substrates and describe new techniques for placing direct, posterior, resin-based composite restorations. These techniques use flowable and microhybrid resin-based composites that are polymerized with a progressive curing technique to restore dentin, as well as a microhybrid composite polymerized with a pulse-curing technique to restore enamel. Combined with an oblique, successive cusp buildup method, these techniques can minimize polymerization shrinkage greatly. CONCLUSIONS: Selection and appropriate use of materials, better placement techniques and control polymerization shrinkage may result in more predictable and esthetic Class II resin-based composite restorations. CLINICAL IMPLICATIONS: By using the techniques discussed by the authors, clinicians can reduce enamel microcracks and substantially improve the adaptation of resin-based composite to deep dentin. As a consequence, marginal discoloration, recurrent caries and postoperative sensitivity can be reduced, and longevity of these restorations potentially can be improved.     

大块充填树脂在牙体修复中的应用与研究进展

传统复合树脂在临床应用中分层充填,步骤较多,树脂的聚合收缩可导致修复体边缘微渗漏、术后敏感等,导致修复失败.2009年,大块充填树脂(bulk-fill resin-based composite)应运而生,改良的基质单体、改性强化的纳米混合填料以及独特的光引发剂,使得大块充填树脂能够一层充填4 mm,其简化操作步骤、节约椅旁时间、并能显著降低聚合收缩和聚合应力.本文就大块充填树脂的分类、固化原理、性能等方面进行阐述和讨论,并提出大块充填树脂的应用发展方向.     

A rational use of dental materials in posterior direct resin restorations in order to control polymerization shrinkage stress

One of the main problems when using resin-based composites is the resulting polymerization shrinkage stress. Composite strain is hindered every time the composite is bonded to the tooth's walls. In the pre-gel phase the shrinkage stress is reduced by the composite flow from the free to the bonded surface areas. Therefore, no stress develops at the dentine-composite interface. When a gel point is reached, the composite flow no longer compensates for the volumetric shrinkage. The generated stress may cause adhesive failure and several other adverse clinical consequences such as enamel fracture, cracked cusps, cuspal movement, microcracking of the restorative material and gaps between the resin and cavity walls which may cause secondary caries and postoperative sensitivity. A sensible use of materials in direct restorations may contribute to a reduced rate of shrinkage stress. To this aim glass-ionomer cement as well as flowable, light-curing and self-curing composites were examined. The aim of this study was to provide some useful information for a sensible choice of restoration materials in order to control shrinkage stress and its negative consequences in direct posterior restorations.     

Effect of adhesive layer properties on stress distribution in composite restorations--a 3D finite element analysis.

OBJECTIVES: Teeth, adhesively restored with resin-based materials, were modeled by 3D-finite elements analysis that showed a premature failure during polymerization shrinkage and occlusal loading. METHODS: Simulation of Class II MOD composite restorations with a resin bonding system revealed a complex biomechanical behavior arising from the simultaneous effects of polymerization shrinkage, composite stiffness and adhesive interface strain. Due to a polymerization contraction, shrinkage stress increases with the rigidity of the composites utilised in the restoration, while the cusp movements under occlusal loading are inversely proportional to the rigidity of the composites. The adhesive layer's strain also plays a relevant role in the attenuation of the polymerization and occlusal loading stresses. RESULTS: The choice of an appropriately compliant adhesive layer, able to partially absorb the composite deformation, limits the intensity of the stress transmitted to the remaining natural tooth tissues. For adhesives and composites of different rigidities, FEM analysis allows the determination of the optimal adhesive layer thickness leading to maximum stress release while preserving the interface integrity. Application of a thin layer of a more flexible adhesive (lower elastic modulus) leads to the same stress relief as thick layers of less flexible adhesive (higher elastic modulus).     

