Composite Restoration Esthetics - IneedCE.com

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This course was 

written for dentists, 

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Composite Restoration 

Esthetics 

A Peer-Reviewed Publication 

Written by Robert C. Margeas, DDS, FAGD 

PennWell designates this activity for 2 Continuing Educational Credits 

Publication date: November 2009 

Go Green, Go Online to take your course 

Review date: March 2011 

Expiry date: February 2014 

This course has been made possible through an unrestricted educational grant. The cost of this CE course is $49.00 for 2 CE credits. 

Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Educational Objectives 

Overall goal: The purpose of this article is to provide dental professionals 

with information about the esthetic considerations and 

strength of direct composites. Upon completion of this course, the 

clinician will be able to do the following: 

1. List and describe the categories of composite resin restorative 

materials available and their characteristics and indications for use. 

2. List and describe the modes of failure for composite resin 

restorative materials. 

3. List and describe the shade considerations involved in the 

attainment of esthetics in composite resin restorations and the use 

of different shading and layering techniques. 

4. List and describe the relevance of a smooth surface and gloss as 

well as polishability, and factors influencing these. 

Abstract 

The increased use of direct composite restorations can be mainly 

attributed to patient demand for esthetic restorations and the 

availability of composites with high strength and excellent esthetics. 

While early composites were weak and suitable only for anterior 

restorations, current composites are highly esthetic and offer 

high strength for their intended purposes. Techniques have also 

evolved, with sophisticated bonding techniques and single-shade, 

dual-shade, and multilayering techniques to optimize esthetics. 

It is important to consider not only the individual case, relative 

strength, and esthetics of different types of composites but also the 

technique to be used when selecting a restorative material. 

Introduction 

Direct composite restorative materials offer esthetic solutions for 

clinicians and patients. Esthetic solutions must be achieved in 

tandem with the functional requirements of strength, volumetric 

and morphologic stability, physical compatibility with the surrounding 

tooth structure, biocompatibility, and the ability either 

to self-adhere to the tooth surface or to adhere with an adhesive 

system for a durable bond at the tooth-restoration interface. Additional 

desirable properties include the ability to inhibit biofilm 

formation, thereby reducing the load of acidogenic and periodontal 

bacteria; stain resistance; and user-friendliness. Ideally, a restorative 

material will meet all these requirements, allowing it to be 

used for both anterior and posterior restorations. While amalgam 

fulfills the physical requirements for direct restorations, 1 is quicker 

and easier to place than are esthetic restorative materials, is more 

tolerant of moisture, and can now be hybrid-bonded with the use 

of amalgam bonding techniques (which has reduced the need for 

classical amalgam preparations, although results have been found 

to be variable), 2,3 its lack of esthetic results means it is suitable 

only for posterior restorations. Its use for posterior restorations 

has also gradually declined 4 as patients have become increasingly 

aware of esthetics and want the improved posterior esthetic materials 

that have become available in response to these demands. 

Clinicians demand esthetic materials with improved physical and 

handling properties. Physical requirements differ for anterior 

and posterior restorations. Anterior restorations, especially those 

involving incisal edges, require high strength as well as high esthetics. 

Posterior restorations have the added requirement of low 

wear. Esthetic restorative materials must offer adequate shade 

availability, suitable chroma and values, translucency, opacity, 

opalescence, fluorescence, a smooth and glossy surface, and stain 

and wear resistance. 

Development of Composite Resins 

When first introduced in the 1970s, composite resins were utilized 

only for anterior restorations. 5 These early variants were typically 

quartz-filled; did not meet the compressive and tensile force 

requirements for posterior restorations; and had relatively high 

surface roughness, low polishability, poor resistance to staining, 

and poor bonding at the tooth-restoration interface, which, in 

combination with polymerization shrinkage, resulted in margin 

degradation and postoperative sensitivity. The choice of shades 

was limited, and the materials, other than being tooth-colored, 

offered poor esthetics with little or no differentiation of shading by 

fluorescence, translucency, or intended location (such as cervical 

shades for cervical restorations). In addition to these disadvantages, 

early resin composites were difficult to handle, required manual 

mixing of the resin paste (A) and the catalyst (B), were available 

only in tubs or syringes of pastes (A and B separately), and were 

always self-cured with a limited working time. Over time, the 

strength characteristics of composite resins were improved and 

the resins were introduced for use in posterior restorations. These 

materials were still unsuitable for posterior restorations in which 

high compressive strength was required to resist occlusal and 

masticatory forces. Wear resistance was also low. Bonding systems 

were still primitive in the 1980s, with limited choice in technique. 

Self-adhesive systems were not available and there was little choice 

in terms of etching methods. The focus was still on enamel etching 

and bonding, and early attempts at dentin bonding resulted in 

weak bonding to the smear layer and a rapidly degrading bond. 6 It 

was also recommended that, after curing of the resin, the enamelrestoration 

interface be re-etched and an unfilled resin be placed 

over this surface to seal it and help inhibit microleakage and 

wear. 7,8 By the 1990s, posterior composite restorations were available 

that were better-suited to Class I and Class II restorations. 9 

These enabled a more conservative approach during preparation 

than amalgam did, and they were used with improved bonding 

systems for improved marginal integrity at the tooth-restoration 

interface. 

