Clinical

Large composite restorations in

the posterior region
Markus Lenhard

Introduction rods (Shimada et al. 2003, Ikeda et al. 2002). Generally,

In many countries composites are considered the standard this corresponds to a preparation angle of 45° to the tooth
material for direct and indirect restorations in the anterior surface. As this can hardly be accurately determined in
and posterior region. The range of indications for indirect clinical situations, the following preparation guidelines
ceramic and direct composite restorations is increasingly apply:
overlapping. While in the early days composite materials Vertical preparation should be performed in areas of the
were predominantly used for small restorations, they are cusp slopes which are inclined towards the central fissures.
now becoming ever more popular for the fabrication of It is important to observe a minimum distance of 1 mm to
extensive restorations, including the reconstruction of the cusp tips. If the distance is shorter than this, the
cusps (Deliperi and Bardwell 2006, Kujis et al. 2006). In corresponding cusps should be shortened (Figures 3 and 4).
our day, the decision whether or not to restore a cavity Proximal, oral and vestibular shoulders should be
with a direct or indirect restoration largely depends on the bevelled. In the middle third of the crown, bevelling
ability of the practitioner to solve a technically challenging should be performed at a 30° angle to the horizontal axis
situation with an adequate intraoral treatment option and in the cervical crown third, the aim should be to
(Figures 1 and 2). achieve a 40° angle.
Current developments in material technology are Proximal (as well as buccal and oral) vertical margins
aimed at further reducing the shrinkage and shrinkage should be provided with an angle of approx. 45° in relation
stress of composite materials as well as streamlining the to the surface.
adhesive technique. However, not all recently developed Normally, labial, lingual and occlusal surfaces can be
materials provide restorations with improved quality. The prepared with rotating diamonds and drills without any
following report sheds light on the decisive parameters in difficulty. By contrast, appropriate preparation of proximal
the restoration of large cavities with composite materials surfaces with rotating instruments without accidentally cutting
and offers advice on the application procedure in the the adjacent teeth is hardly possible. Seventy to 100% of all
dental practice. neighbouring teeth are damaged during the preparation of
Class II cavities or crowns (Lussi 1995, Moopnar and Faulkner
Preparation 1991, Qvist et al. 1992). Lussi and Gygax (1998) observed that
The precept that the preparation margins should be 100% of the teeth adjacent to conventional Class II box
bevelled is a widespread and, unfortunately, misleading preparations showed iatrogenic damage and frequently the
generalization of the preparation guidelines for composite damage extended to deep dentin.
restorations. It is true that enamel bevelling is required to Accidental cutting of adjacent tooth surfaces during
optimize adhesion. Yet, the bevel should not be aligned in proximal preparation can be minimized by using
relation to the horizontal or vertical. Rather, the bevel sonoabrasive, oscillating instruments (Hugo and Stassinakis
should be inclined in relation to the direction of the enamel 1998, Krejci et al. 1998, Hugo 1999, Wicht et al. 2002).
These instruments are used in conjunction with tips that
are coated with diamonds on only one side for proximal
Associate lecturer, Department of Restorative Dentistry and
Periodontology, University of Heidelberg, Germany cavity preparation (Figure 5). It is recommended that dental
Private Practice, Zurich, Switzerland practitioners use the system from KaVo. The following tips

48 INTERNATIONAL DENTISTRY SA VOL. 11, NO. 5

 Clinical

Figure 1: Initial situation. Inadequate amalgam restorations with Figure 2: Situation after direct restoration of the teeth with Tetric
fractured lingual wall. EvoCeram, A3 (Ivoclar Vivadent).

Figure 3: Preparation through the cusp tips: Disintegration of the Figure 4: Schematic representation of preparation design in the
enamel-composite cement bond and fracture of the disto-lingual cusp occlusal area. 1 = correct preparation in the area of the cusp slopes; 2
in the indirect restoration. = incorrect preparation; too close to the cusp tips and, consequently,
mostly parallel to enamel rods; 3 = correct preparation, to avoid
situation 2.

