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Earn 2 CE credits This course was written for dentists, dental hygienists, and assistants. Composite
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2 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.
Composite Restoration
Esthetics
A Peer-Reviewed Publication
Written by Robert C. Margeas, DDS, FAGD
Publication Written by Robert C. Margeas, DDS, FAGD PennWell designates this activity for 2 Continuing

PennWell designates this activity for 2 Continuing Educational Credits

this activity for 2 Continuing Educational Credits Publication date: November 2009 Review date: March 2011

Publication date: November 2009

Review date: March 2011 Expiry date: February 2014 This course has been made possible through an unrestricted educational grant. The cost of this CE course is $49.00 for 2 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

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Educational Objectives

Overall goal: The purpose of this article is to provide dental pro- fessionals with information about the esthetic considerations and strength of direct composites. Upon completion of this course, the clinician will be able to do the following:

1. List and describe the categories of composite resin restorative materials available and their characteristics and indications for use.

2. List and describe the modes of failure for composite resin restorative materials.

3. List and describe the shade considerations involved in the attainment of esthetics in composite resin restorations and the use of different shading and layering techniques.

4. List and describe the relevance of a smooth surface and gloss as well as polishability, and factors influencing these.

Abstract

The increased use of direct composite restorations can be mainly attributed to patient demand for esthetic restorations and the availability of composites with high strength and excellent esthet- ics. While early composites were weak and suitable only for ante- rior restorations, current composites are highly esthetic and offer high strength for their intended purposes. Techniques have also evolved, with sophisticated bonding techniques and single-shade, dual-shade, and multilayering techniques to optimize esthetics. It is important to consider not only the individual case, relative strength, and esthetics of different types of composites but also the technique to be used when selecting a restorative material.

Introduction

Direct composite restorative materials offer esthetic solutions for clinicians and patients. Esthetic solutions must be achieved in tandem with the functional requirements of strength, volumetric and morphologic stability, physical compatibility with the sur- rounding tooth structure, biocompatibility, and the ability either to self-adhere to the tooth surface or to adhere with an adhesive system for a durable bond at the tooth-restoration interface. Ad- ditional desirable properties include the ability to inhibit biofilm formation, thereby reducing the load of acidogenic and periodontal bacteria; stain resistance; and user-friendliness. Ideally, a restor- ative material will meet all these requirements, allowing it to be used for both anterior and posterior restorations. While amalgam fulfills the physical requirements for direct restorations, 1 is quicker and easier to place than are esthetic restorative materials, is more tolerant of moisture, and can now be hybrid-bonded with the use of amalgam bonding techniques (which has reduced the need for classical amalgam preparations, although results have been found to be variable), 2,3 its lack of esthetic results means it is suitable only for posterior restorations. Its use for posterior restorations has also gradually declined 4 as patients have become increasingly aware of esthetics and want the improved posterior esthetic ma- terials that have become available in response to these demands. Clinicians demand esthetic materials with improved physical and handling properties. Physical requirements differ for anterior and posterior restorations. Anterior restorations, especially those

involving incisal edges, require high strength as well as high es- thetics. Posterior restorations have the added requirement of low wear. Esthetic restorative materials must offer adequate shade availability, suitable chroma and values, translucency, opacity, opalescence, fluorescence, a smooth and glossy surface, and stain and wear resistance.

Development of Composite Resins

When first introduced in the 1970s, composite resins were utilized only for anterior restorations. 5 These early variants were typi- cally quartz-filled; did not meet the compressive and tensile force requirements for posterior restorations; and had relatively high surface roughness, low polishability, poor resistance to staining, and poor bonding at the tooth-restoration interface, which, in combination with polymerization shrinkage, resulted in margin degradation and postoperative sensitivity. The choice of shades was limited, and the materials, other than being tooth-colored, offered poor esthetics with little or no differentiation of shading by fluorescence, translucency, or intended location (such as cervical shades for cervical restorations). In addition to these disadvantag- es, early resin composites were difficult to handle, required manual mixing of the resin paste (A) and the catalyst (B), were available only in tubs or syringes of pastes (A and B separately), and were always self-cured with a limited working time. Over time, the strength characteristics of composite resins were improved and the resins were introduced for use in posterior restorations. These materials were still unsuitable for posterior restorations in which high compressive strength was required to resist occlusal and masticatory forces.Wear resistance was also low. Bonding systems were still primitive in the 1980s, with limited choice in technique. Self-adhesive systems were not available and there was little choice in terms of etching methods. The focus was still on enamel etch- ing and bonding, and early attempts at dentin bonding resulted in weak bonding to the smear layer and a rapidly degrading bond. 6 It was also recommended that, after curing of the resin, the enamel- restoration interface be re-etched and an unfilled resin be placed over this surface to seal it and help inhibit microleakage and wear. 7,8 By the 1990s, posterior composite restorations were avail- able that were better-suited to Class I and Class II restorations. 9 These enabled a more conservative approach during preparation than amalgam did, and they were used with improved bonding systems for improved marginal integrity at the tooth-restoration interface. Current composite materials (and bonding systems) are vastly superior to earlier versions. Current materials are available with several types of fillers, advanced enamel and dentin adhesive sys- tems, and they offer strength, lower polymerization shrinkage and stress, wear resistance, and excellent esthetics.

