d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 2938

available at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/dema

Review

Resin compositeState of the art

Jack L. Ferracane
Department of Restorative Dentistry, Oregon Health & Science University, Portland, OR 97239, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: The objective is to review the current state of the art of dental composite mate-
Received 7 October 2010 rials. Methods: An outline of the most important aspects of dental composites was created,
Accepted 22 October 2010 and a subsequent literature search for articles related to their formulation, properties and
clinical considerations was conducted using PubMed followed by hand searching citations
from relevant articles. Results: The current state of the art of dental composites includes a
wide variety of materials with a broad range of mechanical properties, handling character-
istics, and esthetic possibilities. This highly competitive market continues to evolve, with
Keywords: the major emphasis in the past being to produce materials with adequate strength, and
Dental composite high wear resistance and polishability retention. The more recent research and develop-
Composition ment efforts have addressed the issue of polymerization shrinkage and its accompanying
Properties stress, which may have a deleterious effect on the composite/tooth interfacial bond. Cur-
Placement rent efforts are focused on the delivery of materials with potentially therapeutic benets
Review and self-adhesive properties, the latter leading to truly simplied placement in the mouth.
Signicance: There is no one ideal material available to the clinician, but the commercial
materials that comprise the current armamentarium are of high quality and when used
appropriately, have proven to deliver excellent clinical outcomes of adequate longevity.
2010 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2. Dental composite formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.1. Types of dental composites and their development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.2. Composition of current composites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.3. Future developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3. Properties of dental composites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.1. Current materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.2. Future enhancements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4. Important clinical considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.1. Placing dental composites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.2. Finishing, polishing and repairing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.3. Clinical outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5. Final thoughts and perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Corresponding author.
E-mail address: [email protected]
0109-5641/$ see front matter 2010 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2010.10.020
30 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 2938

Fig. 1 A perspective on the evolution of dental composites.

reached at any particular time usually as a result of mod-

1. Introduction ern methods. (Mirriam Webster Dictionary) When discussing
patentable ideas, this has been more precisely dened (Euro-
The composition of resin-based dental composites has pean Patent Convention) as [the] state of the art shall be held
evolved signicantly since the materials were rst introduced to comprise everything made available to the public by means
to dentistry more than 50 years ago (Fig. 1). Until recently, of a written or oral description, by use, or in any other way,
the most important changes have involved the reinforcing before the date of ling of the European patent application.
ller, which has been purposely reduced in size to produce Thus an idea may be based on prior art, but only is considered
materials that are more easily and effectively polished and to be new if it does not form part of the current state of the
demonstrate greater wear resistance. The latter was especially art. Thus, the state of the art is constantly in ux. Further, the
necessary for materials used in posterior applications, but the state of the art is usually distinguishable from what might be
former has been important for restorations in all areas of the termed the standard of care, or the material/technique that
mouth. Current changes are more focused on the polymeric generally has been adopted by the profession for a specic
matrix of the material, principally to develop systems with purpose.
reduced polymerization shrinkage, and perhaps more impor- This difference between state of the art and standard of
tantly, reduced polymerization shrinkage stress, and to make care is made more evident when one examines the devel-
them self adhesive to tooth structure. Several articles recently opment of dental composites and follows the path of a new
have reviewed the current technology of dental composites material (Fig. 2). When a new dental composite material is
[1,2] and described future developments, such as self-repairing conceived by an individual or a company, a patent application
and stimuli-responsive materials [3]. The current review will is typically led to protect the concept. At the same time, or
provide a brief historical perspective on dental resin compos- at some time in the future, the concept is reduced to practice,
ites to serve as a framework for a treatise on the current state providing a material that has application for a specic purpose
of the art, primarily concentrating on work published in the or set of purposes. The material comprises a portion of the
past 5 years. current state of the art by virtue of its publication or presen-
Resin composites are used for a variety of applications tation to the profession. However, the material must proceed
in dentistry, including but not limited to restorative materi- through a more elaborate path to be considered a part of the
als, cavity liners, pit and ssure sealants, cores and buildups, current standard of care. In the ideal process, this requires
inlays, onlays, crowns, provisional restorations, cements for a demonstration that the material is clinically efcacious. In
single or multiple tooth prostheses and orthodontic devices, other words, it must be shown to be used successfully in a con-
endodontic sealers, and root canal posts. It is likely that the trolled situation, such as a clinical trial. However, as has been
use of these materials will continue to grow both in frequency seen many times, there is no guarantee that such a material
and application due to their versatility. The rapidity by which will be shown also to be clinically effective when provided to
the materials have evolved suggests a constantly changing all general practitioners for general use.
state of the art. A material cannot achieve the level of standard of care,
The state of the art is dened as the level of develop- as dened by the degree of care or competence that one is
ment (as of a device, procedure, process, technique, or science) expected to exercise in a particular circumstance or role,
 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 2938 31

