Restorative Composite Resins

Col Kraig S. Vandewalle

USAF Dental Evaluation & Consultation Service

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

Overview
Direct restoratives
composition
classification
performance factors

Flowable
Packables

Click here for briefing on composite resins (PDF)

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

Dental resin composite

soft organic-resin matrix
polymer

hard, inorganic-filler particles

ceramic

Most frequently used

esthetic-restorative material
Leinfelder 1993

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

1948 - acrylic resins

polymethylmethacrylate
high polymerization shrinkage
Rueggeberg J Prosthet Dent 2002

History
(cont.)
1962 Bis-GMA
stronger resin

1969 filled composite resin

improved mechanical properties
less shrinkage
paste/paste system

1970s acid etching and microfills

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

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

Contraindications
Large posterior
restorations
Bruxism
Poor isolation

Advantages

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

Disadvantages
Technique sensitivity
Polymerization shrinkage
marginal leakage
secondary caries
postoperative sensitivity

Decreased wear resistance

Composition
Resin matrix

monomer
initiator
inhibitors
pigments

Bis-GMA
O
CH2=C-C-O-CH2CH-CH2O
CH3

OH

CH3
-CCH3

O
OCH2CHCH2O-C-C=CH2
OH

CH3

Inorganic filler
glass
quartz
colloidal silica

Coupling Agent
Phillips Science of Dental Materials 2003

Monomers
Binds filler particles together
Provides workability
Typical monomers
Bisphenol A glycidyl methacrylate (Bis-GMA)

O
CH2=C-C-O-CH2CH-CH2O
CH3
OH
Urethane dimethacrylate
(UEDMA)

CH3
-C-

O
OCH2CHCH2O-C-C=CH2

CH3

CH3

OH

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

Triethylene glycol dimethacrylate (TEGMA)

CH3

CH3

CH3

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

CH3

Monomers
Bis-GMA
extremely viscous
large benzene rings

lowered by adding TEGDMA

freely movable
increases polymer conversion
increases crosslinking
increases shrinkage

CH3

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

OH

-CCH3

O
OCH2CHCH2O-C-C=CH2
OH

CH3

Monomers
Shrinkage
27%
marginal gap
formation

Filler Particles
Crystalline quartz
larger particles
not polishable

Silica glass

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

Filler Particles
Increase fillers, increase
mechanical properties
strength
abrasion resistance
esthetics
handling

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

Fracture Toughness

% Filler Volume
2
1.5
1
0.5
0

28 37 48 53 62

Ferracane J Dent Res 1995

Coupling Agent
Chemical bond
filler particle - resin matrix
transfers stresses

Organosilane (bifunctional molecule)

siloxane end bonds to hydroxyl groups on filler
methacrylate end polymerizes with resin
CH2
Bis-GMA

OH

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

Bonds with resin

Silane

OH

Bonds with filler

Phillips Science of Dental Materials 2003

Inhibitors
Prevents spontaneous
polymer formation
heat
light

Extends shelf life

Butylated Hydroxytoluene

Phillips Science of Dental Materials 2003

Pigments and UV Absorbers

Pigments
metal oxides
provide shading and opacity
titanium and aluminum oxides

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

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

Initiator reacts with amine activator

Forms free radicals
Initiates addition polymerization
O
CH2=C-C-O-CH2CH-CH2O
CH3

OH

CH3
-C-

O
OCH2CHCH2O-C-C=CH2

CH3

Bis-GMA

OH

CH3

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

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

Termination
Craig Restorative Dental Materials 2002

C=C

C=C

C=C

C=C
C=C

C=C

C=C

C=C

C=C

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

C=C
polymerization

C=C

C=C

C=C

C=C
C=C
C=C

C=C

C=C
C=C
C=C

C=C

C=C

C=C
C=C
C=C
Ferracane

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

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

Difficult to polish
large particles prone to pluck

Poor wear resistance

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

Microfills
Better esthetics and polishability
Tiny particles
0.04 micron colloidal silica
increases viscosity

To increase filler loading

Ground
polymer with
colloidal
silica (50 u)
Polymer
matrix
with
colloidal
silica

filler added to resin

heat cured
ground to large particles
remixed with more resin and filler
Phillips Science of Dental Materials 2003

