Restorative Composite Resins

Restorative Composite ResinsRestorative Composite Resins

Col Kraig S. VandewalleUSAF Dental Evaluation & Consultation Service

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

Overview

• Direct restoratives– composition– classification– performance factors

• Flowable

• Packables

Click here for briefing on composite resins (PDF)

https://decs.nhgl.med.navy.mil/DMNOTES/composites.pdf

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

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

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

Indications

• Anterior restorations

• Posterior restorations– preventive resin– conservative class 1 or 2

Contraindications

• Large posterior restorations

• Bruxism

• Poor isolation

Advantages

• Esthetics

• Conservation of tooth structure

• Adhesion to tooth structure

• Low thermal conductivity

• Alternative to amalgam

Disadvantages

• Technique sensitivity

• Polymerization shrinkage – marginal leakage– secondary caries– postoperative sensitivity

• Decreased wear resistance

Composition• Resin matrix

– monomer– initiator– inhibitors– pigments

• Inorganic filler– glass– quartz– colloidal silica

• Coupling Agent

OCH2CHCH2O-C-C=CH2CH2=C-C-O-CH2CH-CH2O -C-

CH3 CH3

CH3

CH3OH OH

O O

Bis-GMA

Phillip’s Science of Dental Materials 2003

Monomers• Binds filler particles together• Provides “workability”• Typical monomers

– Bisphenol A glycidyl methacrylate (Bis-GMA)

– Urethane dimethacrylate (UEDMA)

– Triethylene glycol dimethacrylate (TEGMA)CH2=C-C-O-CH2CH2-O-C-NHCH2CH2CHCH2-C-CH2-NH-C-

CH3

CH3

OCH2CH2O-C-C=CH2

CH3

O OOO

CH3

CH3


CH3 CH3

CH3

CH3OH OH

O O

CH2=C-C-O-CH2CH2-OCH2CH2

CH3

OCH2CH2O-C-C=CH2

CH3

O O

Monomers• Bis-GMA

– extremely viscous• large benzene rings

– lowered by adding TEGDMA• freely movable• increases polymer conversion• increases crosslinking• increases shrinkage

CH2=C-C-O-CH2CH-CH2O -C- OCH2CHCH2O-C-C=CH2

CH3 CH3

CH3

CH3OH OH

O O

Monomers

• Shrinkage– 2 – 7 %– marginal gap

formation

Filler Particles

• Crystalline quartz– larger particles– not polishable

• Silica glass– barium– strontium– lithium– pyrolytic

• sub-micron


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

Fra

ctur

e T

ough

ness

0 28 37 48 53 62

% Filler Volume

Ferracane J Dent Res 1995

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

CH3-C-C-O-CH2-CH2-CH2-Si-OH

CH2

O OH

OH

Bonds with filler

Silane

Bis-GMABonds with resin


Inhibitors

• Prevents spontaneous polymer formation– heat– light

• Extends shelf life

• Butylated Hydroxytoluene


Pigments and UV Absorbers

• Pigments– metal oxides

• provide shading and opacity• titanium and aluminum oxides

• UV absorbers– prevent discoloration– acts like a “sunscreen”

• Benzophenone


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


CH3 CH3

CH3

CH3OH OH

O O

Bis-GMA

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

C=C

C=C C=C

C=C C=C C=C C=C

C=C C=C

C=C C=CC=C C=C

C=C C=C

C=C C=C

C=C

C=C

C=CC=C

C=C

C=C

C=C C=C C=CC=C C=C

C=C

C=C

polymerization

Ferracane

Classification System

• Historical

• Chronological

• Based on particle size– traditional– microfilled– small particle – hybrid


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


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


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

https://decs.nhgl.med.navy.mil/3QTR05/PRODUCTEVALUATIONS/compositeattachment.htm

Small Particle

• 1 - 5 micron heavy-metalglasses

• 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


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


Hybrids

• Strong

• Good esthetics– polishable

• Suitable– Class 1 to 5

• Multiple available

Click here for table of hybrids

https://decs.nhgl.med.navy.mil/3QTR05/PRODUCTEVALUATIONS/compositeattachment.htm

Property Traditional MicrofilledSmall

ParticleHybrid

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


Table of Properties

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

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)

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

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

Performance Factors

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

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


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

Polymerization Shrinkage

• Significant role in restoration failure– gap formation

• secondary caries formation• marginal leakage• post-operative sensitivity

• Counteract– lower shrinkage composites– incremental placement

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

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

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

Small Particle Hybrid Microfilled Composite

Time

Acquired Polish

Inherent Polish

Polish Mechanisms

Adept Report 1992

Linear wear pattern

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

https://decs.nhgl.med.navy.mil/1QTR04/QA/dm2.htm

Shaded Anatomic

Trans Enamel

A3/A4 Dentin

Enamel Value

Enamel Value

A1 Dentin

A1 Enamel

Dentists Ceramists“Match Shade” “Create Shade”