Current Composite Restorative Materials

Composite resin materials are currently available as microfilled, (micro)hybrid, and nanofilled composites. Their chemistry is typically based on bisphenol-a-glycidyl dimethacrylate (Bis- GMA); however, additive chemistry has been used to reduce

polymerization shrinkage or stress, and the addition of various sizes and types of fillers has altered physical and esthetic proper- ties. Pre-polymerized clusters and increased filler load help reduce polymerization shrinkage and stress, and increasing filled load also results in a higher viscosity composite. Each composite type offers advantages specific to its chemistry. An understanding of these is necessary to select an appropriate material for clinical procedures.

Microfilled Composite Resins Microfilled composite resins contain crushed particles ranging in size from 0.04 to 1 micron. The filler particles are typically prepo- lymerized particles comprised of resin and fumed silica. Filler load is lower in microfilled composite resins, and internal bonding be- tween the matrix resin and the prepolymerized filler resin is weak, resulting in lower strength. This is an important consideration in stress-bearing areas. The very small particle sizes in microfilled resins, however, offer excellent esthetics with high polishability and a long-lasting surface gloss.

Microhybrid/Hybrid Composite Resins Microhybrid composite resins contain silicon dioxide filler with particles ranging in size from approximately 0.04 up to 0.1 mi- cron, and glass particle fillers typically range in size from 0.4 to 0.6 micron (400 to 600 nm). These resins lose their high polish over time with the development of a rougher surface, reducing their suitability for esthetically demanding cases. They do, however, offer strong physical properties and are suitable for stress-bearing restorations. Hybrid resins have slightly larger filler sizes than do microhybrid resins and essentially behave in the same manner.

Nanofilled Composite Resins Nanofilled composite resins have a high filler load in order to obtain strength and wear resistance similar to that of micro- hybrid composite resins. Nanofilled composite resins contain smaller particles of filler in the range of 0.02 to 0.1 microns. One nanofilled composite (Filtek Supreme Plus) contains nanofiller particles that are approximately 0.02 microns in diameter, sintered into nanoclusters of 0.6 to 1.4 microns that contain zirconia/silica particles, in order to improve physical characteristics.

Table 1. Indications for composite resins

 

High-esthetic restorations

Stress-bearing restorations

Microfilled

X

Microhybrid

X

Nanofilled

X

X

Flowable and Packable Composites Another method of categorizing composite resin restorative materials is by flow characteristics. Flowable composite resins have a lower filler load and a low viscosity, enabling them to be syringed directly into preparations, where they flow and conform

to the preparation margins. The flowable composites are used extensively as a liner under posterior restorations and are also used as an initial bulk layer for the sandwich technique, similar to glass ionomer cements, that is then covered with a microfilled or nanofilled composite. They are also used in clinical situations in which heavy stress-bearing is not a requirement. Packable (universal) composites are denser and can be condensed using plastic instruments during placement, prior to curing. One study comparing a nanofilled composite resin with and without an underlying layer of flowable composite after use of a two-step (total etch) or single-step bonding technique found no statistical differences in secondary caries, postoperative sensitivity, mar- ginal discoloration or adaptation, or color at a two-year recall. Both techniques were found to be clinically successful. 10 Pack- able composites have been found to be clinically successful over multiple-year analyses. 11 While clinical function and longevity of esthetic composites are the first prerequisites, optimizing esthetics is desirable and in- creasingly demanded by patients for all direct composite restora- tions. Surface smoothness, polishability, luster (surface gloss), and specific shade attributes and techniques all play important roles in the achievement of optimal esthetics.

Optimizing Esthetics in Composites

The esthetics of composite restorations is influenced by the shape and contouring of the restoration, which must mimic the natural tooth in order to provide a natural appearance. In the case of pos- terior restorations, the use of sectional matrices has considerably simplified the achievement of functional and esthetic contours. Beyond the requirements of contour and shaping, and the use of an appropriate technique that avoids moisture contamination and utilizes an appropriate bonding system, esthetics is deter- mined by the availability and appropriate selection of shade(s) – the fluorescence and translucency, value (degree of lightness or darkness), chroma (intensity of the shade), hue, ability to offer a chameleon effect, polishability, wear resistance, retention of gloss and polish, and technique. Each of these plays a role in developing and maintaining optimal esthetics.

Table 2. Factors in optimized composite esthetics

Shape and contour mimicking natural dentition

Functional and esthetic contours

Use of an appropriate technique

Avoidance of moisture contamination

Use of an appropriate bonding system

Selection of appropriate shade(s)

Polishability of the restorative material

Wear resistance

Retention of gloss and polish

Shades and Shade Selection Composite resin systems are available with multiple shades. The number of available shades depends on the brand selected and typically includes a number of shades in the VITA A, B, C, and D ranges to cover the hues, chroma, and values that will be required for natural-looking direct composite restorations. Shades are also available and categorized by translucency and opacity. Regardless of the technique used, if teeth are stained, the staining should be removed prior to selecting a shade(s). Shade selection also should occur prior to placement of a rubber dam, since this will affect perception of color due to color perception interference with the rubber dam and because a desiccated tooth appears whiter than a moist or wet tooth.