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

Linear clinical wear pattern

Suitable for Class 3, 5
exceptions with reinforced microfills
Class 1 or 2
Click here for table of microfills

Small Particle
1 - 5 micron heavy-metal
glasses
Fracture resistant
Polishable to semi-gloss
Suitable for Class 1 to 5
Example: Prisma-Fil

Silane-coated
silica or glass
(1-5 u)

Polymer
matrix

Phillips Science of Dental Materials 2003

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

0.6 to 1 micron average particle size

distribution of particle sizes

Silane-coated
silica or glass

maximizes filler loading

microfills added
improve handling
reduce stickiness

Polymer
matrix with
colloidal
silica

Phillips Science of Dental Materials 2003

Hybrids
Strong
Good esthetics
polishable

Suitable
Class 1 to 5

Multiple available

Click here for table of hybrids

Table of Properties
Property

Traditional

Microfilled

Small
Particle

Hybrid

Compressive strength
(MPa)

250-300

250-300

350-400

300-350

Tensile strength (MPa)

50-65

30-50

75-90

70-90

Elastic Modulus (GPa)

8-15

3-6

15-20

7-12

Coefficient of Thermal
Expansion (10-6/C)

25-35

50-60

19-26

30-40

Knoop Hardness

55

5-30

50-60

50-60

Phillips Science of Dental Materials 2003

Newer Classification System

Based on particle size
megafill
0.5 - 2 millimeters

macrofill
10 - 100 microns

midifill
1 - 10 microns

minifill

Most new systems

minifillers

Newest trend
nanofillers
trimodal loading
prepolymerized

0.1 - 1 microns

microfill
0.01 - 0.1 microns

nanofill
0.005-0.01 microns

Bayne JADA 1994

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

Relative Particle Sizes

(not to scale)

Nanofill vs. Nanohybrid

Nanofills
nanometer-sized particles throughout
matrix

Nanohybrids
nanometer-sized particles combined with
more conventional filler technology

Swift J Esthet Restor Dent 2005

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

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

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

Biocompatibility
Tolerated by pulp
with good seal

Rare allergic reactions

HEMA

Cytotoxicity
short lived
not a chronic source

Degree of cure important

decrease free monomer
Phillips Science of Dental Materials 2003

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

however, insignificant short-term

risk
literature review
Soderholm JADA 1999
click here for abstract

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

Counteract
lower shrinkage composites
incremental placement

Composite Wear
Less wear
small particle size
less abrasion

heavier filled
less attrition

non-contact areas
3 - 5 times less

less surface area

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

Composite Wear
Reduced wear with smaller particles
less plucking leaving voids

Higher filler loads for enhanced

properties
correlations between wear and fracture
toughness and flexure strength

Higher cure of resin matrix to resist

scratching and gouging by abrasives
Hilton Oper Dentistry: A Contemporary Approach 2001

Polish Mechanisms
Acquired polish
clinician induced

Inherent polish
ultimate surface

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

Hybrids
high acquired, acceptable inherent
Adept Report 1992

Polish Mechanisms
Small Particle Hybrid

Microfilled Composite

Acquired Polish
Time
Linear wear pattern

Inherent Polish
Adept Report 1992

Shaded vs. Anatomic

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

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

Shaded

Anatomic

Dentists

Ceramists
Create Shade

Match Shade
Trans Enamel

Trans Enamel

A1 Enamel
A1 Dentin

Enamel Value
A3/A4 Dentin
Enamel Value

Placement Types
Composite Brands
Shaded

4 Seasons (Ivoclar Vivadent)

Esthet-X (Dentsply)
Filtek Supreme (3M ESPE)
Point 4 (Kerr)
Venus (Heraeus Kulzer)
Renamel (Cosmedent)
Gradia Direct (GC)

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

Jackson PPAD 2003

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

hybrid/microfill veneer combo

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

microfill

Composite Selection
Posterior
hybrid
mini- or midi-fill

reinforced microfill

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

Indications
anterior, posterior, both?