are particularly suitable in conjunction with composite composite restorations. However, the studies carried out to
restorations: date have consistently shown that optimum enamel
Slot cavities: SONICflex bevel tip nos 58 + 59 adhesion can only be attained in conjunction with
Large cavities: SONICflex micro (hemisphere, large), phosphoric acid etching (Gaur et al. 2004, Gomes et al.
nos 31 + 32 2004, Frankenberger and Tay 2005, Frankenberger et al.
Deep proximal shoulders: SONICflex prep ceram 2008). Placing a composite restoration without phosphoric
Conventional preparation diamonds (90 µ grit size) result acid etching may considerably reduce the bonding quality
in crack formation in the adjacent enamel (Xu et al. 1997). of large restorations in particular, as these restorations are
To eliminate these microcracks, all enamel margins should subject to increased polymerisation shrinkage stresses. It is
be re-finished with finishing diamonds. Tooth surfaces that recommendable to use conventional etch-and-rinse
are prepared with oscillating instruments do not require re- adhesives (previously known as total-etch adhesives). The
finishing because of the fine grit size of these tips. enamel should be conditioned with phosphoric acid for at
least 30s and the dentin for no longer than 10s.
Adhesive technique Those dental professionals who prefer to use a self-etch
Self-etch adhesives, including what are known as all-in-one adhesive should not, under any circumstances, utilize an
products, are employed increasingly more frequently in all-in-one system. Rather, they should opt for a self-etch

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Figure 5: Preparation of the proximal marginal bevel with an oscillating Figure 6: Defective light guide. The dark fibres are no longer capable
tip (SONICflex no. 59). of transmitting light.

system that involves the application of a primer and curing light with an output performance of 600 mW/cm2
bonding agent in two individual, consecutive steps is used, the curing time is 20 seconds. The manufacturer’s
(Frankenberger and Tay 2005). In addition, the enamel light output data always indicate the light output at the
should first be selectively etched for 30s. If this procedure light emission window of the light guide. However, as the
is followed, the advantages of phosphoric acid etching on beam path diverges when the light leaves the light
enamel can be combined with the advantages of the self- emission window, the actual light density decreases with
etch technique on dentin, e.g. low technique sensitivity increasing distance between the light emission window
(Schulze et al. 2002, Giachetti et al. 2006) and low and the restoration. When modern curing lights,
postoperative sensitivity (Unemori et al. 2004, particularly in conjunction with what are known as turbo or
Frankenberger et al. 2008). focussing light guides, are used, this loss in light intensity
is approx. 50% if the distance between the light guide tip
Polymerization and composite surface is 5 mm. If the distance to the
The appropriate polymerization of the individual composite restoration surface is 1 cm, the loss in intensity may be in
layers is, at present, probably one of the most critical the region of 80% and higher (Felix and Price 2003).
aspects affecting the longevity of a composite restoration. Hence, two important rules come into play when
Insufficient polymerization results in inferior physical polymerizing composite materials:
properties, such as reduced flexural strength, compressive 1. The light guide should be held as close to the restoration
strength, wear resistance and shade stability. Generally, surface as possible.
curing lights which produce light intensities of less than 2. As it is impossible to avoid a gap in many situations (e.g.
400 mW/cm2 are unfit for clinical applications and fail to first composite layer in a proximal box), the curing time,
provide appropriate polymerization. In Germany, a study, which has been determined with the help of the Total Energy
which is considered representative (Ernst et al. 2006), Concept, should be prolonged by a factor of 1.5 to 2.
showed that more than 25% of the curing lights used in It is essential to know how high the actual energy density
dental practices fail to achieve the minimally required value. (intensity) of the light-curing unit in use is to ensure
The Total Energy Concept is a useful tool to determine appropriate polymerization. Ernst et al. (2006) showed
the appropriate light-curing time of composite materials that, in their advertising materials, many manufacturers
(Koran and Kürschner 1998). This concept is based on the indicate energy densities that are clearly too high for their
fact that a composite material requires, on average, an curing lights. Commercial radiometers are currently not
energy dose of 12,000 to16,000 mJ to properly polymerize suitable for measuring the absolute output value; they are
on the surface. If we assume that a value of 12,000 only useful for monitoring the performance of a curing
mJ/cm2 (or mWs/cm2) presents a sufficiently high energy light over time. This means that a source of error, over
dose, a light-curing unit which provides an energy density which the practitioner has hardly any control, is present.
of 1,200 mW/cm2 has to be allowed an emission time of 10 Like any other equipment, modern light-curing lights
seconds to ensure an appropriate cure. Accordingly, if a also require regular maintenance and care to work