Current composite materials (and bonding systems) are vastly 

superior to earlier versions. Current materials are available with 

several types of fillers, advanced enamel and dentin adhesive systems, 

and they offer strength, lower polymerization shrinkage and 

stress, wear resistance, and excellent esthetics. 

Current Composite Restorative Materials 

Composite resin materials are currently available as microfilled, 

(micro)hybrid, and nanofilled composites. Their chemistry is 

typically based on bisphenol-a-glycidyl dimethacrylate (Bis- 

GMA); however, additive chemistry has been used to reduce 

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polymerization shrinkage or stress, and the addition of various 

sizes and types of fillers has altered physical and esthetic properties. 

Pre-polymerized clusters and increased filler load help reduce 

polymerization shrinkage and stress, and increasing filled load also 

results in a higher viscosity composite. Each composite type offers 

advantages specific to its chemistry. An understanding of these is 

necessary to select an appropriate material for clinical procedures. 

Microfilled Composite Resins 

Microfilled composite resins contain crushed particles ranging in 

size from 0.04 to 1 micron. The filler particles are typically prepolymerized 

particles comprised of resin and fumed silica. Filler load 

is lower in microfilled composite resins, and internal bonding between 

the matrix resin and the prepolymerized filler resin is weak, 

resulting in lower strength. This is an important consideration in 

stress-bearing areas. The very small particle sizes in microfilled 

resins, however, offer excellent esthetics with high polishability 

and a long-lasting surface gloss. 

Microhybrid/Hybrid Composite Resins 

Microhybrid composite resins contain silicon dioxide filler with 

particles ranging in size from approximately 0.04 up to 0.1 micron, 

and glass particle fillers typically range in size from 0.4 to 0.6 

micron (400 to 600 nm). These resins lose their high polish over 

time with the development of a rougher surface, reducing their 

suitability for esthetically demanding cases. They do, however, 

offer strong physical properties and are suitable for stress-bearing 

restorations. Hybrid resins have slightly larger filler sizes than do 

microhybrid resins and essentially behave in the same manner. 

Nanofilled Composite Resins 

Nanofilled composite resins have a high filler load in order to 

obtain strength and wear resistance similar to that of microhybrid 

composite resins. Nanofilled composite resins contain 

smaller particles of filler in the range of 0.02 to 0.1 microns. 

One nanofilled composite (Filtek Supreme Plus) contains 

nanofiller particles that are approximately 0.02 microns in 

diameter, sintered into nanoclusters of 0.6 to 1.4 microns that 

contain zirconia/silica particles, in order to improve physical 

characteristics. 

Table 1. Indications for composite resins 

High-esthetic restorations Stress-bearing restorations 

Microfilled X – 

Microhybrid – X 

Nanofilled X X 

Flowable and Packable Composites 

Another method of categorizing composite resin restorative 

materials is by flow characteristics. Flowable composite resins 

have a lower filler load and a low viscosity, enabling them to be 

syringed directly into preparations, where they flow and conform 

to the preparation margins. The flowable composites are used 

extensively as a liner under posterior restorations and are also 

used as an initial bulk layer for the sandwich technique, similar 

to glass ionomer cements, that is then covered with a microfilled 

or nanofilled composite. They are also used in clinical situations 

in which heavy stress-bearing is not a requirement. Packable 

(universal) composites are denser and can be condensed using 

plastic instruments during placement, prior to curing. One 

study comparing a nanofilled composite resin with and without 

an underlying layer of flowable composite after use of a two-step 

(total etch) or single-step bonding technique found no statistical 

differences in secondary caries, postoperative sensitivity, marginal 

discoloration or adaptation, or color at a two-year recall. 

Both techniques were found to be clinically successful. 10 Packable 

composites have been found to be clinically successful over 

multiple-year analyses. 11 

While clinical function and longevity of esthetic composites 

are the first prerequisites, optimizing esthetics is desirable and increasingly 

demanded by patients for all direct composite restorations. 

Surface smoothness, polishability, luster (surface gloss), and 

specific shade attributes and techniques all play important roles in 

the achievement of optimal esthetics. 

Optimizing Esthetics in Composites 

The esthetics of composite restorations is influenced by the shape 

and contouring of the restoration, which must mimic the natural 

tooth in order to provide a natural appearance. In the case of posterior 

restorations, the use of sectional matrices has considerably 

simplified the achievement of functional and esthetic contours. 

Beyond the requirements of contour and shaping, and the use 

of an appropriate technique that avoids moisture contamination 

and utilizes an appropriate bonding system, esthetics is determined 

by the availability and appropriate selection of shade(s) 

– the fluorescence and translucency, value (degree of lightness or 

darkness), chroma (intensity of the shade), hue, ability to offer 

a chameleon effect, polishability, wear resistance, retention of 

gloss and polish, and technique. Each of these plays a role in 

developing and maintaining optimal esthetics. 