Cost of kit
refills

Click here for synopsis of

restorative composite resins

Government Price
($/gm of refill resin)
8.49

8.53

8.79

8.9

9.44

11.37
9.95

10.15

10.21

7.58
6.3

6.5

Prices current as of Jan 05

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

Click here for synopsis of

restorative composite resins

Radiopacity
(mm of aluminum)
3
2

ISO Requirement

1
0

Source: USAF DECS Project 03-024

Surface Hardness
(24 hrs)
KHN

Source: USAF DECS Project 03-37

40
30
20
10
0

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

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

160
140
120
100
80
60
40
20
0
Supreme

4
Seasons

Venus

Gradia
Ant

Premise

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

Gradia
Post

Volumetric Shrinkage
Source: USAF DECS Project 03-037

5
4
3

2
1
0

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

Composite Variants
Packable
Flowable

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

Subtle alteration of filler

shape
size
particle distribution

Similar resin chemistry and filler volume

Click here for table of packable composites

Packable Composites
Mechanical properties
similar to hybrids
1.8
1.6

Fracture
Toughness

1.4
1.2
1
0.8
0.6

ALERT
Solitare
SureFil
Heliomolar
Z100

0.4
0.2
0

Choi J Esthet Dent 2000

Click here for abstract

Proximal Contact Studies

Packables similar to hybrids
diameter and tightness

Best contacts
sectional matrix system

Peumans Dent Mater 2001

-click here for abstract
Klein Am J Dent 2002

Packable Composite Resin

Depth of Cure
100

%
Hardness
Ratio
80

96.9

96.2

91.2

85.1
71.5

70.2

70.3
2 mm

55.4

60

5 mm
41.4

40
22.4
20
0

0
Pyr-D

Prodigy

SureFil

Alert

Solitaire

0
Pyr-E

Choi J Esthet Dent 2000 Click here for abstract

Packable Vs. Hybrid Composites

Mechanical properties similar

Wear properties similar
Curing depths similar
Similar proximal contacts
Drier, denser feel
Click here for more details

Choi J Esthet Dent 2000

Peumans Dent Mater 2001

Flowable Composites
Marketed

Particle size similar

to hybrid composites
Reduced filler
content

Weight Percent

class 1, 3, 5
liner

Percent Filler Loading

80
70
60
50
40
30
20
10
0

Aeliteflo
FloRestore
Revolution
Ultraseal+
Prodigy

reduces viscosity
Bayne JADA 1998
Click here for abstract

Liners Under Direct Composites

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

Reduced post-operative sensitivity?

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

Polymerization Shrinkage
%

5
4
3
2
1
0

Tolidis JDR 1999

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

Gray value

250
200
150
100

Tetric Flow
Flow-it
Enamel
Revolution
FloRestore
UltraSeal+

50
0
Murchison Quint Int 1999
Click here for abstract

Flowable Composite
Mechanical properties
inferior to hybrids
Fracture Toughness

Flexure Strength

Prodigy
Ultraseal +
Revolution
FloRestore
Aeliteflo
0

0.5

1.5
MPa

2.5

50

100

150

200

MPa

Bayne JADA 1998

Click here for abstract

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

Regular Material Usage*

Civilian Practitioners

Flowable Composite 81%

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

DPR 2005

Review of Clinical Studies

(Failure Rates in Posterior Permanent Teeth)
% Annual Failure

8
6
4
2
0

Amalgam

Direct
Comp

Comp
Inlays

Longitudinal

Ceramic CAD/CAM
Inlays
Inlays

Gold
Inlays &
Onlays

GI

Cross-Sectional
Hickel J Adhes Dent 2001

Review of Clinical Studies

(Failure Rates in Posterior Permanent Teeth)
% Annual Failure

15
Standard Deviation

10
Longitudinal and Cross-Sectional Data

5
0

Manhart Oper Dent 2004

Click here for abstract

Purchasing Considerations
Federal Service
Universal hybrid systems are suitable for
both anterior and posterior restorations
may not need to stock packable systems

additional expense to maintain

no improvement in mechanical properties
no improvement in proximal-contact formation
no increase in depth of cure

Click here for more details

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

Wide diversity of kits available

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

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

More complete universal hybrid kit

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

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

Self-adhesive?

Click here for details

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

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