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Figure 7: Initial situation: The mesio-buccal cusp of tooth 26 has Figure 8: Situation after the amalgam filling has been removed. Cracks
fractured because of the expansion of an existing amalgam filling. have formed in the region of the cavity.

efficiently. It can be assumed that approx. 50% of the light However, shrinkage alone is not the most decisive
guides used in dental practices are defective and/or soiled material-related parameter which comes into play in
with composite or bonding material (Ernst et al. 2006) (Fig. preventing the formation of marginal gaps (microleakage).
6). Depending on how severe the defect or soiling is, the Hooke’s law provides a useful approximation when looking
light guides may make it impossible for the composite at the deformation of solid materials. The following
materials to polymerize properly. equation applies to small deformations:
Some state-of-the-art curing lights are equipped with Stress (i.e. shrinkage stress) = shrinkage x modulus of
soft-start or ramp-cure programs. If these programs are elasticity
used, the composite material is initially irradiated with a The shrinkage-induced forces, which affect the adhesion
reduced light intensity and exposed to the full light to cavity walls (known as shrinkage stress), are essentially
intensity only after 5 to 10s. These methods promote a influenced by the modulus of elasticity. A high modulus of
longer pre-gel phase (Feilzer and Davidson 1997) to allow elasticity, or, in other words, a low degree of elasticity, results
light-cured composite materials to reduce stress more in high shrinkage stress during polymerization shrinkage
effectively by internal flow dyamics. However, the clinical (Kleverlaan and Feilzer 2005, Lu et al. 2004b) and, as a
relevance of the achievable stress reduction is questionable consequence, marginal gap formation is increased
in modern composites designed for fast polymerization, as (Ferracane and Mitchem 2003). If the modulus of elasticity
the largest proportion of the stress tends to occur only at is too low, only a small amount of shrinkage stress is
the end of the post-gel phase and, in addition, the soft- produced, but such a material would not be able to
start-induced reduction in stress may sometimes involve a withstand the masticatory forces in the oral cavity in the long
decrease in the conversion rate (Flemming et al. 2007, run. For this reason, the modulus of elasticity of composites
Hofmann and Hunecke 2006, Lu et al. 2005, Lu et al. should range between 8 and 11 GPa in the occlusal load
2004a). bearing region (Unterbrink and Liebenberg 1999).
Against such a background, polymerization at maximum The above equation presents a simplification of the
intensity may be carried out as standard procedure (except actual situation, as it would be necessary to take the
for composite layers close to the pulp). dynamic development of the two physical properties into
account to provide an accurate statement.
Layering technique and marginal gaps In actual fact, the degree of shrinkage stress does not
The layering technique continues to present the most correlate with the degree of shrinkage. However, a close
effective method to both compensate for volumetric relationship exists between the shrinkage stress and
shrinkage, which occurs during polymerization, and reduce modulus of elasticity (Feilzer et al. 1990, Aarnts et al. 1999).
shrinkage-induced polymerization stresses. The more the The shrinkage of composites can be reduced by
total material volume of a restoration is divided into increasing the amount of inorganic fillers. However, an
individually light-cured increments, the better is the bond increase in the amount of inorganic fillers leads to an
to the cavity walls (Nikolaenko et al. 2004, Félix et al. 2007). increase in the modulus of elasticity and shrinkage stress

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Figure 9: Completed preparation. The cusps have been shortened by Figure 10: Situation after placing a matrix band (ComposiTight,
approx. 1.5 mm and the marginal areas have been finished with Garrison). Selective enamel etching with phosphoric acid.
finishing diamonds. The proximal margins have been bevelled with an
oscillating instrument (SONICflex, hemisphere, large, KaVo).

Figure 11: Situation after application of self-etch primer liquid. The Figure 12: Situation after application of two-component AdheSE
primer has to be thoroughly dried after completion of the reaction bonding agent. Pooling of excess bonding liquid on the proximal
time. Like all self-etch materials, the primer contains water as solvent. shoulder should be avoided, as bonding agents are not radiopaque
The vapour pressure of water is relatively low (47mm Hg at 37° C, and, if present in excess, may look like gaps on bite-wing radiographs.
Weast 1970) and therefore water evaporates rather slowly.
Evaporation has to be helped with an air syringe, as residual water
may prevent the formation of an optimum hybrid layer.