Table 2. Factors in optimized composite esthetics 

Shape and contour mimicking natural dentition 

Functional and esthetic contours 

Use of an appropriate technique 

Avoidance of moisture contamination 

Use of an appropriate bonding system 

Selection of appropriate shade(s) 

Polishability of the restorative material 

Wear resistance 

Retention of gloss and polish 

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Shades and Shade Selection 

Composite resin systems are available with multiple shades. The 

number of available shades depends on the brand selected and 

typically includes a number of shades in the VITA A, B, C, and D 

ranges to cover the hues, chroma, and values that will be required 

for natural-looking direct composite restorations. Shades are also 

available and categorized by translucency and opacity. Regardless 

of the technique used, if teeth are stained, the staining should be 

removed prior to selecting a shade(s). Shade selection also should 

occur prior to placement of a rubber dam, since this will affect 

perception of color due to color perception interference with the 

rubber dam and because a desiccated tooth appears whiter than a 

moist or wet tooth. 

Opacity and Translucency 

Different shades offer greater or lesser opacity, opalescence, and 

translucency. Opacity is an important property for composites, 

offering flexibility by enabling the creation of many shades, 

ranging from very translucent, which is required for incisal edges 

and outer multilayering, to highly opaque, which is required for 

the body of a restoration replacing dentin. 12 Opacity is essential 

for deeper restorations and restorations with a darker pulpal 

floor/underlying area, in order to prevent shine-through of the 

darkened dentin. In extreme cases, opaquers and tinters may be 

required. 13 Selecting opaque and/or translucent shades can be 

critical for the esthetic outcome of an individual case, 14 and more 

chromatic shades have been found to be more opaque. 15 

Controlling the size and volume of filler particles is a contributing 

factor to light-scattering properties and therefore 

the perceived color and translucency of composite resins. 16 A 

matching of filler size and resin is essential for light transmission 

in composite resins and translucency. Translucency increases 

as the restorative material becomes thinner, irrespective of the 

shade used – a consideration when using a multilayering technique. 

17 Filler size in composite resins has been found to influence 

the transmission and reflection of color, and it results in 

variations in translucency and opalescence. Opalescence varies 

with the size and amount of the filler. In general, increased filler 

load decreases translucency. 18 Nanosized filler particles enable 

the transmission of light, resulting in translucency. Their ability 

to scatter blue light provides the nanofilled composite with opalescence, 

which enhances the lifelike appearance of composite 

resin materials. 

Table 3. Influence of filler on esthetics and strength 

Transmission of light 

Reflection of color 

Variations in translucency 

Variations in opalescence 

Low filler is less strong 

Viscosity 

Single-Shade, Dual-Shade, and Multilayering 

Techniques 

From a practical perspective, there is a need for composite resin 

systems that offer the ability to provide esthetic restorations using 

only one shade. Single-shade restorations are simpler and quicker 

to place. Single-shade restorations require that the composite be 

able to blend in with the surrounding tooth structure through a 

chameleon effect, such that the gradation from different areas of 

the tooth’s structure to the restoration is not obvious and results in 

a natural-looking restoration. 

More esthetically demanding clinical situations can require a 

dual-shade or multilayering technique to mimic the adjacent tooth 

structure. Dual-shade restorative procedures are suited to situations 

in which there may be substantial variations in two adjacent 

areas – for example, for a darker cervical versus coronal area, or 

for a highly translucent and wide incisal edge versus the more 

opaque coronal area being restored. When using a dual-shade 

technique, the dentin color (body of the tooth) should be selected 

first, followed by the enamel shade (and if a translucent shade 

is also used, this should be chosen last). Dietschi et al. reported 

on a shading concept that compared enamel and dentin shades 

with the opacity and specific color of teeth. After comparing teeth 

with similar chroma (green-red/blue-yellow values), it was found 

that only the blue-yellow values varied. Translucency was found 

to be relatively constant for dentin, and it increased with age in 

enamel. From these conclusions, a simplified dual-layering technique 

was developed – the “natural layering concept” – that uses 

a universal dentin hue and one of three enamel hues, depending 

on the age of the patient (young, adult, and old). 19 Multilayering 

techniques are the most time-consuming and complex, requiring 

more shades to be used, but they offer the most esthetic solution 

for specific cases. The blending effect varies with the size of 

the restoration. 20 Advanced layering techniques can also utilize 

color tints to modify composite shades, such as for the creation of 

hypocalcification-like areas to mimic adjacent teeth with hypocalcifications 

where these are not being treated. 21 

It is important when using dual- or multiple-shade techniques 

to use the same brand of composite and the shade guide 

for that composite system. The translucency and shade of composites, 

while almost universally using the VITA shade guide 

system for labeling purposes, show variation across brands. 22 For 

multilayering techniques, the blending effect depends on both 

the specific brand of composite and the shades used. 23 Significant 

differences in color, translucency, and fluorescence have also 

been found between flowable and packable (universal) composites 

that were different brands but labeled as the same shades. 24 

Curing and polishing change the color and translucency of a 

composite resin, again varying by brand and shade. 25,26,27 The 

shade guide, not uncured resin, should be used for shade selection. 