The use of resin-based composite in children

Resin-based composites are an integral component of contemporary pediatric restorative dentistry. They can be utilized effectively for preventive resin restorations, moderate Class II restorations, Class III restorations, Class IV restorations, Class V restorations and strip crowns. Tooth isolation to prevent contamination is a critical factor, and high-risk children may not be ideal candidates for resin-based composite restorations. Important factors to consider during composite placement are isolation, polymerization shrinkage and extent of restoration. When utilized correctly, resin-based composites can provide excellent restorations in the primary and permanent dentition.     

The benefits of glass ionomer self-adhesive materials in restorative dentistry

Bonded, resin-based composite restorative materials have potential advantages. If the dentin bond achieved is not greater than the polymerization stress, loss of retention is likely, resulting in areas of microleakage and postoperative sensitivity. Class 5 lesions restored with no preparation have been used for testing the clinical performance of new adhesive restorative systems. Laboratory studies have demonstrated that bond strength varies according to the depth of dentin and the degree of calcification. Until the later generations of dentin bonding agents, retention rates for bonded, resin-based composites were typically more erratic and lower than glass ionomer (GI) and resin-modified glass ionomer (RMGI) restorative materials. Providing stress relief during setting is inherent in GI and RMGI materials, which helps to explain their good retention rates, despite their low bond strengths. GI and RMGI liners and lightly filled resin bonding agents provide similar stress relief. Current evidence supports the use of both RMGI and composite restorations placed with a liner of lightly filled resin in adhesive Class 5 restorations. Bonded, resin-based composite has the advantage of finishing to a high-gloss surface, making it more acceptable in areas of the mouth that are highly visible.     

大块充填树脂的研究进展

目前大块充填树脂已经越来越广泛应用于临床。一次4-6mm的固化深度是大块充填树脂最突出的优点,便于临床操作。树脂的聚合收缩和边缘微渗漏及性能的长期稳定性与材料的临床应用效果密切相关。如何保证树脂具有较高的固化深度,较低的聚合收缩和边缘微渗漏,以及临床效果评价是大块充填树脂的研究热点,本文将对上述方面的研究进展进行综述。     

Effect of material properties on stresses at the restoration-dentin interface of composite restorations during polymerization.

BACKGROUND: Numerous analyses for the shrinkage stress in the adhesive resin-based composite restorations mostly rely on numerical models. However, various finite element studies have inherent difficulties and inconsistencies associated with the use of different anatomy (tooth and restoration), boundary conditions (root and interfaces) and shrinkage models. As a consequence many numerical results remain inconclusive. OBJECTIVE: The objective of this paper is to develop a simplified analytical model of shrinkage stress and investigate effects of material properties of the restorative material, size of the restoration and volumetric shrinkage on the magnitude of the shrinkage stress in the vicinity of the dental-restoration interface. METHODS: The model is based on the following assumptions. The geometry is axisymmetric; all materials are linear-elastic; and the polymerization of the restoration material results in uniform volume shrinkage. An application of compatibility conditions leads to the system of five linear algebraic equations to five unknown variables, which can be easily resolved using standard techniques. RESULTS: An explicit equation for the tensile stress at the interface was obtained. It was shown that higher Young's modulus, Poisson's ratio and volume shrinkage of the restorative material normally lead to larger tensile stress at the interface, which increases the risk of debonding. The results obtained based in this work, in general, are in a good agreement with published results of finite element studies. SIGNIFICANCE: The model allows comparison of different adhesive restorative materials with respect to the fracture risk of the interface induced by the development of the shrinkage stress at the restoration-dentine interface during polymerization. The model can be used to validate more sophisticated computational models as well as to conduct various optimization studies and preliminary assessments of fracture risk.     

Clinical challenges and the relevance of materials testing for posterior composite restorations.

