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An Alternative Method to Reduce Polymerization Shrinkage in Direct COSMETIC & RESTORATIVE CARE ABSTRACT Background. Polymerization shrinkage is one of dental clinicians’ main concerns when placing A D A direct, posterior, resin- J ✷ ✷ based composite restora- C N An alternative O tions. Evolving improve- O N I ments associated with T T I A N U C I U resin-based composite A N E D method to reduce R G 3 materials, dental adhesives, TICLE filling techniques and light polymerization curing have improved their predictability, but shrinkage problems remain. shrinkage in direct Methods. The authors propose restoring enamel and dentin as two different sub- posterior composite strates and describe new techniques for placing direct, posterior, resin-based com- posite restorations. These techniques use restorations flowable and microhybrid resin-based com- posites that are polymerized with a progres- sive curing technique to restore dentin, as SIMONE DELIPERI, D.D.S.; DAVID N. BARDWELL, D.M.D., M.S. well as a microhybrid composite polymeri- zed with a pulse-curing technique to restore enamel. Combined with an oblique, succes- sive cusp buildup method, these techniques malgam was the material of choice worldwide can minimize polymerization shrinkage for Class I and Class II restorations for more greatly. than a century.1 Its high strength, good wear Conclusions. Selection and appropriate resistance, technique insensitivity, low cost use of materials, better placement tech- and adaptability for restoring small, medium niques and control polymerization Aand large lesions were responsible for this success.1-6 A shrinkage may result in more predictable declining acceptance of amalgam among and esthetic Class II resin-based composite restorations. To minimize clinicians and patients, however, began in the early 1980s due to some inherent Clinical Implications. By using the the stress from problems. For example, amalgam’s corro- techniques discussed by the authors, clini- polymerization sion and difficulty bonding to tooth struc- cians can reduce enamel microcracks and shrinkage, ture, along with the necessity to remove substantially improve the adaptation of efforts have sound tooth structure for retention, are resin-based composite to deep dentin. As a consequence, marginal discoloration, recur- been directed problematic.7,8 Also at issue for some rent caries and postoperative sensitivity toward people are its lack of esthetics and fears about potential mercury toxicity.1,5-9 The can be reduced, and longevity of these resto- improving need for amalgam alternatives has been rations potentially can be improved. placement a topic in the dental literature for several techniques, years. material and Resin-based composites were advo- difficulties in achieving good proximal composite cated as a possible solution to this contact and contour, polymerization formulation, problem because they were mercury-free shrinkage and poor dentin marginal and thermally nonconductive, and they adaptation.10-14 To avoid these shortcom- and curing matched the shade of natural teeth and ings, indirect resin-based composite and methods. bonded to tooth structure readily with ceramic inlays were introduced,15 the use of adhesive systems. Histori- spurning intensive research on resin- cally, dentists who used resin-based composites to based composites. restore posterior teeth experienced poor wear resistance, In the past 10 years, a dramatic JADA, Vol. 133, October 2002 1387 Copyright ©2002 American Dental Association. All rights reserved. COSMETIC & RESTORATIVE CARE improvement in newer-generation bonding agents technique that is associated with the use of a and resin-based composite formulations has clear matrix and reflective wedges. It attempts to occurred. The improved performance of resin- guide the polymerization vectors toward the gin- based composites and the increasing demand for gival margin. esthetics are encouraging more clinicians to dOblique technique. In this technique, wedge- select resin-based composites for posterior resto- shaped composite increments are placed to fur- rations.16-19 Although wear resistance of contem- ther prevent distortion of cavity walls and reduce porary resin-based composites has improved sig- the C-factor. This technique may be associated nificantly19-22 and good proximal contact and with polymerization first through the cavity contour can be achieved,23-25 polymerization walls and then from the occlusal surface to direct shrinkage remains the biggest challenge in direct vectors of polymerization toward the adhesive resin-based composite restorations.26-29 surface (indirect polymerization technique).28,38 dSuccessive cusp buildup technique.39-41 In this METHODS AND MATERIALS technique, the first composite increment is Polymerization shrinkage is