Alternatively, recently cured resin can be used. 28 It is also 

important to consider the availability and quality of light within 

the daylight UV spectrum when selecting shades. As the daylight 

UV varies, so too does the perceived color of composite resins 29 

and teeth. The use of computerized shade guide determination 


through colorimetric analysis, together with the use of multilayering 

with nanofilled composites, was found in one study to 

result in improved esthetics. 30 

In selecting a composite, sufficient shades should be available 

in the same brand of composite to satisfy clinical requirements for 

single-shade, dual-shade, and multilayering techniques. Either an 

accurate match to the VITA Classical shade guide, or an accurate 

custom shade guide must be available for the selected composite’s 

shade system. 

Table 4. Tips for Multilayering Techniques 

Use the same brand of composite for all layers 

Ensure the amount and quality of daylight is adequate for shade selection 

Do not use uncured resin to determine shades 

Use the VITA shade guide if the composite system accurately mimics this 

Use a custom shade guide if the composite system has custom 

shade labeling 

Surface Attributes and Esthetics 

Surface smoothness and retention of surface gloss are important 

for function and esthetics. 31 A high-gloss, smooth surface reflects 

light, giving a more natural appearance. The scattering and absorption 

of light on rough surfaces results in a darker, duller appearance. 

The initial smoothness of composite resins is influenced 

by the filler particle size and the technique used for polishing and 

finishing the resin. Composite resins with smaller filler particles 

are smoother and exhibit greater luster than do larger particle-size 

filled resins, thus explaining the greater surface smoothness and 

polish seen in both microfilled and nanofilled composite resins. 

Nanofilled composite resin containing nanoclusters has been 

shown to exhibit high translucency, polishability, and gloss, and its 

long-term polish is comparable to the characteristics of microfilled 

composite resins. Nanofilled translucent shades retained polish 

better than did similar microfilled shades. 32,33 Microhybrids are 

not as glossy or smooth, but their polishability and esthetics have 

been enhanced in recent years. 34 

Polishing Composites 

Composites can be polished using two-step or one-step systems. 

These can include the use of silicon tips, Sof-Lex discs, rubber 

cups, and polishing pastes and liquid polishers. Polishing 

composites has been found to achieve the greatest improvement in 

surface gloss within five seconds of polishing. 35 One-step polishing 

systems are suitable for nanocomposite polishing (Filtek 

Supreme Plus (or XT outside of US); Grandio; CeramX; Premise; 

and Tetric EvoCeram) as well as flowable restorative materials; 

polishing results in a more stain-resistant surface. 36,37 Surface 

sealants have been recommended for use following finishing 

and polishing in order to impart the smoothest surface. 38 It has 

also been found that removing the outer surface layer during 

polishing helps stain resistance. 39 The optimal polisher depends 

on the specific composite. 40 

Table 5. Surface smoothness and polisher 

Filtek 

Supreme 

Plus 

Mylar PoGo OptraPol One Gloss 

Smoother Smoother Rougher Rougher 

Grandio Smoother Smoother Rougher Rougher 

Tetric Less rough Roughest Less rough Less rough 

EvoCeram 

Premise No significant differences 

CeramX No significant differences 

Source: Ergucu et al. Operative Dentistry, 2007. 

It is therefore important to follow the manufacturer’s recommendations 

for specific composites. 

Wear Resistance and Surface Roughness 

Over time, surface roughness develops in response to abrasion (as 

well as acid erosion) of composite surfaces. In vitro three-surface 

wear testing and simulated cycles of toothbrushing are used to 

measure the anticipated susceptibility of composite resins to intraoral 

abrasion from mastication or toothbrushing. In one study, 

in vitro–simulated toothbrushing resulted in rougher surfaces in 

microfilled and microhybrid composites than it did in packable 

composites, compomers, and resin-modified glass ionomers. Polishing 

composite resins at recall appointments can help to reduce 

surface roughness that has developed and to impart a smooth 

surface. 41 Both the amount of surface wear and mechanism of wear 

over time have been found to differ among resins. Surface roughness 

is also positively correlated with staining of composites. 42 

Very small particles contained in microfilled resins result in 

an even wear pattern and thus retention of a smoother surface. 