composites has been bis-GMA, which due to its high viscos-

ity is mixed with other dimethacrylates, such as TEGDMA,
UDMA or other monomers [5]. Some of these monomers, or
modied versions of them, also serve as base monomers in
many commercial materials. While there have been attempts
to develop different polymerization promoting systems, most
composites are light-activated, either as the sole polymer-
ization initiator or in a dual cure formulation containing a
chemically cured component. The most common photoini-
tiator system is camphoroquinone, accelerated by a tertiary
amine, typically an aromatic one [6]. Some commercial for-
mulations have included other photoinitiators, such as PPD
(1-phenyl-1,2-propanedione) [7], Lucirin TPO (monoacylphos-
phine oxide), and Irgacure 819 (bisacylphosphine oxide) [8],
which are less yellow than CQ and thus potentially more color
stable. Additional photoinitiators, such as OPPI (p-octyloxy-
phenyl-phenyl iodonium hexauoroantimonate) have been
Fig. 2 The pathway through the state of the art toward proposed based on encouraging experimental results [9].
building the standard of care. The different types of composite materials are distin-
guished by their consistency. The universal restorative capable
of being placed with a syringe or instrument may have a vari-
(Merriam-Websters Dictionary of Law) until it has been ety of consistencies depending upon its formulation. These
broadly accepted by the profession for its intended purpose(s). materials are distinguished from the owable composites,
If efcacy and/or effectiveness cannot be proven for the new designed to be dispensed from very ne bore syringes into
composite, then it may simply fade into history as many other tight spaces for enhanced adaptation, and from the packable
good ideas. If the material does prove to be effective, it may composites, designed to provide signicant resistance to an
still not become the standard of care, perhaps because there amalgam condenser or other instrument in order to avoid
are better options available that are easier to use, of lower slumping and to enhance the formation of tight interproximal
cost, or have some other benet. The material may simply contacts. Flowable composites are typically produced with a
then become a useful adjunct to the current standard of care. lower viscosity by reducing the ller content of the mixture, or
The standard of care is also uid, and a material that was the by adding other modifying agents, such as surfactants, which
standard may simply with time relapse to becoming a use- enhance the uidity while avoiding a large reduction in ller
ful adjunct or just another good idea. Thus, the state of the content that would signicantly reduce mechanical properties
art and the standard of care are likely to be very different. and increase shrinkage [10]. Packable composites achieve their
This is emphasized by the fact that the time from which a thicker consistency through modication of the ller size dis-
new idea/practice option is introduced to when it becomes tributions or through the addition of other types of particles,
accepted by the majority of dental practitioners may be more such as bers, but generally not by increasing overall ller level
than 10 years [4]. [11].
Describing the state of the art in dental composites requires Within each type of composite, the materials are further
a discussion of the formulation of current materials and the distinguished by the characteristics of their reinforcing llers,
potential for future developments, the properties and limita- and in particular their size (Fig. 3). Conventional dental com-
tions of the currently marketed products, and the important posites had average particle sizes that far exceeded 1 m, and
considerations for their clinical use. This manuscript will dis- typically had llers close to or exceeding the diameter of a
cuss each of these issues. human hair (50 m). These macroll materials were very
strong, but difcult to polish and impossible to retain sur-
face smoothness. To address the important issue of long-term
2. Dental composite formulation esthetics, manufacturers began to formulate microll com-
posites, admittedly inappropriately named at the time, but
2.1. Types of dental composites and their development probably done to emphasize the fact that the particles were
microscopic. In truth, these materials were truly nanocom-
Dental composites can be distinguished by differences in posites, as the average size of the amorphous spherical silica
formulation tailored to their particular requirements as reinforcing particles was approximately 40 nm. The eld of
restoratives, sealants, cements, provisional materials, etc. nanotechnology is dened at the nanoscale, and includes the
These materials are similar in that they are all composed 1100 nm size range. Thus, the original microlls would have
of a polymeric matrix, typically a dimethacrylate, reinforcing more accurately been called nanolls, but likely were not
llers, typically made from radiopaque glass, a silane cou- due to the lack of recognition of the concept of nano at the
pling agent for binding the ller to the matrix, and chemicals time. The ller level in these materials was low, but could be
that promote or modulate the polymerization reaction. The increased by incorporating highly lled, pre-polymerized resin
many types of llers in use recently have been reviewed [1]. llers (PPRF) within the matrix to which additional microll
The predominant base monomer used in commercial dental particles were added.
32 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 2938