Posterior composite restorations have been in use for approximately 30 years. The early experiences with this treatment indicated there were more clinical challenges and higher failure rates than amalgam restorations. Since the early days of posterior composites, many improvements in materials, techniques, and instruments for placing these restorations have occurred. This paper reviews what is known regarding current clinical challenges with posterior composite restorations and reviews the primary method for collecting clinical performance data. This review categorizes the challenges as those related to the restorative materials, those related to the dentist, and those related to the patient. The clinical relevance of laboratory tests is discussed from the perspective of solving the remaining clinical challenges of current materials and of screening new materials. The clinical problems related to early composite materials are no longer serious clinical challenges. Clinical data indicate that secondary caries and restoration fracture are the most common clinical problems and merit further investigation. The effect of the dentist and patient on performance of posterior composite restorations is unclear and more clinical data from hypothesis-driven clinical trials are needed to understand these factors. Improvements in handling properties to ensure void-free placement and complete cure should be investigated to improve clinical outcomes. There is a general lack of data that correlates clinical performance with laboratory materials testing. A proposed list of materials tests that may predict performance in a variety of clinical factors is presented. Polymerization shrinkage and the problems that have been attributed to this property of composite are reviewed. There is a lack of evidence that indicates polymerization shrinkage is the primary cause of secondary caries. It is recommended that composite materials be developed with antibacterial properties as a way of reducing failures due to secondary caries. Post-operative sensitivity appears to be more related to the dentin adhesives' ability to seal open dentinal tubules rather than the effects of polymerization shrinkage on cuspal deflections and marginal adaptation.     

Low-shrink monomers for dental restorations

The main disadvantages of resin-based composites (RBCs) for use in load-bearing posterior restorations include the polymerization shrinkage following curing and inadequate wear resistance in service. These properties are largely influenced by the monomer system and research is currently being undertaken to decrease polymerization shrinkage and improve resin wear characteristics in an attempt to increase RBC restoration longevity. The scope of the current review will identify the development of resin-based restoratives, indicating the reported advantages and disadvantages of resin types routinely used in dental practice today and review the most recent advancements in resin technology.     

Repair of dimethacrylate-based composite restorations by a silorane-based composite: a one-year randomized clinical trial

SUMMARY Purpose : To investigate clinical performance of a low-shrinkage silorane-based composite resin when used for repairing conventional dimethacrylate-based composite restorations. Background : Despite the continued development of resin-based materials, polymerization shrinkage and shrinkage stress still require improvement. A silorane-based monomer system was recently made available for dental restorations. This report refers to the use of this material for making repairs and evaluates the clinical performance of this alternative treatment. Materials and Methods : One operator repaired the defective dimethacrylate-based composite resin restorations that were randomly assigned to one of two treatment groups: control (n=50) repair with Adper SE Plus (3M/ESPE) and Filtek P60 Posterior Restorative (3M/ESPE), and test (n=50) repair with P90 System Adhesive Self-Etch Primer and Bond (3M/ESPE) and Filtek P90 Low Shrink Posterior Restorative (3M/ESPE). After one week, restorations were finished and polished. Two calibrated examiners (Kw≥0.78) evaluated all repaired restorations, blindly and independently, at baseline and one year. The parameters examined were marginal adaptation, anatomic form, surface roughness, marginal discoloration, postoperative sensitivity, and secondary caries. The restorations were classified as Alpha, Bravo, or Charlie, according to modified US Public Health Service criteria. Mann-Whitney and Wilcoxon tests were used to compare the groups. Results : Of the 100 restorations repaired in this study, 93 were reexamined at baseline. Dropout from baseline to one-year recall was 11%. No statistically significant differences were found between the materials for all clinical criteria, at baseline or at one-year recall (p>0.05). No statistically significant differences were registered (p>0.05) for each material when compared for all clinical criteria at baseline and at one-year recall. Conclusions : The hypothesis tested in this randomized controlled clinical trial was accepted. After the one-year evaluations, the silorane-based composite exhibited a similar performance compared with dimethacrylate-based composite when used to make repairs.     