The combination of nanofillers around nanoclusters results in 

removal during wear of the very small nanofilled particles that 

are packed in the nanocluster surface, again resulting in a more 

even pattern of wear and a smoother surface. Scanning electron 

micrographs (SEM) have demonstrated the removal of individual 

small nanofiller particles from larger zirconia-silica nanoclusters. 43 

In contrast, SEMs of microhybrid resins show larger defects at the 

surface following wear, proposed to be due to the removal of larger 

individual particles that leave voids and a less even pattern of wear, 

resulting in a rougher surface than observed with microfilled and 

nanofilled composites. 44 

Figure 1. Scanning electron micrographs of composite fillers 

Nanofiller 

Courtesy of Dr. Jorge Perdigao 

Hybrid filler 


Surface wear results in loss of gloss followed by loss of the layer 

below the gloss. In vitro data indicates that the microhardness of a 

nanofilled composite is higher than that of microfilled composites, 

attributable to the filler. 45 

The aging of esthetic restorative materials results in surface 

changes and therefore changes in the light-scattering absorption 

properties of glass ionomers, modified glass ionomers, compomers, 

and resin composites. 46 Aging of flowable composites has also 

been found to result in more color changes compared to universal 

composites. 47 Accelerated in vitro aging was found in one in vitro 

study to result in the loss of translucency but not to affect opacity 

of composite resins. 48 

Bacterial Considerations 

A smooth, glossy appearance is also important to reduce the potential 

for bacterial adhesion and the accumulation of biofilm. In 

vitro studies have found amalgam to be bactericidal and to inhibit 

the formation of biofilm. 49,50 The converse has been found with 

resin-based restorative materials, although, interestingly, the experimental 

addition of microparticulate silver to composite resin 

material has been found in vitro to have a bactericidal effect as 

well as to inhibit bacterial adhesion. 51 These findings increase the 

importance of selecting a material that both achieves and retains 

a smooth surface. 52 In vitro studies on packable resin composites, 

compomers (polyacid-modified composite resins), and glass ionomer 

cements found no antibacterial properties for these materials, 

while one found a minimal effect for a few days with composite 

resin. 53,54,55,56 In the case of the packable composites tested, newly 

polymerized resin would actually support the development of 

biofilm, and one study found that bacteria formed a dense biofilm 

on composite resin. 57,58 

Combining Strength and Esthetics 

While predictable and reliable esthetics is important, this must 

not result in compromised functionality. Microfilled resins are 

highly esthetic, suitable for anterior restorations in low stressbearing 

restorations. Microhybrid and nanofilled composites are 

suitable for stress-bearing restorations. Some variability in the 

mechanical properties of different nanofilled composites has been 

found in in vitro testing. 59 

Beun et al. compared the mechanical properties of nanofilled, 

microhybrid, and microfilled composites. The nanofilled composites 

had an elastic modulus and physical properties at least 

equivalent or better than those of universal composite and superior 

to those of microfilled composite. 60 One study comparing the 

properties of nanofilled composite resin containing nanoclusters 

and microfilled and hybrid resin composites found that nanofilled/nanocluster 

composites offered physical characteristics and 

strength comparable to those of microhybrid composites. Physical 

characteristics measured and compared included wear resistance – 

also a factor in esthetics, compressive and diametral strengths, and 

fracture resistance. 61 The same nanofilled composite was found in 

other in vitro testing to have higher diametral tensile strength than 

did microhybrid composites. 62 

Latest Developments in Composite Resins 

Recent developments in composite resin technology have included 

reductions in polymerization shrinkage and in polymerization 

stress. These have been achieved through increased filler loads 

and novel chemical technology. Polymerization shrinkage, and 

therefore stress, has been reduced through the use of siloranering-based 

chemistry 63 as well as by increasing conversion rate 

of the monomer. 64 Direct reduction of polymerization stress 

has now also been achieved through the use of a polymerization 

modulator to reduce stress. A recent development has improved 

esthetics in a high-strength, esthetic nanofilled composite. 

Changes in the synthesis of nanoclusters in nanofilled composite 

resin have demonstrated improved polish retention and handling, 

while maintaining wear resistance, in in vitro testing. The 

same material has fracture toughness equal to that of the upper 

range of other composites, as well as high flexural strength. 65 

The cases below illustrate the use of this new nanofilled/ 

nanocluster composite for single-shade and multilayering techniques. 

Case Studies 

Case 1. Multi-layering technique 

The patient presented with an old, worn and defective composite. 

After discussion, it was decided to replace the Class IV composite. 

The old composite was removed, followed by etching of the 

enamel and dentin, rinsing and drying, then use of the bonding 

agent. The composite (Filtek TM Supreme Ultra universal composite) 

was then layered for optimal esthetics, using a thin layer of 

WE, followed by A1 to create a ‘dentin replacement layer’ at the 

lobes. This was followed by application of grey translucent shade 

between the lobes and B1 enamel shade. The final restoration was 

polished using a Sof-Lex disc, followed by a cup brush and polish 

for an esthetic, high gloss smooth surface finish. 

Figure 2. Old, worn composite restoration 

Figure 3. Old composite removed 


Figure 4. Etchant applied 

Figure 9. Final, polished restoration 

Figure 5. Bonding agent applied 

Figure 6. Thin layer of WE against impression template 

Case 2. Single-shade restoration 

In this case the patient presented with a carious DO lesion, visible 

unaided as well as radiographically. The patient preferred an esthetic 

composite restoration. After removing the carious enamel and dentin, 

the tooth was first etched, rinsed and dried, and then the adhesive 

layer applied. Shade A3 body was then used and the composite 

resin syringed directly into the preparation. The composite was then 

packed into the tooth and light-cured. Finishing of the restoration 

was achieved using a fine diamond for fine occlusal contouring, followed 

first by a Sof-Lex disc and then a brush cup and polish. 

Figure 10. Carious DO lesion 

Figure 7. Cured lingual wall of WE 

Figure 11. Etchant applied 

Figure 8. Application of B1 enamel 

Figure 12. Adhesive applied 


Figure 13. Nanofilled, nanocluster composite, shade A3, syringed into 

preparation 

Figure 14. Packing of composite into preparation 

Figure 15. Final, esthetic single-shade posterior restoration 

Summary 

Esthetic composite restorations have gained popularity with patients 

and increased usage by clinicians. During the development 

of composite restorations, several categories have been developed. 