(Sabbagh et al. 2002, Kleverlaan and Feilzer 2005, Lu et C = bonded surface area / unbonded surface area
al. 2004, Condon and Ferracane 2000). The higher the C-factor is, i.e. the ratio of the bonded
Therefore, the marginal gap behaviour of a composite surface area to the unbonded surface area, the more cavity
material that demonstrates low shrinkage but a high walls compete for adhesion and the more shrinkage stress
modulus of elasticity may not be better than that of a is produced (Feilzer et al. 1987, Choi et al. 2004,
composite with more shrinkage but a lower modulus of Nikolaenko et al. 2004, Wattanawongpitak 2006, Moreira
elasticity. While the marketing statements of most da Silva et al. 2007).
manufacturers aim at presenting low shrinkage values; An average Class I restoration features a C-factor of
such information is not useful if the modulus of elasticity is approx. 4 (Macorra and Gomez-Fernandez 1996). By
not included. contrast, the C-factor of a Class IV restoration is usually
The C-factor (configuration factor) is the most decisive lower than 1.
non-material-related parameter, affecting the resulting If a restoration is built up using a layering technique, the
shrinkage stress to a larger extent than any other factor. C-factor of each individual increment should, in theory, be
The C-factor describes the ratio of the bonded surface area considered. However, as composite materials are subject to
to the unbonded surface area of a composite restoration post-shrinkage upon completion of the exposure time and
(Feilzer et al. 1987): 90% of the total shrinkage is only achieved after 5 minutes

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Figure 13: Situation after application of an initial thin layer (< 0,5 mm) Figure 14: The first layer of a nano-optimzied fine-hybrid composite is
of flowable Tetric EvoFlow composite. The flowable composite is first applied horizontally.
applied to the cavity floor, then distributed on all cavity walls with a
brush and polymerized.

Figure 15: Additional increments are placed at an angle to build up the Figure 16: After the proximal wall has been re-built, the matrix band
proximal walls. Correct reconstruction of the height of the proximal may be removed to obtain a better view of the treatment area.
ridge is important to minimize the necessity for final adjustments. The
marginal ridge of the neighbouring tooth can be used as point of
reference for this purpose.

(Sakaguchi et al. 1992), the restoration is prone to shrinkage restorations (Unlu et al. 2003, Yazici et al. 2003,
"en bloc" to a certain degree regardless of the shrinkage of Wattanawongpitak 2006, Cunha et al. 2006). However,
the individual layers. Therefore, the C-factor of the entire the presence of this effect is not undisputed in the scientific
cavity is also of relevant importance. In this context, the literature (Lindberg et al. 2005). If an initial layer of a
restoration of large cavities including the build-up of cusps flowable composite is applied, the thickness of this layer
appears to offer an advantage as the C-factor of such a should not exceed 0.5 mm.
restoration is considerably lower because the natural cusps
are shortened and built-up with composite material. Clinical procedure
The ideal thickness of the increment is 2 mm when the Generally, it is preferable to apply a rubber dam. The use of
layering technique is used. Layer thicknesses larger than 3 a rubber dam does not have an effect on the survival rate
mm should be avoided at any cost, as most composites of composite restorations (Raskin et al. 2000); however,
cannot be appropriately polymerized when applied in thick rubber dam application provides a better view of the
layers. Opaque dentin shades in particular should not be treatment area and enables are more efficient working
applied in layers thicker than 2 mm. procedure (Figures 7 and 8).
A number of studies have shown that the application of The preparation is performed according to the above
an initial thin layer of a flowable composite has a described guidelines. The cusps should be shortened by
favourable effect on the marginal quality of composite approx. 1.5 mm (Figures 8 and 9), if the preparation margin

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Figure 17: The main axis of the cusp slopes should be determined Figure 18: A line of composite is administered directly from the Cavifil
before starting to build up the cusps. into the preparation. The material is applied in the direction of the
main axis of the cusp.

Figure 19: The microbrush is the most important sculpting instrument, Figure 20: The crista transversa is reconstructed first.
both for forming the cusps and for adapting the proximal layers.

Figure 21: Reconstruction of the mesio-buccal cusp. Figure 22: Completion of the mesio-palatal cusp. Generally, the fissures
should be reconstructed to be as deep as possible. This reduces the C-factor
of the restoration and helps to obtain a correct occlusion more easily.

is situated too close to the cusp tips or if cracks, which make sure that the height of the matrix band does not
may have been caused by the expansion of previous exceed the height of the marginal ridge of the
amalgam restorations, are present in the tooth structure. neighbouring tooth in order to maintain an unobstructed
When the matrix band is placed, care should be taken to view of the treatment area (Figure 8).