Opacity and Translucency Different shades offer greater or lesser opacity, opalescence, and translucency. Opacity is an important property for composites, offering flexibility by enabling the creation of many shades, ranging from very translucent, which is required for incisal edges and outer multilayering, to highly opaque, which is required for the body of a restoration replacing dentin. 12 Opacity is essential for deeper restorations and restorations with a darker pulpal floor/underlying area, in order to prevent shine-through of the darkened dentin. In extreme cases, opaquers and tinters may be required. 13 Selecting opaque and/or translucent shades can be critical for the esthetic outcome of an individual case, 14 and more chromatic shades have been found to be more opaque. 15 Controlling the size and volume of filler particles is a con- tributing factor to light-scattering properties and therefore the perceived color and translucency of composite resins. 16 A matching of filler size and resin is essential for light transmission in composite resins and translucency. Translucency increases as the restorative material becomes thinner, irrespective of the shade used – a consideration when using a multilayering tech- nique. 17 Filler size in composite resins has been found to influ- ence the transmission and reflection of color, and it results in variations in translucency and opalescence. Opalescence varies with the size and amount of the filler. In general, increased filler load decreases translucency. 18 Nanosized filler particles enable the transmission of light, resulting in translucency. Their ability to scatter blue light provides the nanofilled composite with opal- escence, which enhances the lifelike appearance of composite resin materials.

Table 3. Influence of filler on esthetics and strength

Transmission of light

Reflection of color

Variations in translucency

Variations in opalescence

Low filler is less strong

Viscosity

Single-Shade, Dual-Shade, and Multilayering Techniques From a practical perspective, there is a need for composite resin systems that offer the ability to provide esthetic restorations using only one shade. Single-shade restorations are simpler and quicker to place. Single-shade restorations require that the composite be able to blend in with the surrounding tooth structure through a chameleon effect, such that the gradation from different areas of

the tooth’s structure to the restoration is not obvious and results in

a natural-looking restoration. More esthetically demanding clinical situations can require a dual-shade or multilayering technique to mimic the adjacent tooth structure. Dual-shade restorative procedures are suited to situa- tions in which there may be substantial variations in two adjacent areas – for example, for a darker cervical versus coronal area, or for a highly translucent and wide incisal edge versus the more opaque coronal area being restored. When using a dual-shade technique, the dentin color (body of the tooth) should be selected first, followed by the enamel shade (and if a translucent shade is also used, this should be chosen last). Dietschi et al. reported on a shading concept that compared enamel and dentin shades

with the opacity and specific color of teeth. After comparing teeth with similar chroma (green-red/blue-yellow values), it was found that only the blue-yellow values varied. Translucency was found to be relatively constant for dentin, and it increased with age in enamel. From these conclusions, a simplified dual-layering tech- nique was developed – the “natural layering concept” – that uses

a universal dentin hue and one of three enamel hues, depending

on the age of the patient (young, adult, and old). 19 Multilayering techniques are the most time-consuming and complex, requiring more shades to be used, but they offer the most esthetic solu- tion for specific cases. The blending effect varies with the size of the restoration. 20 Advanced layering techniques can also utilize color tints to modify composite shades, such as for the creation of hypocalcification-like areas to mimic adjacent teeth with hypocal- cifications where these are not being treated. 21 It is important when using dual- or multiple-shade tech- niques to use the same brand of composite and the shade guide for that composite system. The translucency and shade of com- posites, while almost universally using the VITA shade guide system for labeling purposes, show variation across brands. 22 For multilayering techniques, the blending effect depends on both the specific brand of composite and the shades used. 23 Significant differences in color, translucency, and fluorescence have also been found between flowable and packable (universal) compos- ites that were different brands but labeled as the same shades. 24 Curing and polishing change the color and translucency of a composite resin, again varying by brand and shade. 25,26,27 The shade guide, not uncured resin, should be used for shade selec- tion. Alternatively, recently cured resin can be used. 28 It is also important to consider the availability and quality of light within the daylight UV spectrum when selecting shades. As the daylight UV varies, so too does the perceived color of composite resins 29 and teeth. The use of computerized shade guide determination

through colorimetric analysis, together with the use of multi- layering with nanofilled composites, was found in one study to result in improved esthetics. 30 In selecting a composite, sufficient shades should be available in the same brand of composite to satisfy clinical requirements for single-shade, dual-shade, and multilayering techniques. Either an accurate match to the VITA Classical shade guide, or an accurate custom shade guide must be available for the selected composite’s shade system.

