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1. Restorative Composite ResinsRestorative Composite Resins
Dr shabeel pn
                                                                             

2. 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

3. Overview
•Direct restoratives
–composition
–classification
–performance factors
•Flowable
•Packables
Click here for briefing on composite resins (PDF)

4. 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

5. 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

6. History
(cont.)
•1962 – Bis-GMA
–stronger resin
•1969 – filled composite resin
–improved mechanical properties
–less shrinkage
–paste/paste system
•1970’s – acid etching and microfills
•1980’s – light curing and hybrids
•1990’s – flowables and packables
•2000’s – nanofills
Rueggeberg J Prosthet Dent 2002

7. Indications
•Anterior restorations
•Posterior restorations
–preventive resin
–conservative class 1 or 2

8. Contraindications
•Large posterior
restorations
•Bruxism
•Poor isolation

9. Advantages
•Esthetics
•Conservation of tooth structure
•Adhesion to tooth structure
•Low thermal conductivity
•Alternative to amalgam

10. Disadvantages
•Technique sensitivity
•Polymerization shrinkage
–marginal leakage
–secondary caries
–postoperative sensitivity
•Decreased wear resistance

11. Composition
•Resin matrix
–monomer
–initiator
–inhibitors
–pigments
•Inorganic filler
–glass
–quartz
–colloidal silica
•Coupling Agent
OCH
2
CHCH
2
O-C-C=CH
2
CH
2
=C-C-O-CH
2
CH-CH
2
O -C-
CH
3
CH
3
CH
3
CH
3
OH OH
O O
Bis-GMA
Phillip’s Science of Dental Materials 2003

12. Monomers
•Binds filler particles together
•Provides “workability”
•Typical monomers
–Bisphenol A glycidyl methacrylate (Bis-GMA)
–Urethane dimethacrylate (UEDMA)
–Triethylene glycol dimethacrylate (TEGMA)
CH
2
=C-C-O-CH
2
CH
2
-O-C-NHCH
2
CH
2
CHCH
2
-C-CH
2
-NH-C-
CH
3
CH
3
OCH
2
CH
2
O-C-C=CH
2
CH
3
O OOO
CH
3
CH
3
OCH
2CHCH
2O-C-C=CH
2CH
2=C-C-O-CH
2CH-CH
2O -C-
CH
3
CH
3
CH
3
CH
3OH OH
O O
CH
2
=C-C-O-CH
2
CH
2
-OCH
2
CH
2
CH
3
OCH
2
CH
2
O-C-C=CH
2
CH
3
O O

13. Monomers
•Bis-GMA
–extremely viscous
•large benzene rings
–lowered by adding TEGDMA
•freely movable
•increases polymer conversion
•increases crosslinking
•increases shrinkage
CH
2
=C-C-O-CH
2
CH-CH
2
O -C- OCH
2
CHCH
2
O-C-C=CH
2
CH
3
CH
3
CH
3
CH
3
OH OH
O O

14. Monomers
•Shrinkage
–2 – 7 %
–marginal gap
formation

15. Filler Particles
•Crystalline quartz
–larger particles
–not polishable
•Silica glass
–barium
–strontium
–lithium
–pyrolytic
•sub-micron
  
                                   
Phillip’s Science of Dental Materials 2003

16. Filler Particles
•Increase fillers, increase
mechanical properties
–strength
–abrasion resistance
–esthetics
–handling
•50 to 86 % by weight
•35 to 71% by volume
0
0.5
1
1.5
2
F
r
a
c
t
u
r
e

T
o
u
g
h
n
e
s
s
02837485362
% Filler Volume
Ferracane J Dent Res 1995

17. 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
CH
3-C-C-O-CH
2-CH
2-CH
2-Si-OH
CH
2
O OH
OH
Bonds with filler
Silane
Bis-GMA
Bonds with resin
Phillip’s Science of Dental Materials 2003

18. Inhibitors
•Prevents spontaneous
polymer formation
–heat
–light
•Extends shelf life
•Butylated Hydroxytoluene
Phillip’s Science of Dental Materials 2003

19. Pigments and UV Absorbers
•Pigments
–metal oxides
•provide shading and opacity
•titanium and aluminum oxides
•UV absorbers
–prevent discoloration
–acts like a “sunscreen”
•Benzophenone
Phillip’s Science of Dental Materials 2003