Recent advances and developments in composite dental restorative materials

Composite dental restorations represent a unique class of biomaterials with severe restrictions on biocompatibility, curing behavior, esthetics, and ultimate material properties. These materials are presently limited by shrinkage and polymerization-induced shrinkage stress, limited toughness, the presence of unreacted monomer that remains following the polymerization, and several other factors. Fortunately, these materials have been the focus of a great deal of research in recent years with the goal of improving restoration performance by changing the initiation system, monomers, and fillers and their coupling agents, and by developing novel polymerization strategies. Here, we review the general characteristics of the polymerization reaction and recent approaches that have been taken to improve composite restorative performance.     

Establishing proximal contacts with pre-polymerized composite inserts

A technique of restoring Class II posterior restorations with resin-based composite and a pre-polymerized composite insert was presented. This technique is intended to aid the practitioner in obtaining tight, broad, proximal contacts without having to purchase special instruments or materials. This method is not time-consuming, nor technically difficult. Another benefit of this technique is that it reduces the total amount of volumetric shrinkage of restorative material inside the cavity preparation, as the composite insert is pre-polymerized before placement.     

Light curing of resin-based composites in the LED era

This review thoroughly accumulated information regarding new technologies for state-of-the-art light curing of resin composite materials. Visible light cured resin-based composites allow the dentist to navigate the initiation of the polymerization step for each layer being applied. Curing technology was regularly subjected to changes during the last decades, but meanwhile the LED era is fully established. Today, four main polymerization types are available, i.e. halogen bulbs, plasma are lamps, argon ion lasers, and light emitting diodes. Additionally, different curing protocols should help to improve photopolymerization in terms of less stress being generated. Conclusions were: (1) with high-power LED units of the latest generation, curing time of 2 mm thick increments of resin composite can be reduced to 20 seconds to obtain durable results; (2) curing depth is fundamentally dependent on the distance of the resin composite to the light source, but only decisive when exceeding 6 mm; (3) polymerization kinetics can be modified for better marginal adaptation by softstart polymerization; however, in the majority of cavities this may not be the case; (4) adhesives should be light-cured separately for at least 10 seconds when resin composite is applied directly; (5) photocuring through indirect restorations such as ceramics is still a problem, therefore, both dual-cured adhesives and dual-cured composites and resin coating in any way are recommended; and (6) heat generation with high-power photopolymerization units should not be underestimated as a biological problem for both gingival and pulpal tissues.     

Light-curing considerations for resin-based composite materials: a review. Part II

As discussed in Part I, the type of curing light and curing mode impact the polymerization kinetics of resin-based composite (RBC) materials. Major changes in light-curing units and curing modes have occurred. The type of curing light and mode employed affects the polymerization shrinkage and associated stresses, microhardness, depth of cure, degree of conversion, and color change of RBCs. These factors also may influence the microleakage in an RBC restoration. Apart from the type of unit and mode used, the polymerization of RBCs is also affected by how a light-curing unit is used and handled, as well as the aspects associated with RBCs and the environment. Part II discusses the various clinical issues that should be considered while curing RBC restorations in order to achieve the best possible outcome.     

Types of resin-based inlay materials and their properties.

The composition of 'chairside' resin-based inlay materials is similar to that of direct resin-based filling materials. The handling and curing procedures vary for the different inlay materials. Some systems involve precuring inside the oral cavity and a final cure at elevated temperature outside the oral cavity. Others are only cured extra-orally. The advantage of the inlay technique is that polymerisation shrinkage of the composite occurs before bonding to tooth structure. After cementation, therefore, the inlay gives good marginal adaptation in occlusal restorations. Some of the curing procedures for inlays give good conversion. The systems with good conversion also show better mechanical properties than the equivalent resin-based material cured according to the direct filling technique.     