Fig. 3 The chronological development of the state of the art of dental composite formulations based on ller particle
modications.

The microll composites were polishable but generally be due to the incorporation of pre-polymerized resin llers
weak due to their relatively low ller content, and a com- [18]. Regarding clinical evaluations, two recent studies over
promise was needed to produce adequate strength with 2 and 4 years, respectively, showed similar excellent results
enhanced polishability and esthetics. Therefore, the particle in class II cavities for a nanoll vs. a microhybrid [19] and
size of the conventional composites was reduced through nanohybrid vs. a microhybrid, with slight evidence for better
further grinding to produce what was ultimately called marginal integrity for the micro-hybrid in the latter study [20].
small particle hybrid composites. These were further dis-
tinguished as midills, with average particle sizes slightly 2.2. Composition of current composites
greater than 1 m but also containing a portion of the 40
nm-sized fumed silica microllers. Further renements The state of the art of the composition of dental compos-
in the particle size through enhanced milling and grinding ites has been changing rapidly in the past few years. The
techniques resulted in composites with particles that were nanoll and nanohybrid materials represent the state of the
sub-micron, typically averaging about 0.41.0 m, which art in terms of ller formulation [1,2]. Comprehensive elec-
initially were called minills [12] and ultimately came tron microscopy and elemental analysis has been performed
to be referred to as microhybrids. These materials are on many current composites to verify the signicant differ-
generally considered to be universal composites as they ences in ller composition, particle size and shape [21]. New
can be used for most anterior and posterior applications options for reinforcing llers generally have focused on nano-
based on their combination of strength and polishability. The sized materials and hybrid organic-inorganic llers [1]. Years
most recent innovation has been the development of the ago, novel organically modied ceramics (ORMOCERS) were
nanoll composites, containing only nanoscale particles. developed [22] and have been used in commercial products.
Most manufacturers have modied the formulations of their However, signicant progress has been made in the devel-
microhybrids to include more nanoparticles, and possibly opment of new monomers for composite formulations with
pre-polymerized resin llers, similar to those found in the reduced polymerization shrinkage or shrinkage stress, as well
microll composites, and have named this group nanohy- as those with self-adhesive properties.
brids. In general, it is difcult to distinguish nanohybrids The epoxy-based silorane system used in Filtek Silorane
from microhybrids. Their properties, such as exure strength LS (3 M ESPE) [23], provides veried lower shrinkage than
and modulus, tend to be similar, with the nanohybrids as typical dimethacrylate-based resins, likely due to the epox-
a group being in the lower range of the microhybrids, and ide curing reaction that involves the opening of an oxirane
both being greater than microlls [13,14]. While some have ring. This commercial composite has been shown to have
shown evidence for reduced stability during water storage good mechanical properties [15,24]. In one clinical study,
for nano-hybrid or nano-ll composites vs. microhybrids [15], the marginal quality of the silorane composite was shown
others have shown an opposite trend [16] or fairly similar to be somewhat inferior to that of a nanohybrid compos-
susceptibility to aging [17]. It has been suggested that the ite [25]. Perhaps this is not surprising in that contraction
slightly lower properties of some nanohybrid composites may stress, and not contraction itself, is considered to be the
 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 2938 33