20. 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
OCH
2
CHCH
2
O-C-C=CH
2
CH
2
=C-C-O-CH
2
CH-CH
2
O -C-
CH
3
CH
3
CH
3
CH
3
OH OH
O O
Bis-GMA

21. 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

22. 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
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
Ferracane

23. Classification System
•Historical
•Chronological
•Based on particle size
–traditional
–microfilled
–small particle
–hybrid
Phillip’s Science of Dental Materials 2003

24. 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
Phillip’s Science of Dental Materials 2003

25. Microfills
•Better esthetics and polishability
•Tiny particles
–0.04 micron colloidal silica
–increases viscosity
•To increase filler loading
–filler added to resin
–heat cured
–ground to large particles
–remixed with more resin and filler
Ground
polymer with
colloidal
silica (50 u)
Polymer
matrix
with
colloidal
silica
Phillip’s Science of Dental Materials 2003

26. 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

27. 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
Phillip’s Science of Dental Materials 2003

28. Hybrids
•Popular as “all-purpose”
–AKA universal hybrid, microhybrids,
microfilled hybrids
•0.6 to 1 micron average particle size
–distribution of particle sizes
•maximizes filler loading
–microfills added
•improve handling
•reduce stickiness
Silane-coated
silica or glass
Polymer
matrix with
colloidal
silica
Phillip’s Science of Dental Materials 2003

29. Hybrids
•Strong
•Good esthetics
–polishable
•Suitable
–Class 1 to 5
•Multiple available
Click here for table of hybrids

30. Property TraditionalMicrofilled
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
/ºC)
25-35 50-60 19-26 30-40
Knoop Hardness 55 5-30 50-60 50-60
Phillip’s Science of Dental Materials 2003
Table of Properties

31. Newer Classification System
•Based on particle size
–megafill
•0.5 - 2 millimeters
–macrofill
•10 - 100 microns
–midifill
•1 - 10 microns
–minifill
•0.1 - 1 microns
–microfill
•0.01 - 0.1 microns
–nanofill
•0.005-0.01 microns
•Most new systems
–minifillers
•Newest trend
–nanofillers
–trimodal loading
•prepolymerized
Bayne JADA 1994

32. Midi-filler -
2 um
(beachball)
Mini-filler -
0.6 um
(canteloupe)
Nanofiller-
.02 um (pea)
Microfiller-
.04 um
(marble)
Relative Particle Sizes
(not to scale)

33. 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

34. 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

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

36. 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
Phillip’s Science of Dental Materials 2003

37. 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

38. Polymerization Shrinkage
•Significant role in restoration failure
–gap formation
•secondary caries formation
•marginal leakage
•post-operative sensitivity
•Counteract
–lower shrinkage composites
–incremental placement

39. 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

40. 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

41. 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

42. Small Particle Hybrid Microfilled Composite
Time
Acquired Polish
Inherent Polish
Polish Mechanisms
Adept Report 1992
Linear wear pattern

43. 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

45. 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

46. 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

47. Composite Selection
•Posterior
–hybrid
•mini- or midi-fill
–reinforced microfill

48. 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

49. Government Price
($/gm of refill resin)
6.3
6.5
7.58
8.498.53
8.798.9 9
9.44
10.1510.21
11.37
9.95
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Prices current as of Jan 05

50. 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

51. 0
1
2
3
V
e n
u
s
S
u
p
r e m
e
4 S
e a s o
n
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c e
G
r a d
i a P
o
s t
D
e n
t i n
G
r a d
i a A
n
t
Radiopacity
(mm of aluminum)
Source: USAF DECS Project 03-024
ISO Requirement

52. Surface Hardness
(24 hrs)
0
10
20
30
40
Z
2
5
0
S
u
p
r e
m
e
V
i t a
l e
s
c
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V
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P
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t
Horizontal lines connect nonsignificant differences (p<0.05); N=5
Source: USAF DECS Project 03-37
KHN

53. Flexural Strength
(24 hrs)
0
20
40
60
80
100
120
140
160
Supreme 4
Seasons
Venus Gradia
Ant
PremiseGradia
Post
Horizontal lines connect nonsignificant differences (p<0.05); N=5
Source: USAF DECS Project 03-037