Polymerization shrinkage of resin-based composites for dental restorations: A digital volume correlation study

ObjectiveResin-based composites are widely used in dental restorations; however, their volumetric shrinkage during polymerization leads to several issues that reduce the restoration survival rates. For overcoming this problem, a deep study of shrinkage phenomena is necessary.MethodsIn this study, micro-tomography (μ-CT) is combined with digital volume correlation (DVC) to investigate the effect of several factors on the polymerization strain of dental composites in model cavities: the presence/absence of an adhesive, the use of transparent/blackened cavities, and irradiation times between 1 and 40 s.ResultsThe results indicate that the presence of an adhesive at the interface between the cavity and composite does not reduce the total strain but instead limits it to a preferential direction. In addition, regardless of the conditions, the main strain is generated along the axis parallel to the polymerization irradiation (the vertical axis). Finally, the total strain appears to occur in the first 5 s of irradiation, with no further evolution observed for longer irradiation times.SignificanceThis work provides new insight into resin-based composite shrinkage and demonstrates the benefit of coupling DVC and μ-CT to better understand the degradation mechanisms of these materials.     

Factors involved in the development of polymerization shrinkage stress in resin-composites: a systematic review.

OBJECTIVES: Polymerization shrinkage stress of resin-composite materials may have a negative impact on the clinical performance of bonded restorations. The purpose of this systematic review is to discuss the primary factors involved with polymerization shrinkage stress development. DATA: According to the current literature, polymerization stress of resin composites is determined by their volumetric shrinkage, viscoelastic behavior and by restrictions imposed to polymerization shrinkage. Therefore, the material's composition, its degree of conversion and reaction kinetics become aspects of interest, together with the confinement and compliance of the cavity preparation. SOURCES: Information provided in this review was based on original scientific research published in Dental, Chemistry and Biomaterials journals. Textbooks on Chemistry and Dental Materials were also referenced for basic concepts. CONCLUSIONS: Shrinkage stress development must be considered a multi-factorial phenomenon. Therefore, accessing the specific contribution of volumetric shrinkage, viscoelastic behavior, reaction kinetics and local conditions on stress magnitude seems impractical. Some of the restorative techniques aiming at stress reduction have limited applicability, because their efficiency varies depending upon the materials employed. Due to an intense research activity over the years, the understanding of this matter has increased remarkably, leading to the development of new restorative techniques and materials that may help minimize this problem.     

A new approach to restorative dentistry: fabricating ceramic restorations using CEREC CAD/CAM

Ceramic materials provide an alternative when choosing a tooth-colored restoration. Currently, posterior composite restorations can be used to achieve esthetic restorations; however, they have many disadvantages with regard to wear, polymerization shrinkage, discoloration, marginal leakage, and technique sensitivity. The use of CEREC CAD/CAM enables the dentist to place feldspathic porcelain (Vitablocs Mark II) and machinable glass ceramic (Dicor MGC) restorations in a single visit. When compared to composite materials, these materials closely approximate the physical properties of enamel in compressive and tensile strength and wear resistance. This study evaluated 50 CEREC CAD/CAM restorations after 4 years in service. Restorations ranged from Class I to 7/8s crown preparations.     

Does layering minimize shrinkage stresses in composite restorations?

Polymerization shrinkage of resin composites may impair restoration longevity. It is hypothesized that layering, rather than bulk, techniques result in less stress in the tooth-restoration complex. The aim of this study was to compare shrinkage stresses for different restorative techniques used for cusp-replacing restorations with direct resin composite. In a 3-D FE model, the dynamic process of shrinkage during polymerization was simulated. Time-dependent parameters (shrinkage, apparent viscosity, Young's modulus, Poisson ratio, and resulting creep), which change during the polymerization process, were implemented. Six different restorative procedures were simulated: a chemically cured bulk technique, a light-cured bulk technique, and 4 light-cured layering techniques. When polymerization shrinkage is considered, a chemically cured composite shows the least resulting stress. The differences seen among various layering build-up techniques were smaller than expected. The results indicate that the stress-bearing locations are the interface and the cervical part of the remaining cusp.