Table 4. Tips for Multilayering Techniques

Use the same brand of composite for all layers

Ensure the amount and quality of daylight is adequate for shade selection

Do not use uncured resin to determine shades

Use the VITA shade guide if the composite system accurately mimics this

Use a custom shade guide if the composite system has custom shade labeling

Surface Attributes and Esthetics

Surface smoothness and retention of surface gloss are important for function and esthetics. 31 A high-gloss, smooth surface reflects light, giving a more natural appearance. The scattering and ab- sorption of light on rough surfaces results in a darker, duller ap- pearance. The initial smoothness of composite resins is influenced by the filler particle size and the technique used for polishing and finishing the resin. Composite resins with smaller filler particles are smoother and exhibit greater luster than do larger particle-size filled resins, thus explaining the greater surface smoothness and polish seen in both microfilled and nanofilled composite resins. Nanofilled composite resin containing nanoclusters has been shown to exhibit high translucency, polishability, and gloss, and its long-term polish is comparable to the characteristics of microfilled composite resins. Nanofilled translucent shades retained polish better than did similar microfilled shades. 32,33 Microhybrids are not as glossy or smooth, but their polishability and esthetics have been enhanced in recent years. 34

Polishing Composites Composites can be polished using two-step or one-step systems. These can include the use of silicon tips, Sof-Lex discs, rub- ber cups, and polishing pastes and liquid polishers. Polishing composites has been found to achieve the greatest improvement in surface gloss within five seconds of polishing. 35 One-step polish- ing systems are suitable for nanocomposite polishing (Filtek Supreme Plus (or XT outside of US); Grandio; CeramX; Premise; and Tetric EvoCeram) as well as flowable restorative materials; polishing results in a more stain-resistant surface. 36,37 Surface sealants have been recommended for use following finishing and polishing in order to impart the smoothest surface. 38 It has also been found that removing the outer surface layer during polishing helps stain resistance. 39 The optimal polisher depends on the specific composite. 40

Table 5. Surface smoothness and polisher

 

Mylar

PoGo

OptraPol

One Gloss

Filtek

Smoother

Smoother

Rougher

Rougher

Supreme

Plus

Grandio

Smoother

Smoother

Rougher

Rougher

Tetric

Less rough

Roughest

Less rough

Less rough

EvoCeram

Premise

No significant differences

 

CeramX

No significant differences

 

Source: Ergucu et al. Operative Dentistry, 2007.

It is therefore important to follow the manufacturer’s recom- mendations for specific composites.

Wear Resistance and Surface Roughness Over time, surface roughness develops in response to abrasion (as

well as acid erosion) of composite surfaces. In vitro three-surface wear testing and simulated cycles of toothbrushing are used to measure the anticipated susceptibility of composite resins to in- traoral abrasion from mastication or toothbrushing. In one study, in vitro–simulated toothbrushing resulted in rougher surfaces in microfilled and microhybrid composites than it did in packable

composites,compomers,andresin-modifiedglassionomers.Pol-

ishing composite resins at recall appointments can help to reduce surface roughness that has developed and to impart a smooth surface. 41 Both the amount of surface wear and mechanism of wear over time have been found to differ among resins. Surface roughness is also positively correlated with staining of composites. 42 Very small particles contained in microfilled resins result in an even wear pattern and thus retention of a smoother surface. The combination of nanofillers around nanoclusters results in removal during wear of the very small nanofilled particles that are packed in the nanocluster surface, again resulting in a more even pattern of wear and a smoother surface. Scanning electron micrographs (SEM) have demonstrated the removal of individual small nanofiller particles from larger zirconia-silica nanoclusters. 43 In contrast, SEMs of microhybrid resins show larger defects at the surface following wear, proposed to be due to the removal of larger individual particles that leave voids and a less even pattern of wear, resulting in a rougher surface than observed with microfilled and nanofilled composites. 44

Figure 1. Scanning electron micrographs of composite fillers

Nanofiller

electron micrographs of composite fillers Nanofiller Courtesy of Dr. Jorge Perdigao Hybrid filler www.ineedce.com

Courtesy of Dr. Jorge Perdigao

Hybrid filler

electron micrographs of composite fillers Nanofiller Courtesy of Dr. Jorge Perdigao Hybrid filler www.ineedce.com 5

Surface wear results in loss of gloss followed by loss of the layer below the gloss. In vitro data indicates that the microhardness of a nanofilled composite is higher than that of microfilled composites, attributable to the filler. 45 The aging of esthetic restorative materials results in surface changes and therefore changes in the light-scattering absorption properties of glass ionomers, modified glass ionomers, compom- ers, and resin composites. 46 Aging of flowable composites has also been found to result in more color changes compared to universal composites. 47 Accelerated in vitro aging was found in one in vitro

study to result in the loss of translucency but not to affect opacity

of composite resins. 48

Bacterial Considerations

A smooth, glossy appearance is also important to reduce the po-

tential for bacterial adhesion and the accumulation of biofilm. In vitro studies have found amalgam to be bactericidal and to inhibit the formation of biofilm. 49,50 The converse has been found with resin-based restorative materials, although, interestingly, the ex- perimental addition of microparticulate silver to composite resin material has been found in vitro to have a bactericidal effect as well as to inhibit bacterial adhesion. 51 These findings increase the importance of selecting a material that both achieves and retains a smooth surface. 52 In vitro studies on packable resin composites, compomers (polyacid-modified composite resins), and glass iono- mer cements found no antibacterial properties for these materials, while one found a minimal effect for a few days with composite

resin. 53,54,55,56 In the case of the packable composites tested, newly polymerized resin would actually support the development of biofilm, and one study found that bacteria formed a dense biofilm