more important phenomena, and it has been shown that It is expected that universal restorative materials based on
Silorane LS does not produce lower contraction stress than the self-adhesive monomers being used or proposed in the
other composites [26]. Others have experimented with other owable systems also will be forthcoming.
monomers, such as tetraoxaspiroundecane (TOSU), added to Other areas of development have included the incorpora-
silorane systems and showed stress reduction, but the reduced tion of anti-bacterial agents and remineralizing agents into
stress may also be due in part to a reduction in mechanical composites. Examples of compounds that have been added
properties [27]. to resin composites to kill bacteria or inhibit biolm forma-
Other monomers with increased molecular weight have tion include uoride [32,33], chlorhexidine [40], zinc oxide
been developed for composites with reduced shrinkage. The nanoparticles [41], quaternary ammonium polyethyleneimine
modied urethane dimethacrylate resin DX511 from Dupont nanoparticles [42], and MDPB monomer [43]. The effectiveness
found in Kalore (GC) is said to reduce shrinkage due to its of the various uoride-releasing restorative materials have
relatively high molecular weight compared with bis-GMA and been critically reviewed, and it was concluded that the clinical
traditional UDMA (895 g/mole vs. 512 g/mole vs. 471 g/mole, results are not conclusive for dental restorative materials,
respectively). The urethane monomer TCD-DI-HEA found in including composites [44]. Remineralization may be promoted
Venus Diamond (Kulzer) has been shown to produce lower by the slow release of calcium and phosphate ions followed by
polymerization contraction stress than other composites the precipitation of new calcium-phosphate mineral [32,33].
marketed as low-shrinking [26]. The dimer acid monomers Years ago a material was developed which was purported to
used in NDurance (Septodont) are also of relatively high exhibit smart release of these ions as a result of an acidic
molecular weight, i.e. 673849 g/mole, and have been shown challenge, as occurs during caries formation. This material,
to have high conversion of carbon double bonds while under- Ariston pHc, was not ultimately successful, in large part due
going lower polymerization shrinkage than bis-GMA-based to the fact that it absorbed too much water which affected its
systems [28,29]. dimension and properties. But the idea of a smart material
The latest trend has been toward the development of that reacts to its environment to release remineralizing ions
owable composites containing adhesive monomers, such as or anti-microbial agents is attractive and still a focal point of
Vertise Flow (Kerr) and Fusio Liquid Dentin (Pentron Clinical). research.
These formulations are based on traditional methacry-
late systems, but incorporating acidic monomers typically
found in dentin bonding agents, such as glycerolphosphate 3. Properties of dental composites
dimethacrylate (GPDM) in Vertise Flow, which may be capa-
ble of generating adhesion through mechanical and possibly 3.1. Current materials
chemical interactions with tooth structure. These materials
are currently recommended for liners and small restorations, Current dental composites have adequate mechanical proper-
and are serving as the entry point for universal self-adhesive ties for use in all areas of the mouth. But concern still exists
composites. when the materials are placed in high stress situations, espe-
cially in patients with bruxing or parafunctional habits. The
2.3. Future developments concern here is for fracture of the restoration as well as wear.
Wear is considered to be a lesser problem for current mate-
A recent review noted that efforts to modify llers have rials as compared to those that were the standard of care a
been aimed at improving the properties of composites by decade ago, in large part due to renement in the size of the
the addition of polymer nonobers, glass bers, and titania reinforcing llers which signicantly reduced the magnitude
nanoparticles [2]. There is also very interesting work incorpo- of abrasive wear. However, when placed in large preparations,
rating silsesquioxane nanocomposites which are essentially perhaps on several teeth in a quadrant, and when used to
an organicinorganic hybrid molecule that reduce shrink- replace cusps, the wear of these materials still warrants atten-
age, but also reduce mechanical properties if used in too tion [20].
high of a concentration [30]. Perhaps the most promising Nearly exhaustive datasets on the mechanical properties
work in composites with modied llers for both enhanced of dental composites have been presented in recent years,
mechanical properties and remineralizing potential by virtue and these informative articles can be consulted for more spe-
of calcium and phosphate release has been the work with cic information [1315]. In the authors lab, various brands of
fused silica whiskers and dicalcium or tetracalcium phosphate materials have been evaluated (Figs. 46). The data provides
nanoparticles [31,32]. These composites may be stronger and an opportunity for an overall view of the relative magnitude
tougher, but the optical properties are not ideal and their of the properties for the different composites types, and gen-
opacity requires them to be self-cured or heat-processed at erally show that mechanical properties are mostly related to
this point. Calcium uoride containing llers also have been ller content, with the composites having the most ller being
added to lled dental resins and have shown high uoride the strongest (Fig. 4), stiffest (Fig. 5), and toughest (Fig. 6).
release and good mechanical properties [33]. There are other This is not surprising, as this trend is predicted by the rule
monomers that are in various stages of development for of mixtures for composite materials. However, it is instructive
potential use in dental composites, such as the (meth)acrylate to compare the mechanical properties of dental composites
vinyl ester hybrid polymerization system which exhibits to other dental restorative materials. In general, dental com-
phase separation during curing [34], thiolene monomers [35], posites have similar exure strength, fracture toughness and
multimethacrylate derivatives of bile acids, and others [3639]. tensile strength as porcelain and amalgam, and are superior to
34 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 2938