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Figure 23: Reconstruction of the disto-palatal cusp. Figure 24: Contouring of the marginal ridge.

advisable to use a composite in a Cavifil or single-dose

delivery form for this purpose, so that the material can be
administered directly from the container onto the tooth
surface (Figure 18). The volume of the individual increment
plays a less important role when reconstructing the cusps,
as the C-factor of these increments is very low. However, it
may be necessary to light-cure the individual increments
from two sides to ensure an appropriate polymerization.
The best modelling instrument is a microbrush, since this
instrument enables easy shaping of the final cusp anatomy
and adaptation of the composite even in the area of the
proximal marginal bevels. Even if the microbrush is not
wetted with bonding agent, the composite does not stick
Figure 25: The fissures may be characterized with a composite shade. to it (Figure 19). Wetting modelling instruments with
bonding liquid is a widespread technique to facilitate
material adaptation. As long as only a minimal amount of
As described above, the adhesive technique may be liquid is used (if a microbrush is utilized, the brush should
performed with an etch-and-rinse adhesive or with a two- be wiped off on paper), this technique may be considered
component self-etch adhesive combined with selective acceptable.
enamel etching (Figures 10 – 13). If, subsequently, a first If a single-component adhesive is used, wetting the
layer of a flowable composite is applied (Figure 13), this modelling instruments is, as a general rule, not permissible.
layer should be polymerized before continuing with the All of these adhesives contain a solvent (alcohol, water or
layering technique. acetone), which would be applied repeatedly, each time the
Next, the proximal walls are reconstructed using a fine brush is dipped into the adhesive. Finishing is performed
hybrid or nanofiller composite. For this purpose, the first with Soflex discs, finishing diamonds to fine-tune the
layer should be positioned horizontally to facilitate the occlusion and silicone polishers. Abrasive brushes are
adaptation of the material (Nikolaenko et al. 2004). employed for final high-gloss polishing (Figures 26 and 27).
Subsequently, the proximal walls are completed with
additional increments, which are placed at an angle Application of enamel and dentin shades
(Figures 14 – 16). Posterior restorations may be layered with a variety of
To reconstruct the occlusal surface of deep cavities, the shades, i.e. dentin materials, to optimize the esthetic
deepest areas are first built up with composite material. appearance of the restoration. However, it is important to
The cusps are reconstructed similar to the wax-up be aware of the fact that patients do not benefit from
technique. Each cusp is built up individually with composite such an optimization as the optical and esthetic
and shaped as accurately as possible (Figures 17 – 25). It is improvements achieved in the posterior region cannot be

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Figure 26: Completed restoration. Figure 27: Occlusal check.