on composite resin. 57,58

Combining Strength and Esthetics

While predictable and reliable esthetics is important, this must not result in compromised functionality. Microfilled resins are highly esthetic, suitable for anterior restorations in low stress- bearing restorations. Microhybrid and nanofilled composites are suitable for stress-bearing restorations. Some variability in the mechanical properties of different nanofilled composites has been found in in vitro testing. 59 Beun et al. compared the mechanical properties of nanofilled, microhybrid, and microfilled composites. The nanofilled com- posites had an elastic modulus and physical properties at least equivalent or better than those of universal composite and supe- rior to those of microfilled composite. 60 One study comparing the properties of nanofilled composite resin containing nanoclusters and microfilled and hybrid resin composites found that nano- filled/nanocluster composites offered physical characteristics and strength comparable to those of microhybrid composites. Physical characteristics measured and compared included wear resistance – also a factor in esthetics, compressive and diametral strengths, and fracture resistance. 61 The same nanofilled composite was found in other in vitro testing to have higher diametral tensile strength than did microhybrid composites. 62

Latest Developments in Composite Resins

Recent developments in composite resin technology have includ- ed reductions in polymerization shrinkage and in polymerization stress. These have been achieved through increased filler loads and novel chemical technology. Polymerization shrinkage, and therefore stress, has been reduced through the use of silorane- ring-based chemistry 63 as well as by increasing conversion rate of the monomer. 64 Direct reduction of polymerization stress has now also been achieved through the use of a polymerization modulator to reduce stress. A recent development has improved esthetics in a high-strength, esthetic nanofilled composite. Changes in the synthesis of nanoclusters in nanofilled composite resin have demonstrated improved polish retention and han- dling, while maintaining wear resistance, in in vitro testing. The same material has fracture toughness equal to that of the upper range of other composites, as well as high flexural strength. 65 The cases below illustrate the use of this new nanofilled/ nanocluster composite for single-shade and multilayering tech- niques.

Case Studies

Case 1. Multi-layering technique The patient presented with an old, worn and defective composite. After discussion, it was decided to replace the Class IV compos- ite. The old composite was removed, followed by etching of the enamel and dentin, rinsing and drying, then use of the bonding agent. The composite (Filtek TM Supreme Ultra universal com- posite) was then layered for optimal esthetics, using a thin layer of WE, followed by A1 to create a ‘dentin replacement layer’ at the lobes. This was followed by application of grey translucent shade between the lobes and B1 enamel shade. The final restoration was polished using a Sof-Lex disc, followed by a cup brush and polish for an esthetic, high gloss smooth surface finish.

Figure 2. Old, worn composite restoration

gloss smooth surface finish. Figure 2. Old, worn composite restoration Figure 3. Old composite removed 6

Figure 3. Old composite removed

gloss smooth surface finish. Figure 2. Old, worn composite restoration Figure 3. Old composite removed 6

Figure 4. Etchant applied

Figure 4. Etchant applied Figure 5. Bonding agent applied Figure 6. Thin layer of WE against

Figure 5. Bonding agent applied

Figure 4. Etchant applied Figure 5. Bonding agent applied Figure 6. Thin layer of WE against

Figure 6. Thin layer of WE against impression template

Figure 6. Thin layer of WE against impression template Figure 7. Cured lingual wall of WE

Figure 7. Cured lingual wall of WE

impression template Figure 7. Cured lingual wall of WE Figure 8. Application of B1 enamel Figure

Figure 8. Application of B1 enamel

Cured lingual wall of WE Figure 8. Application of B1 enamel Figure 9. Final, polished restoration

Figure 9. Final, polished restoration

of B1 enamel Figure 9. Final, polished restoration Case 2. Single-shade restoration In this case the

Case 2. Single-shade restoration In this case the patient presented with a carious DO lesion, visible unaided as well as radiographically. The patient preferred an esthetic composite restoration. After removing the carious enamel and den- tin, the tooth was first etched, rinsed and dried, and then the adhe- sive layer applied. Shade A3 body was then used and the composite resin syringed directly into the preparation.The composite was then packed into the tooth and light-cured. Finishing of the restoration was achieved using a fine diamond for fine occlusal contouring, fol- lowed first by a Sof-Lex disc and then a brush cup and polish.

Figure 10. Carious DO lesion

then a brush cup and polish. Figure 10. Carious DO lesion Figure 11. Etchant applied Figure

Figure 11. Etchant applied

cup and polish. Figure 10. Carious DO lesion Figure 11. Etchant applied Figure 12. Adhesive applied

Figure 12. Adhesive applied

cup and polish. Figure 10. Carious DO lesion Figure 11. Etchant applied Figure 12. Adhesive applied

Figure 13. Nanofilled, nanocluster composite, shade A3, syringed into preparation

nanocluster composite, shade A3, syringed into preparation Figure 14. Packing of composite into preparation Figure 15.