3.2. Future enhancements

Improvements in the properties of dental resin composites

are constantly being sought. The target mechanical and phys-
ical properties are difcult to dene because there is currently
little correlation between the properties of composites and
their clinical performance. However, given that secondary
caries and fracture are the two primary reasons given for
replacement of dental composites [45], it is warranted to con-
tinue to pursue improvements in strength and toughness, as
well as shrinkage and its accompanying stress. The target
shrinkage level is likely somewhere greater than zero to allow
room for expansion due to water sorption. Current resin sys-
tems are not completely hydrophobic. The extent of water
uptake is dependent upon the monomer formulation, and a
recent study has shown lower water uptake for silorane-based
systems [46]. But as new formulations are designed to be self-
adhesive, they will most likely be even more hydrophilic than
current resins. Thus, a shrinkage level between 0.5% and 1.0%
by volume would seem to be a reasonable target, and some
systems already are at or near this level.
Regarding strength and toughness, current materials are
nearly as strong (exure, compression and tension) as dental
amalgams and porcelain, but less strong than high-strength
ceramic systems and casting alloys. This is signicant, in that
casting alloys for PFMs and the high strength ceramics, such as
those used as substructures for dental restorations, typically
do not fail by bulk fracture. Rather, the veneering porcelain
chips or delaminates [47], which is consistent with its gener-
ally low strength. Thus, because amalgams and porcelains do
fracture, and they have similar strength as dental composite, it
is likely that exure strength of several hundred MPa, equiv-
alent to that of the high strength ceramics, would be most
ideal. This is not an easy challenge, and even the inclusion
of high strength whiskers into heat-cured dental resins has
only increased the exure strength of highly lled compos-
ites to a little over 200 MPa [48]. Fracture toughness is another
important property, and may correlate with intraoral chipping
of surfaces and margins [49,50]. The best current composites
have fracture toughness below 2.0 MPa m1/2 , which is simi-
lar to amalgam and better than porcelain. However, higher
strength ceramics have fracture toughness that are 23 as
great, and this may be a reasonable target for dental com-
posites based on the statements made above with respect to
strength and fracture. Again, ber or whisker reinforcement
has produced very signicant enhancements in toughness
[48], but not to the range of high toughness ceramics or
casting alloys, and this may be what is required to ren-
der the materials essentially fracture resistant under all oral
Figs. 46 Comparison of the exure strength, exure conditions.
modulus and fracture toughness of representative
commercial composites.
4. Important clinical considerations
glass ionomers. Perhaps the property in which dental compos-
ite is most conspicuously decient in comparison to amalgam 4.1. Placing dental composites
is elastic modulus, where composite is typically several times
lower. This lower modulus may allow enhanced deforma- The primary reason for the clinical replacement of dental
tion and dimensional change on occlusal surfaces under high composites is secondary caries, followed by fracture [45]. The
stress which lead to defect formation or enhanced wear due former is proposed to be related to the polymerization shrink-
to increased surface contact. age and shrinkage stress created on the interfacial bond, as
 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 2938 35