Current composites can be categorized as microfilled, (micro) 

hybrid, and nanofilled, as well as flowable and packable. Recent 

developments in composite technology have resulted in improved 

physical characteristics and improved esthetics, without compromising 

strength. Each type of composite offers different physical 

and esthetic characteristics that must be considered when selecting 

a composite and technique for individual cases. 

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2006;22(4):299-307. Epub 2005 Aug 8. 

21 Chalifoux PR. Composite tints: mixing composite materials to alter 

color and techniques to simulate hypocalcification and craze lines. 

Compend Contin Educ Dent. 2004;25(8):583-4, 586, 588 passim; quiz 

592, 613. 

22 Yu B, Lee YK. Translucency of varied brand and shade of resin 

composites. Am J Dent. 2008;21(4):229-32. 

23 Paravina RD, Westland S, Kimura M, Powers JM, Imai FH. Color 

interaction of dental materials: blending effect of layered composites. 

Dent Mater. 2006;22(10):903-8. Epub 2005 Dec 27. 

24 Yu B, Lee YK. Differences in color, translucency and fluorescence 

between flowable and universal resin composites. J Dent. 2008 

Oct;36(10):840-6. Epub 2008 Jul 14. 

25 Lee YK, Lim BS, Rhee SH, Yang HC, Powers JM. Color and 

translucency of A2 shade resin composites after curing, polishing and 

thermocycling. Oper Dent. 2005;30(4):436-42. 

26 Lee YK, Lim BS, Rhee SH, Yang HC, Powers JM. Changes of optical 

properties of dental nano-filled resin composites after curing and 

thermocycling. J Biomed Mater Res B Appl Biomater. 2004;71(1):16- 

21. 

27 Lee YK, Lim BS, Rhee SH, Yang HC, Powers JM. Changes of optical 

properties of dental nano-filled resin composites after curing and 


thermocycling. J Biomed Mater Res B Appl Biomater. 2004;71(1):16- 

21. 

28 Sidhu SK, Ikeda T, Omata Y, Fujita M, Sano H. Change of color 

and translucency by light curing in resin composites. Oper Dent. 

2006;31(5):598-603. 

29 Lee YK, Kim JH, Ahn JS. Influence of the changes in the UV component 

of illumination on the color of composite resins. 

J Prosthet Dent. 2007;97(6):375-80. 

30 Milnar FJ. Selecting nanotechnology-based composites using 

colorimetric and visual analysis for the restoration of anterior dentition: 

a case report. J Esthet Restor Dent. 2004;16(2):89-100. 

31 Koupis NS, Marks LA, Verbeeck RM, Martens LC.Review: finishing 

and polishing procedures of (resin-modified) glass ionomers 

and compomers in paediatric dentistry. Eur Arch Paediatr Dent. 

2007;8(1):22-8. 





34 Morgan M. Finishing and polishing of direct posterior resin restorations. 

Pract Proced Aesthet Dent. 2004;16(3):211-7. 

35 Heintze SD, Forjanic M, Rousson V. Surface roughness and gloss of 

dental materials as a function of force and polishing time in vitro. Dent 

Mater. 2006;22(2):146-65. 

36 Ergücü Z, Türkün LS, Aladag A. Color stability of nanocomposites 

polished with one-step systems. Oper Dent. 2008;33(4):413-20. 

37 Ozel E, Korkmaz Y, Attar N, Karabulut E. Effect of one-step polishing 

systems on surface roughness of different flowable restorative materials. 

Dent Mater J. 2008;27(6):755-64. 

38 Attar N. The effect of finishing and polishing procedures on the 

surface roughness of composite resin materials. J Contemp Dent Pract. 

2007;8(1):27-35. 

39 Ergücü Z, Türkün LS, Aladag A. Color stability of nanocomposites 


40 Ergücü Z, Türkün LS. Surface roughness of novel resin composites 


41 Neme AL, Frazier KB, Roeder LB, Debner TL. Effect of prophylactic 

polishing protocols on the surface roughness of esthetic restorative 

materials. Oper Dent. 2002;27(1):50-8. 

42 Lu H, Roeder LB, Lei L, Powers JM. Effect of surface roughness 

on stain resistance of dental resin composites. J Esthet Restor Dent. 

2005;17(2):102-8; discussion 109. 



44 Ibid. 

45 Barros BACD, Lopes GC, Baratieri LN, Araujo E. Surface microhardness 

of different resin composites. IADR; Abstact 0574;2004. 

46 Lee YK, Lim BS, Rhee SH, Yang HC, Lim YK. Changes in scattering 

and absorption properties of esthetic filling materials after aging. J 

Biomed Mater Res B Appl Biomater. 2007;80(1):131-9. 

47 Yu B, Lee YK. Comparison of the color stability of flowable and 

universal resin composites. Am J Dent. 2009;22(3):160-4. 

48 Lee YK, Lu H, Powers JM. Changes in opalescence and fluorescence 

properties of resin composites after accelerated aging. Dent Mater. 

2006 Jul;22(7):653-60. 

49 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial 

analysis of amalgam and composite resins. J Dent. 2007;35(3):201-6. 

50 Willershausen B, Callaway A, Ernst CP, Stender E. The influence of 

oral bacteria on the surfaces of resin-based dental restorative materials: 

an in vitro study. Int Dent J. 1999;49(4):231-9. 