Figure 14. Packing of composite into preparation

preparation Figure 14. Packing of composite into preparation Figure 15. Final, esthetic single-shade posterior

Figure 15. Final, esthetic single-shade posterior restoration

15. Final, esthetic single-shade posterior restoration Summary Esthetic composite restorations have gained

Summary

Esthetic composite restorations have gained popularity with pa- tients and increased usage by clinicians. During the development of composite restorations, several categories have been developed. Current composites can be categorized as microfilled, (micro) hybrid, and nanofilled, as well as flowable and packable. Recent developments in composite technology have resulted in improved physical characteristics and improved esthetics, without compro- mising strength. Each type of composite offers different physical and esthetic characteristics that must be considered when selecting a composite and technique for individual cases.

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26 Lee YK, Lim BS, Rhee SH, Yang HC, Powers JM. Changes of optical properties of dental nano-filled resin composites after curing and thermocycling. J Biomed Mater Res B Appl Biomater. 2004;71(1):16-

21.

27 Lee YK, Lim BS, Rhee SH, Yang HC, Powers JM. Changes of optical properties of dental nano-filled resin composites after curing and

thermocycling. J Biomed Mater Res B Appl Biomater. 2004;71(1):16-

21.

28 Sidhu SK, Ikeda T, Omata Y, Fujita M, Sano H. Change of color and translucency by light curing in resin composites. Oper Dent.

2006;31(5):598-603.

29 Lee YK, Kim JH, Ahn JS. Influence of the changes in the UV component of illumination on the color of composite resins.

J Prosthet Dent. 2007;97(6):375-80.

30 Milnar FJ. Selecting nanotechnology-based composites using colorimetric and visual analysis for the restoration of anterior dentition:

a case report. J Esthet Restor Dent. 2004;16(2):89-100.

31 Koupis NS, Marks LA, Verbeeck RM, Martens LC.Review: finishing and polishing procedures of (resin-modified) glass ionomers and compomers in paediatric dentistry. Eur Arch Paediatr Dent.

2007;8(1):22-8.

32 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.

33 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.

34 Morgan M. Finishing and polishing of direct posterior resin restorations. Pract Proced Aesthet Dent. 2004;16(3):211-7.

35 Heintze SD, Forjanic M, Rousson V. Surface roughness and gloss of dental materials as a function of force and polishing time in vitro. Dent Mater. 2006;22(2):146-65.

36 Ergücü Z, Türkün LS, Aladag A. Color stability of nanocomposites polished with one-step systems. Oper Dent. 2008;33(4):413-20.

37 Ozel E, Korkmaz Y, Attar N, Karabulut E. Effect of one-step polishing systems on surface roughness of different flowable restorative materials. Dent Mater J. 2008;27(6):755-64.

38 Attar N. The effect of finishing and polishing procedures on the surface roughness of composite resin materials. J Contemp Dent Pract.

2007;8(1):27-35.

39 Ergücü Z, Türkün LS, Aladag A. Color stability of nanocomposites polished with one-step systems. Oper Dent. 2008;33(4):413-20.

40 Ergücü Z, Türkün LS. Surface roughness of novel resin composites polished with one-step systems. Oper Dent. 2007;32(2):185-92.

41 Neme AL, Frazier KB, Roeder LB, Debner TL. Effect of prophylactic polishing protocols on the surface roughness of esthetic restorative materials. Oper Dent. 2002;27(1):50-8.

42 Lu H, Roeder LB, Lei L, Powers JM. Effect of surface roughness on stain resistance of dental resin composites. J Esthet Restor Dent. 2005;17(2):102-8; discussion 109.

43 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.

44 Ibid.

45 Barros BACD, Lopes GC, Baratieri LN, Araujo E. Surface microhardness of different resin composites. IADR; Abstact 0574;2004.

46 Lee YK, Lim BS, Rhee SH, Yang HC, Lim YK. Changes in scattering and absorption properties of esthetic filling materials after aging. J Biomed Mater Res B Appl Biomater. 2007;80(1):131-9.

47 Yu B, Lee YK. Comparison of the color stability of flowable and universal resin composites. Am J Dent. 2009;22(3):160-4.

48 Lee YK, Lu H, Powers JM. Changes in opalescence and fluorescence properties of resin composites after accelerated aging. Dent Mater. 2006 Jul;22(7):653-60.

49 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial analysis of amalgam and composite resins. J Dent. 2007;35(3):201-6.

50 Willershausen B, Callaway A, Ernst CP, Stender E. The influence of oral bacteria on the surfaces of resin-based dental restorative materials:

an in vitro study. Int Dent J. 1999;49(4):231-9.

51 Bürgers R, Eidt A, Frankenberger R, Rosentritt M, Schweikl H, Handel G, Hahnel S. The anti-adherence activity and bactericidal effect of microparticulate silver additives in composite resin materials. Arch Oral Biol. 2009;54(6):595-601. Epub 2009 Apr 16.

52 Quirynen M, Bollen CM. The influence of surface roughness and surface-free energy on supra- and subgingival plaque formation in man. A review of the literature. J Clin Periodontol. 1995;22(1):1-14.

53 Matalon S, Slutzky H, Weiss EI. Surface antibacterial properties of

packable resin composites: part I. Quintessence Int. 2004;35(3):189-

93.

54 Matalon S, Weiss EI, Gozaly N, Slutzky H. Surface antibacterial properties of compomers. Eur Arch Paediatr Dent. 2006;7(3):136-41.