responsible for the applied to a single dentin surface without con- formation of a gap between resin-based com- tacting the opposing cavity walls, and the resto- posite and the cavity wall. This gap may vary ration is built up by placing a series of wedge- from 1.67 to 5.68 percent of the total volume of shaped composite increments to minimize the the restoration,30 and it may be filled with oral C-factor in 3-D cavity preparations. Each cusp fluids. Oral fluids contain bacteria, which may be then is built up separately. responsible for postoperative sensitivity and Direct shrinkage. A chemically cured resin- recurrent caries.31 When resin-based composites based composite is used on the gingival floor in are cured, they shrink, and a residual polymeri- an attempt to direct the vectors of polymerization zation stress is generated, which may be toward the warmer cavity walls. This should help responsible for bonding failure. Stress from po- to reduce the gap at the cervical margin.23,42,43 lymerization shrinkage is influenced by restora- Bulk technique. The bulk technique is recom- tive technique, modulus of resin elasticity, po- mended by some authors to reduce stress at the lymerization rate, and cavity configuration or cavosurface margins.34,44 Some manufacturers “C-factor.” The C-factor is the ratio between recommend using this technique with packable bonded and unbonded surfaces32; an increase in composites even though this is not supported by this ratio results in increased polymerization a recent study.45 Rueggeberg and colleagues46 stress. Three-dimensional cavity preparations showed that the depth of cure does not exceed (Class I) have the highest (most unfavorable) more than 2 mm when curing resin-based com- C-factor because only outer unbonded surfaces posites with modern light-curing units. absorb stress. To minimize the stress from po- Resin-based composite materials. In the lymerization shrinkage, efforts have been past 20 years, resin-based composites have been directed toward improving placement techniques, improved by reducing particle size, increasing material and composite formulation, and curing filler quantity, improving adhesion between filler methods. and organic matrix, and using low-molecular- Placement techniques and issues. The weight monomers to improve handling and po- incremental technique. This technique is based lymerization.8,47-51 By experimenting with particle on polymerizing with resin-based composite size, shape and volume, manufacturers have layers less than 2-millimeters thick33,34 and can introduced resin-based composites with differing help achieve good marginal quality, prevent dis- physical and handling properties (Table 1). tortion of the cavity wall (thus securing adhesion Microfill, hybrid, microhybrid, packable and flow- to dentin) and ensure complete polymerization of able composites now are available to be used for the resin-based composite. Following are vari- varying clinical situations (Table 2). ances related to differing stratifications: Microfills. Microfills are 35 to 50 percent filled dHorizontal technique.28,34,35 This technique is by volume and have an average particle size an occlusogingival layering generally used for ranging from 0.04 to 0.1 micrometer. They have small restorations; this technique increases the low modulus of elasticity and high polishability; C-factor. however, they exhibit low fracture toughness and dThree-site technique.36,37 This is a layering increased marginal breakdown. 1388 JADA, Vol. 133, October 2002 Copyright ©2002 American Dental Association. All rights reserved. COSMETIC & RESTORATIVE CARE TABLE 1 RESIN-BASED COMPOSITES CLASSIFICATION AND PHYSICAL PROPERTIES. COMPOSITE AVERAGE PARTICLE FILLER PERCENTAGE PHYSICAL PROPERTIES† TYPE SIZE (MICROMETERS) (VOLUME %)* Wear Fracture Polishability Resistance Toughness Microfill 0.04-0.1 35-50 E F E Hybrid 1-3 70-77 F↔G‡ E G Microhybrid 0.4-0.8 56-66 E E G Packable 0.7-20 48-65 P↔G‡ P↔E‡ P Flowable 0.04-1 44-54 P P F↔G‡ * Sources: Kugel,47 Wakefield and Kofford50 and Leinfelder and colleagues.53 † E: Excellent; G: good; F: fair; P: poor. ‡ Varying among the same type of resin-based composite. Hybrids. Hybrids TABLE 2 are 70 to 77 percent filled by volume and CLINICAL INDICATIONS OF RESIN-BASED COMPOSITES. an average particle COMPOSITE TYPE CLINICAL INDICATIONS size ranging from 1 to 3 µm. They do not Microfill Enamel replacement in Class III, IV and V restorations Minimal correction of tooth form and localized maintain a high polish discoloration but do have improved Hybrid Posterior resin-based composite restoration physical properties Class V restoration when compared with Dentin build-up in Class III and IV restoration microfills. Microhybrid Posterior and anterior direct composite restoration Microhybrids. Micro-
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