Trans Enamel

Placement TypesComposite 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

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

Composite Selection

• Posterior– hybrid

• mini- or midi-fill

– reinforced microfill

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

Government Price($/gm of refill resin)

6.3 6.5

7.588.49 8.53 8.79 8.9 9

9.4410.15 10.21

11.37

9.95

4 Sea

sons

Gradia

Post

Gradia

Ant

Hercu

lite

XRV

Prodig

y

Point 4

Z100

Venus

Vitale

scen

ce

Esthet

XZ25

0

Prem

ise

Suprem

e

Prices current as of Jan 05

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

0

1

2

3

Venu

s

Supr

eme

4 Sea

sons

Enam

el

Vital

esce

nce

Gradia

Pos

t

Dentin

Gradia

Ant

Radiopacity(mm of aluminum)

Source: USAF DECS Project 03-024

ISO Requirement

Surface Hardness(24 hrs)

0

10

20

30

40

Z250

Suprem

e

Vitale

scen

ce

Venus

Esthet

-X

Point 4

4 Sea

sons

Prem

ise

Gradia

Post

Gradia

Ant

Horizontal lines connect nonsignificant differences (p<0.05); N=5

Source: USAF DECS Project 03-37KHN

Flexural Strength(24 hrs)

0

20

40

60

80

100

120

140

160

Supreme 4Seasons

Venus GradiaAnt

Premise GradiaPost



Volumetric Shrinkage

0

1

2

3

4

5

A110

Gra

dia D

irect

Z100

Prem

ise

4 Sea

sons

Venus

Renew

Esthet

-X F

low

%



Composite Variants

• Packable

• Flowable

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

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

ALERTSolitareSureFilHeliomolarZ100

Fracture Toughness

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

96.9 96.291.2

85.1

71.5 70.370.2

55.4

41.4

22.4

0 00

20

40

60

80

100

Pyr-D Prodigy SureFil Alert Solitaire Pyr-E

2 mm

5 mm

Depth of Cure

Packable Composite Resin

% Hardness Ratio

Choi J Esthet Dent 2000 Click here for abstract

Packable Vs. Hybrid Composites

• Mechanical properties similar

• Wear properties similar

• Curing depths similar

• Similar proximal contacts

• Drier, denser feel

Choi J Esthet Dent 2000Peumans Dent Mater 2001

Click here for more details

Flowable Composites

• Marketed – class 1, 3, 5– liner

• Particle size similar to hybrid composites

• Reduced filler content– reduces viscosity

01020304050607080

We

igh

t P

erce

nt

Percent Filler Loading

Aeliteflo

FloRestore

Revolution

Ultraseal+

Prodigy

Bayne JADA 1998 Click here for abstract

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

Polymerization Shrinkage

0

1

2

3

4

5

Aelite-

Flo

Revolu

tion

Wav

e

Flow-it

Tetric

Flo

wAle

rt

SureFil

Z100

Heliom

olar

%

Tolidis JDR 1999

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

Flowable Composite

• Mechanical properties– inferior to hybrids

0 0.5 1 1.5 2 2.5MPa

Fracture Toughness

Prodigy

Ultraseal +

Revolution

FloRestore

Aeliteflo

0 50 100 150 200MPa

Flexure Strength

Bayne JADA 1998 Click here for abstract

Flowable Composites

• Clinical applications– preventive resin restorations– small Class 5– provisional repair– composite repair– liners??

Regular Material Usage*Civilian Practitioners

• Flowable Composite 81%• Hybrid Composite 69%• Amalgam 67%• All-Purpose Composite 53%• Microfill Composite 52%• Resin-modified Glass ionomer 45%• Packable Composite 33%• Compomer 7%• Other 1%

DPR 2005*Multiple responses

Review of Clinical Studies(Failure Rates in Posterior Permanent Teeth)

0

2

4

6

8

Amalgam DirectComp

CompInlays

CeramicInlays

CAD/CAMInlays

GoldInlays &Onlays

GI

Longitudinal Cross-Sectional

Hickel J Adhes Dent 2001

% Annual Failure

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)

Purchasing ConsiderationsFederal 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


• 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



• 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 kitfor general use by entire facility or training program– several systems available

• e.g., 4 Seasons (Ivoclar Vivadent)


Future Composites

• Low-shrinking monomers– expanding spiroorthocarbonates– epoxy-based resins– liquid crystal

• Self-adhesive?

Click here for details

Acknowledgments

• Dr. Dave Charlton

• Dr. Jack Ferracane

• Dr. Tom Hilton

Questions/CommentsCol Kraig Vandewalle

– DSN 792-7670

– [email protected]

Restorative Composite Resins

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Restorative Composite Resins