51 Bürgers R, Eidt A, Frankenberger R, Rosentritt M, Schweikl H, Handel 

G, Hahnel S. The anti-adherence activity and bactericidal effect of 

microparticulate silver additives in composite resin materials. Arch 

Oral Biol. 2009;54(6):595-601. Epub 2009 Apr 16. 

52 Quirynen M, Bollen CM. The influence of surface roughness and 

surface-free energy on supra- and subgingival plaque formation in 

man. A review of the literature. J Clin Periodontol. 1995;22(1):1-14. 

53 Matalon S, Slutzky H, Weiss EI. Surface antibacterial properties of 

packable resin composites: part I. Quintessence Int. 2004;35(3):189- 

93. 

54 Matalon S, Weiss EI, Gozaly N, Slutzky H. Surface antibacterial 

properties of compomers. Eur Arch Paediatr Dent. 2006;7(3):136-41. 

55 Slutsky H, Weiss EI, Lewinstein I, Slutzky S, Matalon S. Surface 

antibacterial properties of resin and resin-modified dental cements. 

Quintessence Int. 2007;38(1):55-61. 

56 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial 

analysis of amalgam and composite resins. J Dent. 2007;35(3):201-6. 

57 Matalon S, Slutzky H, Weiss EI. Surface antibacterial properties of 

packable resin composites: part I. Quintessence Int. 2004;35(3):189- 

93. 

58 Willershausen B, Callaway A, Ernst CP, Stender E. The influence of 

oral bacteria on the surfaces of resin-based dental restorative materials: 

an in vitro study. Int Dent J. 1999;49(4):231-9. 

59 Mota EG, Oshima HM, Burnett LH Jr, Pires LA, Rosa RS. Evaluation 

of diametral tensile strength and Knoop microhardness of five 

nanofilled composites in dentin and enamel shades. Stomatologija. 

2006;8(3):67-9. 

60 Beun S, Glorieux T, Devaux J, Vreven J, Leloup G. Characterization 

of nanofilled compared to universal and microfilled composites. Dent 

Mater. 2007;23(1):51-9. 



62 Lopes GC, Zucco J, De Lucca C, Baratieri L, Vieira L. Diametral tensile 

strength of micro-hybrid composite resins. IADR; Abstact 0585;2004. 

63 Ilie N, Jelen E, Clementino-Luedemann T, Hickel R. Lowshrinkage 

composite for dental application. Dent Mater J. 2007;26(2):149-55. 

64 Bracho-Troconis C, Rudolph S, Boulden J, Wong N. Conversion vs. 

Shrinkage of N’Durance, Dimer Acid based Nanohybrid Composite. 

IADR. 2008, Rotonto July 1-4. Abstract 1812. 

65 Kobussen GA, Craid BD, Halvorson RH, Doruff MC, Bigham WS. 

Optical Properties of an Experimental Highly Aesthetic Composite 

Restorative. IADR 2009, April 1 –3, Miami. Avstract 1508. 

Author Profile 

Robert C. Margeas, DDS, FAGD 

Dr. Margeas graduated from the University of Iowa College 

of Dentistry in 1986 and completed his AEGD residency 

the following year. He is currently an adjunct professor in 

the department of Operative Dentistry at the University of 

Iowa. He is Board Certified by the American Board of Operative 

Dentistry. He is a Diplomate of the American Board of Aesthetic 

Dentistry , a Fellow of the Academy of General Dentistry and International 

Team of Oral Implantologists (ITI). He has written numerous articles on 

esthetic and implant dentistry, and lectures and presents hands-on courses 

nationally and internationally on those subjects. He serves on the Editorial 

Advisory board of Inside Dentistry, Compendium, and is a contributing 

editor to Dentistry Today and Oral Health in Canada. Dr. Margeas maintains 

a full-time private practice focusing on comprehensive restorative and 

implant dentistry in Des Moines, Iowa. 

Disclaimer 

Dr. Margeas has been a speaker on behalf of 3M ESPE as well as 

other composite manufacturers. 

Reader Feedback 

We encourage your comments on this or any PennWell course. 

For your convenience, an online feedback form is available at www. 

ineedce.com. 


Online Completion 

Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. 

Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will 

be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, 

sign in and return to your Archives Page. 

Questions 

1. Esthetic solutions for restorations must be 

achieved in tandem with _______________. 

a. the functional requirements of strength 

b. physical compatibility with the surrounding tooth 

structure 

c. volumetric and morphologic stability 

d. all of the above 

2. The use of amalgam for posterior restorations 

has _______________ in recent years. 

a. gradually increased 

b. remained the same 

c. gradually decreased 

d. increased dramatically 

3. Early composite resins _______________. 

a. were typically quartz-filled 

b. did not meet the compressive and tensile force requirements 

for posterior restorations 

c. had high surface roughness and low polishability 


4. Early posterior composite materials were 

_______________. 

a. suitable for anterior restorations 

b. suitable for posterior restorations 

c. suitable for indirect restorations 


5. Composite resin is currently available as 

_______________ composite. 

a. microfilled 

b. microhybrid 

c. nanofilled 


6. The addition of various sizes and types of 

fillers has altered the _______________ 

properties of composites. 