seen by them. Furthermore, using several shades increases cuspal coverage with posterior composite resin restorations. J
the amount of material and time required to complete the Esthet Restor Dent. 18(5): 256-65.
restoration. Therefore, it is normally appropriate to use Ernst CP, Busemann I, Kern T, Willershausen B (2006). Feldtest
only one shade for the fabrication of posterior zur Lichtemissionsleistung von Polymerisationsgeräten in
restorations. If necessary, dentin shades may be used to zahnärztlichen Praxen. Dtsch Zahnärztl Z 61(9): 466 – 471.
mask severely discoloured areas. Feilzer AJ, De Gee AJ, Davidson CL (1987). Setting stress in
composite resin in relation to configuration of the restoration.
J Dent Res 66: 1636-1639.
Shrinkage-free composites – do they exist?
Feilzer AJ, De Gee AJ, Davidson CL (1990). Relaxation of
At present, shrinkage-free composites are not available.
polymerization contraction shear stress by hydroscopic
Recently, a silorane-based composite (Filtek Silorane, 3M
expansion. J Dent Res 69(1): 36-39.
Espe) has been introduced for the first time. The Davidson CL, Feilzer AJ (1997). Polymerization shrinkage and
polymerization-induced volumetric shrinkage of this polymerization shrinkage stress in polymer-based restoratives.
material is said to be below 1% (with a modulus of Review. J Dent 25(6): 435-40.
elasticity of approx. 10 Gpa). The chemistry embodied in Felix CA, Price RB (2003). The effect of distance from
this material is based on a cationic polymerization light source on light intensity from curing lights. J Adhes
mechanism, rather than radical polymerization. For this Dent 5(4): 283-91.
reason, this composite can only be used together with the Félix SA, González-López S, Mauricio PD, Aguilar-Mendoza
accompanying adhesive. Experience with large composite JA, Bolanos-Carmoña MV (2007). Effects of filling techniques
restorations are not yet available for this material. on the regional bond strength to lateral walls in Class I cavities.
Oper Dent 32(6): 602-609.
References Fleming GJ, Cara RR, Palin WM, Burke FJ (2007). Cuspal
Aarnts MP Akimade A, Feilzer AJ (1999). Effect of filler load movement and microleakage in premolar teeth restored with
on contraction stress and volumetric shrinkage. J Dent Res 78 resin-based filling materials cured using a 'soft-start'
(special issue): # 3014. polymerisation protocol. Dent Mater 23(5): 637-43.
Choi KK, Ryu GJ, Choi SM, Park SJ, Ferracane, JL (2004). Frankenberger R, Tay FR (2005). Self-etch vs. etch-and-rinse
Effects of cavity configuration on composite restoration. Oper adhesives: Effect of thermo-mechanical loading on marginal
Dent 29(4): 462-469. quality of bonded resin composite restorations. Dent Mater
Condon JR, Ferracane JL. (2000). Assessing the effect of 21(5): 397-412.
composite formulation on polymerization stress. J Am Dent Frankenberger R, Lohbauer U, Schaible RB, Nikolaenko SA,
Assoc.131(4): 497-503. Naumann C (2008). Luting of ceramic inlays in vitro: marginal
Cunha LG, Alonso RC, Sobrinho LC, Sinhoreti MA (2006). quality of self-etch and etch and rinse adhesives versus self-etch
Effect of resin liners and photoactivation methods on the cements. Dent Mater 24: 185 -191.
shrinkage stress of a resin composite. J Esthet Restor Dent 18(1): Frankenberger R, Lohbauer U, Roggendorf MJ, Naumann
29-36; discussion 36-37. m, Taschner M (2008) Seletive enamel etching
Deliperi S, Bardwell DN (2006). Clinical evaluation of direct Reconsidered: Better than etch-and-rinse and self-etch? J

48 INTERNATIONAL DENTISTRY SA VOL. 11, NO. 5

 Lenhard

Adhes Dent 10 (5): 399-344. 36(2): 136-140.