54. Volumetric Shrinkage
0
1
2
3
4
5
A
1
1
0
G
r a
d
i a
D
i r e
c
t
Z
1
0
0
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m
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4
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V
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n
u
s
R
e
n
e
w
E
s
t h
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t - X
F
l o
w
%
Horizontal lines connect nonsignificant differences (p<0.05); N=5
Source: USAF DECS Project 03-037

55. Composite Variants
•Packable
•Flowable

56. 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

57. Packable Composites
•Mechanical properties
–similar to hybrids
Choi J Esthet Dent 2000
Click here for abstract
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
ALERT
Solitare
SureFil
Heliomolar
Z100
Fracture
Toughness

58. 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

59. 96.9 96.2
91.2
85.1
71.5 70.370.2
55.4
41.4
22.4
0 0
0
20
40
60
80
100
Pyr-DProdigySureFilAlertSolitairePyr-E
2 mm
5 mm
Depth of Cure
Packable Composite Resin
%
Hardness
Ratio
Choi J Esthet Dent 2000 Click here for abstract

60. Packable Vs. Hybrid Composites
•Mechanical properties similar
•Wear properties similar
•Curing depths similar
•Similar proximal contacts
•Drier, denser feel
Choi J Esthet Dent 2000
Peumans Dent Mater 2001
Click here for more details

61. Flowable Composites
•Marketed
–class 1, 3, 5
–liner
•Particle size similar
to hybrid composites
•Reduced filler
content
–reduces viscosity
0
10
20
30
40
50
60
70
80
W
e
i
g
h
t

P
e
r
c
e
n
t
Percent Filler Loading
Aeliteflo
FloRestore
Revolution
Ultraseal+
Prodigy
Bayne JADA 1998
Click here for abstract

62. 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

63. Polymerization Shrinkage
0
1
2
3
4
5
A
e
l i t e
- F
l o
R
e
v
o
l u
t i o
n
W
a
v
e
F
l o
w
- i t
T
e
t r i c
F
l o
w
A
l e
r t
S
u
r e
F
i l
Z
1
0
0
H
e
l i o
m
o
l a
r
%
Tolidis JDR 1999

64. Radiopacity
•Reduced
radiopacity?
–product specific
–may be more
difficult to
distinguish on
radiograph
Murchison Quint Int 1999
Click here for abstract
0
50
100
150
200
250
Tetric Flow
Flow-it
Enamel
Revolution
FloRestore
UltraSeal+
Gray value

65. Flowable Composite
•Mechanical properties
–inferior to hybrids
0 0.51 1.52 2.5
MPa
Fracture Toughness
Prodigy
Ultraseal +
Revolution
FloRestore
Aeliteflo
0 50 100 150 200
MPa
Flexure Strength
Bayne JADA 1998
Click here for abstract

66. Flowable Composites
•Clinical applications
–preventive resin restorations
–small Class 5
–provisional repair
–composite repair
–liners??

67. Regular Material Usage*
Civilian Practitioners
•Flowable Composite81%
•Hybrid Composite 69%
•Amalgam67%
•All-Purpose Composite53%
•Microfill Composite52%
•Resin-modified Glass ionomer45%
•Packable Composite33%
•Compomer7%
•Other1%
DPR 2005*Multiple responses

68. Review of Clinical Studies
(Failure Rates in Posterior Permanent Teeth)
0
2
4
6
8
Amalgam Direct
Comp
Comp
Inlays
Ceramic
Inlays
CAD/CAM
Inlays
Gold
Inlays &
Onlays
GI
LongitudinalCross-Sectional
Hickel J Adhes Dent 2001
% Annual Failure

69. 0
5
10
15
% Annual Failure
Manhart Oper Dent 2004
Click here for abstract
Standard Deviation
Longitudinal and Cross-Sectional Data
Review of Clinical Studies
(Failure Rates in Posterior Permanent Teeth)

70. 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

71. 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

72. 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

73. Future Composites
•Low-shrinking monomers
–expanding spiroorthocarbonates
–epoxy-based resins
–liquid crystal
•Self-adhesive?
Click here for details

74. Acknowledgments
•Dr. Dave Charlton
•Dr. Jack Ferracane
•Dr. Tom Hilton
Questions/Comments
Col Kraig Vandewalle
– DSN 792-7670
– [email protected]