well as the durability of this bond, and on the quality of the another study, the slumping resistance of owable compos-
placement of the restoration. The latter is due to limitations of ites also was shown to be related to the complex viscosity,
the mechanical properties of the materials, as well as to issues as one might expect [63]. Signicant variation in slumping
related to cavity design, amount and quality of supportive tendency has been shown for four commercial materials by
tooth structure, and the specic occlusion. measuring of the deformation of an uncured composite cast
Layering is the standard of care for placement of dental made from an impression [62]. Another subjective character-
composites in cavity preparations exceeding 2 mm. This pro- istic of composites is stickiness. An attempt has been made to
cedure is based on the desire to ensure as complete a cure as quantitate stickiness by measuring the force exerted against
possible by virtue of sufcient exposure of the entire incre- a plunger as it is removed from a composite mass [64]. Three
ment to the curing light, as well as to reduce the volume commercial composites have been tested by placing steel,
of contracting material to mitigate to some extent poly- dentin and bonded dentin to the bottom of the probe to mea-
merization shrinkage stresses. Various techniques have been sure stickiness to these various surfaces. [65]. Stickiness was
proposed in the literature [51,52] and many variations on the highest against dentin and lowest on bonded dentin, and
theme can be expected. The bulk curing of composite, consid- tended to increase as the temperature was increased from
ering that ample light energy was able to be transferred to the 23 to 37 C.
material, has been suggested for large preparations, but the
evidence seems largely against this approach due to concerns 4.2. Finishing, polishing and repairing
over elevated stress generation and tooth deformation [53].
However, it is important to note that little if any strong clini- The nish and polish attainable on dental resin composites is
cal data exists to support one particular composite application to some extent a function of their composition, with some
method over another. In fact, though polymerization shrink- materials demonstrating a preference for certain polishing
age and its associated stress are presumed to affect marginal methods [6668]. In the past, ne particle disks provided the
integrity and clinical performance, there is not denitive clin- best overall surface nish and gloss for most composites, but
ical data to support this hypothesis [45,54]. more recent studies suggest that while the use of successively
Due to concerns over post-operative sensitivity and achiev- ner disks are still very effective, recently developed two-
ing and maintaining adhesion to dentin, dental composite and one-step systems may be slightly better at producing the
restorations are often lined with glass ionomers or owable highest gloss for most types of dental composite [66,69]. Most
composites. Clinical evidence for enhanced longevity of class clinicians will admit that the high initial shine may be impor-
II composites with resin modied glass ionomer liners vs. tant to the patient, especially for the anterior teeth, but the
adhesive bonding exists [55], but there also is evidence for main concern of the dentist is the surface quality after months
enhanced performance of class II composite restorations rely- and years of service. One guideline suggests that a gloss level
ing solely on adhesive bonding in the proximal area [56]. of 40% is the minimum acceptable clinically [69]. All compos-
A recent study conducted in a university setting showed ites will roughen with time as the surface is exposed to the
no difference in performance for lined vs. unlined posterior erosive and abrasive effects of food, drink, and other things.
composites, though the authors noted that results in gen- Studies examining the polish retention show a difference in
eral practice may not be predicted by this clinical evaluation the maintenance of surface quality based on the ller parti-
model [57]. It is fair to say that at this time, both methods cle size, with roughness and gloss tending to increase with
for restoring class II composites represent the standard of particle size, though this is dependent upon brushing load
care. and time [70,71]. Some composites, specically nanolls and
The other important aspect with respect to placement microlls, may show a reduction in gloss during toothbrushing
of dental composites relates to their handling characteris- experiments, while microhybrid composites typically show
tics. This is evident in the way in which the practitioner has an increase in gloss after the initial stages of brushing, fol-
embraced owable composites, and the number of publica- lowed by maintenance of a steady state or slight reduction [72].
tions assessing handling properties of all types of composites, This differs from surface roughness, which typically increases
such as rheology [5860], slumping [6163], and stickiness for all types of composites during brushing, but to different
[64,65], and the development of test methods to assess these extents. The differences are most likely signicant in terms
subjective qualities. The viscosity is a property that is most of surface shine, and less important from the standpoint of
important for owable composites, and studies show that vis- plaque retention. When exposed to toothbrushing in experi-
cosity varies greatly among brands, without a correlation to ments, most nano-hybrid and micro-ll composites maintain
ller particle shape and only a weak correlation to ller vol- a surface roughness below 0.2 m, which is considered to be
ume that does not hold within a specic type of composite, i.e. the threshold for plaque retention [73]. Further, though there
within owables [58,60]. However, composites are pseudoplas- is a strong correlation between surface roughness and surface
tic, or shear-thinning materials, meaning that they become gloss, gloss has been shown to be the more sensitive char-
more uid when placed under greater shearing forces, such acteristic for measuring the retention of surface quality after
as during placement with a syringe. The slumping resistance brushing [70,71].
of the composite is related to viscosity, but is more complex. A The repair of resin dental composites is an important
slumping resistance index (SRI) has been estimated using an feature, and one that has only recently being investigated
imprint method for three commercial composites and shown through formal studies. The limited body of work in this area
to be related to shear ow resistance, with a nanoll com- was the subject of a recent review [74]. While the review
posite having a higher SRI than two microhybrids [61]. In notes that there is a deciency in randomized controlled
36 d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 2938