Gaur A, Pinzon LM, Parker KP, Powers JM (2004). Effect of Moreira da Silva E, dos Santos GO, Guimaraes JGA,
pre-etch on bond of self-etching adhesives to teeth. J Dent Res Barcellos AAL, Sampaio EM (2007). The influence of C-
82, (special issue) abstr. no. 1763. factor, flexural modulus and viscous flow on gap formation
Giachetti L, Russo DS, Bertini F, Pierleoni F, Nieri N (2006). in resin composites restorations. Oper Dent 32(4): 356-362.
Effect of operator skill in relation to microleakage of total-etch Nikolaenko SA, Lohbauer U, Roggendorf M, Petschelt A,
and self-etch bonding systems. J Dent 35(4): 289-293. Dasch W, Frankenberger R (2004). Influence of C-factor and
Gomes G, Perdigao J, Duarte Jr S, Lopes MM (2004). Enamel layering technique on microtensile bond strength to dentin.
bond strengths of self-etch vs. total-etch adhesives. J Dent Res Dent Mat 20: 579-585.
82, (special issue) abstr. no. 0236. V Qvist V, Johannessen L, Bruun M(1992). Progression of
Hofmann N, Hunecke A (2006). Influence of curing methods approximal caries in relation to iatrogenic preparation
and matrix type on the marginal seal of class II resin-based damage. J Dent Res 71(7): 1370-1373.
composite restorations in vitro. Oper Dent 31(1): 97-105. Raskin A, Setcos JC, Vreven J, Wilson NH (2000).
Hugo B, Stassinikis A (1998). Preparation and restoration Influence of the isolation method on the 10-year clinical
of small interproximal carious lesions with sonic behaviour of posterior resin composite restorations. Clin
instruments. Pract Periodont Aesthet Dent 10(3): 353-359. Oral Investig 4(3): 148-52.
Hugo B (1998). Oszilliernde Verfahren in der Sabbagh J, Vreven J, Leloup G (2002). Dynamic and
Präparationstechnik (Teil 1). Schweiz Monatsschr Zahnmed static moduli of elasticity of resin-based materials. Dent
109(2): 140-153. Mat 18: 64-71.
Ikeda T, Uno S, Tanaka T, Kawakami S, Komatsu H, Sano H Sakaguchi RL, Douglas WC, Peters MC (1992). Curing
(2002). Relation of enamel prism orientation to microtensile light performance and polymerization of composite
bond strength. Am J Dent 15: 109-113. restorative materials. J Dent 20: 183-188.
Koran P, Kürschner R (1998). Effect of sequential versus Schulze KA, Oliveira SSA, Marshall GW, Gansky SA,
continuous irradiation of a light-cured resin composite on Marshall SJ. Technique sensitivity of a self-etching versus an
shrinkage, viscosity, adhesion, and degree of polymerization. acid etching system. J Dent Res 80, 2002 (special issue)
Am J Dent 11(1): 17-22. abstr. no. 0947
Krejci I, Dietschi D, Lutz FU (1998). Principles of proximal Shimada Y, Tagmani J (2003). Effect of regional enamel
cavity preparation and finishing with ultrasonic diamond tips. and prism orientation on resin bonding. Oper Dent 28:
Pract Periodont Aesthet Dent 10(3): 295-298. 20-27.
Kujis RH, Fennis WM, Kreulen CM, Roeters FJ, Creugers NH, Unemori M, Matsuya Y, Akashi A, Goto Y, Akamine A
Burgersdijk RC (2006). A randomized clinical trial of cusp- (2004). Self-etching adhesives and postoperative sensitivity.
replacing resin composite restorations: efficiency and short-term Am J Dent 17(3): 191-195.
effectiveness. Int J Prosthod 19(4): 349-354. Unlu N, Krakaya S, Ozer F, Say EC (2003). Reducing
Lindberg A, van Dijken JW, Hörstedt P (2005). In vivo microleakage in composite resin restorations. An in vitro
interfacial adaptation of class II resin composite restorations with study. Eur J Prosthodont Restor Dent 11(4): 171-175.
and without a flowable resin composite liner. Clin Oral Investig Unterbrink GL, Liebenberg WH (1999). Flowable resin
9(2): 77-83. composites as „filled adhesives“: Literature review and
Lu H, Stansbury JW, Bowman CN (2004 a). Towards the clinical recommendations. Quintessence Int 30(4): 249-257.
elucidation of shrinkage stress development and relaxation in Wattanawongpitak N, Yoshikawa T, Burrow MF, Tagami J
dental composites. Dent Mat 20: 979 – 986. (2006).The effect of bonding system and composite type
Lu H, Stansbury JW, Bowmann CN (2004 b). Filler effect on on adaptation of different C-factor restorations. Dent Mater
shrinkage stress and in situ polymerization kinetics. J Dent Res J 25(1): 45-50.
(special Issue) 82; abst. no.: 0059 Weast CC (1970). Handbook of chemistry and physics,
Lu H, Stansbury JW, Bowman CN. (2005). Impact of 51st Edition. CRC Press, Cranwood Parkway, OH.
curing protocol on conversion and shrinkage stress. J Dent Wicht MJ, Haak R, FritzUB, Noack MJ (2002). Primary
Res 84(9): 822-6 preparation of class II cavities with oscillating systems. Am
Lussi A (1995). Verletzung der Nachbarzähne bei der J Dent 15(1): 21-5.
Präparation approximaler Kavitäten. Schweiz Monatsschr Xu HH, Kelly JR, Jahanmir S, Thompson VP, Rekow ED
Zahnmed 105(10): 1259-1264. (1997). Enamel subsurface damage due to tooth
Lussi A, Gygax M (1998). Iatrogenic damage to adjacent preparation with diamonds.
teeth during classical approximal box preparation. J Dent 26(5- J Dent Res 76(10): 1698-706.
6): 435-441. Yazici AR, Baseren M, Dayangac B (2003). The effect of
Moopnar M, Faulkner KDB (1991). Accidental damage to flowable resin composite on microleakage in Class V
teeth adjacent to crown abutment teeth. Aust Dent J cavities. Oper Dent 28(1): 42-46.

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