55 Slutsky H, Weiss EI, Lewinstein I, Slutzky S, Matalon S. Surface

antibacterial properties of resin and resin-modified dental cements. Quintessence Int. 2007;38(1):55-61.

56 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial analysis of amalgam and composite resins. J Dent. 2007;35(3):201-6.

57 Matalon S, Slutzky H, Weiss EI. Surface antibacterial properties of packable resin composites: part I. Quintessence Int. 2004;35(3):189-

93.

58 Willershausen B, Callaway A, Ernst CP, Stender E. The influence of oral bacteria on the surfaces of resin-based dental restorative materials:

an in vitro study. Int Dent J. 1999;49(4):231-9.

59 Mota EG, Oshima HM, Burnett LH Jr, Pires LA, Rosa RS. Evaluation of diametral tensile strength and Knoop microhardness of five nanofilled composites in dentin and enamel shades. Stomatologija.

2006;8(3):67-9.

60 Beun S, Glorieux T, Devaux J, Vreven J, Leloup G. Characterization of nanofilled compared to universal and microfilled composites. Dent Mater. 2007;23(1):51-9.

61 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.

62 Lopes GC, Zucco J, De Lucca C, Baratieri L, Vieira L. Diametral tensile strength of micro-hybrid composite resins. IADR; Abstact 0585;2004.

63 Ilie N, Jelen E, Clementino-Luedemann T, Hickel R. Lowshrinkage composite for dental application. Dent Mater J. 2007;26(2):149-55.

64 Bracho-Troconis C, Rudolph S, Boulden J, Wong N. Conversion vs. Shrinkage of N’Durance, Dimer Acid based Nanohybrid Composite. IADR. 2008, Rotonto July 1-4. Abstract 1812.

65 Kobussen GA, Craid BD, Halvorson RH, Doruff MC, Bigham WS. Optical Properties of an Experimental Highly Aesthetic Composite Restorative. IADR 2009, April 1 –3, Miami. Avstract 1508.

Author Profile

Robert C. Margeas, DDS, FAGD Dr. Margeas graduated from the University of Iowa College of Dentistry in 1986 and completed his AEGD residency the following year. He is currently an adjunct professor in the department of Operative Dentistry at the University of Iowa. He is Board Certified by the American Board of Op- erative Dentistry. He is a Diplomate of the American Board of Aesthetic Dentistry , a Fellow of the Academy of General Dentistry and International Team of Oral Implantologists (ITI). He has written numerous articles on esthetic and implant dentistry, and lectures and presents hands-on courses nationally and internationally on those subjects. He serves on the Editorial Advisory board of Inside Dentistry, Compendium, and is a contributing editor to Dentistry Today and Oral Health in Canada. Dr. Margeas main- tains a full-time private practice focusing on comprehensive restorative and implant dentistry in Des Moines, Iowa.

restorative and implant dentistry in Des Moines, Iowa. Disclaimer Dr. Margeas has been a speaker on

Disclaimer

Dr. Margeas has been a speaker on behalf of 3M ESPE as well as other composite manufacturers.

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Questions

1.

2.

3.

4.

5.

6.

7.

Esthetic solutions for restorations must be achieved in tandem with

a.

b.

c.

d.

the functional requirements of strength physical compatibility with the surrounding tooth structure volumetric and morphologic stability all of the above

The use of amalgam for posterior restorations

has

in recent years.

a.

b.

c.

d.

gradually increased remained the same gradually decreased increased dramatically

Early composite resins

a.

b.

c.

d.

were typically quartz-filled did not meet the compressive and tensile force require- ments for posterior restorations had high surface roughness and low polishability all of the above

Early posterior composite materials were

a.

b.

c.

d.

suitable for anterior restorations suitable for posterior restorations suitable for indirect restorations all of the above

Composite resin is currently available as composite.

a.

b.

c.

d.

microfilled microhybrid nanofilled all of the above

The addition of various sizes and types of fillers has altered the properties of composites.

a.

b.

c.

d.

physical esthetic genetic a and b

Microfilled composite resins

8.

a.

b.

c.

d.

contain crushed filler particles, typically prepolymer- ized and comprised of resin and fumed silica have a lower filler load than microhybrid composite resins offer high polishability and excellent esthetics all of the above

Microhybrid composite resins

a.

b.

c.

d.

develop a rougher surface over time offer strong physical properties are suitable for stress-bearing restorations all of the above

9.

Nanofilled composite resins have high filler loads in order to obtain similar to that of microhybrid composite resins.

a.

b.

c.

d.

strength and wear resistance wear and elasticity elasticity and esthetics none of the above

10.

Flowable composite resins

a.

b.

c.

d.

have lower filler loads than packable composites flow and conform to the preparation margins have a high viscosity a and b

11.

One study comparing restorations using

nanofilled composite resin found those of flowable composite to be clinically successful.

Questions

a.

b.

c.

d.

those with an underlying layer those without an underlying later those with and without an underlying layer none of the above

12.

The value of a composite shade refers to the

a.

b.

c.

d.

use of hues degree of lightness or darkness the opacity of the shade none of the above

13.

Chroma refers to the

a.

b.

c.

d.

color of a shade opalescence of a shade intensity of a shade none of the above

14.