trials of composite repair, it does point out that recent clini- ing, both materials show higher failure rates in high caries risk
cal studies of 23-year duration have shown good outcomes patients.
for repairs or resealing of marginal defects in composites
[7577]. The most recent article describes a 7-year recall
and reinforces the success of this conservative interven-
5. Final thoughts and perspectives
tion strategy [78]. In a recent survey of general practitioners,
one half stated that they would repair a composite restora- Dental composites are versatile materials whose usage has
tion with a defective margin in enamel, though most would continued to grow since their introduction to the profession
replace the restoration if the defective margin was on dentin over 50 years ago. The expanded use of these materials in a
[79]. These results suggest that repair of composite restora- wide range of applications puts great demands on their prop-
tions with defective margins in enamel is considered state erties and performance. This demand requires an ongoing
of the art, and that it may be becoming the standard of investment in research and development and is evidenced
care. by continuous introduction of new products to the market.
The conservative nature of repairing chips, defects, stains, While the state of the art of dental composites is very uid
etc. has long been recognized as desirable, but in some cases and represents an abundance of options for the clinician,
has been considered to be a compromise in terms of the the standard of care is in general much more stable. This is
overall quality and longevity of the restoration. The repair logical in that the savvy practitioner likely demands some
method has improved little over the years, being predomi- level of clinical proof before choosing to make a signicant
nantly an exercise in attaining strong mechanical adhesion to change in their practice behavior. This should be true for
the aged surface. Attempts to expose and bond with residual all dental restorative selections. Expectations are that further
methacrylate groups have been presented, but there is little development of these materials will include enhancements in
evidence that this aspect of bonding is signicant or supe- strength and fracture resistance, reductions in polymerization
rior to mechanical adhesion. Mechanical bonding is achieved shrinkage and its associated stress, adhesion to tooth surfaces
by roughening the intra-oral surface through air abrasion, without special surface preparations or the application of sep-
phosphoric acid application to clean the surface of debris arate bonding resins, the inclusion of antibacterial agents
and etch any available enamel, application of a thin layer and/or compounds capable of enhancing their remineralizing
of unlled resin for enhanced adaptation to the roughened potential, and designed responsiveness to the changing oral
surface, followed by placement of the resin composite of environment.
choice. Recent studies also suggest that air abrasion com-
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