If teeth are stained, the staining should be

removed

selecting a shade.

a.

b.

c.

d.

prior to at the same time as after any of the above

15.

Selecting a shade while a rubber dam is on

the teeth can affect the choice of shade due to the

a.

b.

c.

d.

altered color perception because of the influence of the rubber damitself altered appearance of dessicated teeth altered number of teeth that are visible a and b

16.

Opacity in a composite

a.

b.

c.

d.

enables the creation of many shades ranging from opaque to highly translucent is higher in more chromatic shades is essential for deeper restorations all of the above

17.

Selecting

shades can

be critical for the esthetic outcome of an individual case.

a.

b.

c.

d.

opaque translucent opaque and/or translucent none of the above

The size and volume of filler particles in a composite resin

18.

a.

b.

c.

d.

contributes to light-scattering properties influences the perceived color influences the perceived translucency all of the above

19.

Nanosized filler particles

a.

b.

c.

d.

enable the transmission of light scatter blue light enhance the lifelike appearance of composite resin materials all of the above

20.

In general, increased filler load translucency.

a.

b.

c.

d.

increases decreases does not affect mimics

21.

Single-shade restorations

a.

b.

c.

d.

require that the composite be able to blend in with the surrounding tooth structure are quicker and simpler to place than dual or multiple shade restorations are rarely practical a and b

22.

When using a dual shade technique, the color should be selected

first, followed by the

and then, if used, the translucent shade.

shade

a.

b.

c.

d.

enamel; dentin dentin; enamel cementum none of the above

23.

Multilayering techniques

a.

b.

c.

d.

require the most shades are the most time-consuming and complex offer the most esthetic solution for specific cases all of the above

24.

It is important when using dual- or multiple-

shade techniques to use

that composite system.

for

a.

b.

c.

d.

the same brand of composite the same brand shade guide the same brand matrix a and b

Shade selection for a composite can be determined using

25.

a.

b.

c.

d.

the shade guide or uncured resin uncured or cured resin the shade guide or cured resin the shade guide for a glass ionomer

26.

A high-gloss, smooth surface

a.

b.

c.

d.

reflects light results in an appearance that is not as dark or dull as a rough surface gives a more natural appearance all of the above

27.

The combination of nanofillers around

nanoclusters has been shown to result in

a.

b.

c.

d.

a more even pattern of wear a rougher surface a smoother surface a and c

28.

In vitro data indicates that the

microhardness of a nanofilled composite

is

composites.

that of microfilled

a.

b.

c.

d.

higher than the same as lower than a or c

A smooth, glossy surface can reduce the potential for

29.

a.

b.

c.

d.

bacterial removal

bacterial adhesion

bactericidal activity

viral removal

Each type of composite offers properties that must be considered when selecting a composite and technique for an individual case.

30.

a.

b.

c.

d.

the same physical and different esthetic the same physical and esthetic different physical and the same esthetic different physical and esthetic

ANSWER SHEET

Composite Restoration Esthetics

Name:

Title:

Specialty:

Address:

E-mail:

City:

State:

ZIP:

Country:

Telephone: Home (

)

Office (

)

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

Educational Objectives

1. List and describe the categories of composite resin restorative materials available and their characteristics and indications for use.

2. List and describe the modes of failure for composite resin restorative materials.

3. List and describe the shade considerations involved in the attainment of esthetics in composite resin restorations and the use of different shading and layering techniques.

4. List and describe the relevance of a smooth surface and gloss as well as polishability, and factors influencing these.

Course Evaluation

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

1. Were the individual course objectives met?

Objective #1:

Yes No

Objective #3:

Yes No

Objective #2:

Yes No

Objective #4:

Yes No

2. To what extent were the course objectives accomplished overall?

5

4

3

2

1

0

3. Please rate your personal mastery of the course objectives.

5

4

3

2

1

0

4. How would you rate the objectives and educational methods?

5

4

3

2

1

0

5. How do you rate the author’s grasp of the topic?

5

4

3

2

1

0

6. Please rate the instructor’s effectiveness.

5

4

3

2

1

0

7. Was the overall administration of the course effective?

5

4

3

2

1

0

8. Do you feel that the references were adequate?

Yes

No

9. Would you participate in a similar program on a different topic?

 

Yes

No

10. If any of the continuing education questions were unclear or ambiguous, please list them.

11. Was there any subject matter you found confusing? Please describe.

12. What additional continuing dental education topics would you like to see?

continuing dental education topics would you like to see? Please check here if you wish to

Please check here if you wish to receive future communications from the sponsor of this course, 3M eSPe

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A Division of PennWell Corp.

P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447

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AUTHOR DISCLAIMER Dr. Margeas has been a speaker on behalf of 3M ESPE as well as other composite manufacturers.

SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant from 3M ESPE. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com.

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INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination.

EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell.

Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

COURSE CREDITS/COST All participants scoring at least 70% on the examination will receive a verification form verifying 2 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $49.00 to $110.00.

Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANB’s annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANB’s Recertification Department at 1-800-FOR-DANB, ext. 445.

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division

of PennWell

©

2009

by

the

Academy

of

Dental

Therapeutics

and

Stomatology,

a