a. physical 

b. esthetic 

c. genetic 

d. a and b 

7. Microfilled composite resins 

_______________. 

a. contain crushed filler particles, typically prepolymerized 

and comprised of resin and fumed silica 

b. have a lower filler load than microhybrid composite 

resins 

c. offer high polishability and excellent esthetics 


8. Microhybrid composite resins 

_______________. 

a. develop a rougher surface over time 

b. offer strong physical properties 

c. are suitable for stress-bearing restorations 


9. Nanofilled composite resins have high filler 

loads in order to obtain _______________ 

similar to that of microhybrid composite 

resins. 

a. strength and wear resistance 

b. wear and elasticity 

c. elasticity and esthetics 

d. none of the above 

10. Flowable composite resins _______________. 

a. have lower filler loads than packable composites 

b. flow and conform to the preparation margins 

c. have a high viscosity 

d. a and b 

11. One study comparing restorations using 

nanofilled composite resin found those 

_______________ of flowable composite to be 

clinically successful. 

Questions 

a. those with an underlying layer 

b. those without an underlying later 

c. those with and without an underlying layer 


12. The value of a composite shade refers to the 

_______________. 

a. use of hues 

b. degree of lightness or darkness 

c. the opacity of the shade 


13. Chroma refers to the _______________. 

a. color of a shade 

b. opalescence of a shade 

c. intensity of a shade 


14. If teeth are stained, the staining should be 

removed _______________ selecting a shade. 

a. prior to 

b. at the same time as 

c. after 

d. any of the above 

15. Selecting a shade while a rubber dam is on 

the teeth can affect the choice of shade due to 

the _______________. 

a. altered color perception because of the influence of the 

rubber dam itself 

b. altered appearance of dessicated teeth 

c. altered number of teeth that are visible 

d. a and b 

16. Opacity in a composite _______________. 

a. enables the creation of many shades ranging from 

opaque to highly translucent 

b. is higher in more chromatic shades 

c. is essential for deeper restorations 


17. Selecting _______________ shades can 

be critical for the esthetic outcome of an 

individual case. 

a. opaque 

b. translucent 

c. opaque and/or translucent 


18. The size and volume of filler particles in a 

composite resin _______________. 

a. contributes to light-scattering properties 

b. influences the perceived color 

c. influences the perceived translucency 


19. Nanosized filler particles _______________. 

a. enable the transmission of light 

b. scatter blue light 

c. enhance the lifelike appearance of composite resin 

materials 


20. In general, increased filler load 

_______________ translucency. 

a. increases 

b. decreases 

c. does not affect 

d. mimics 

21. Single-shade restorations _______________. 

a. require that the composite be able to blend in with the 

surrounding tooth structure 

b. are quicker and simpler to place than dual or multiple 

shade restorations 

c. are rarely practical 

d. a and b 

22. When using a dual shade technique, the 

_______________ color should be selected 

first, followed by the _______________ shade 

and then, if used, the translucent shade. 

a. enamel; dentin 

b. dentin; enamel 

c. cementum 


23. Multilayering techniques _______________. 

a. require the most shades 

b. are the most time-consuming and complex 

c. offer the most esthetic solution for specific cases 


24. It is important when using dual- or multipleshade 

techniques to use _______________ for 

that composite system. 

a. the same brand of composite 

b. the same brand shade guide 

c. the same brand matrix 

d. a and b 

25. Shade selection for a composite can be 

determined using _______________. 

a. the shade guide or uncured resin 

b. uncured or cured resin 

c. the shade guide or cured resin 

d. the shade guide for a glass ionomer 

26. A high-gloss, smooth surface 

_______________. 

a. reflects light 

b. results in an appearance that is not as dark or dull as a 

rough surface 

c. gives a more natural appearance 


27. The combination of nanofillers around 

nanoclusters has been shown to result in 

_______________. 

a. a more even pattern of wear 

b. a rougher surface 

c. a smoother surface 

d. a and c 

28. In vitro data indicates that the 

microhardness of a nanofilled composite 

is _______________ that of microfilled 

composites. 

a. higher than 

b. the same as 

c. lower than 

d. a or c 

29. A smooth, glossy surface can reduce the 

potential for _______________. 

a. bacterial removal 

b. bacterial adhesion 

c. bactericidal activity 

d. viral removal 

30. Each type of composite offers 

_______________ properties that must be 

considered when selecting a composite and 

technique for an individual case. 

a. the same physical and different esthetic 

b. the same physical and esthetic 

c. different physical and the same esthetic 

d. different physical and esthetic 


ANSWER SHEET 

Composite Restoration Esthetics 

Name: Title: Specialty: 

Address: 

E-mail: 

City: State: ZIP: Country: 

Telephone: Home ( ) Office ( ) 

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all 

information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn 

you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822 

Educational Objectives 

1. List and describe the categories of composite resin restorative materials available and their characteristics and 

indications for use. 

2. List and describe the modes of failure for composite resin restorative materials. 

3. List and describe the shade considerations involved in the attainment of esthetics in composite resin restorations and 

the use of different shading and layering techniques. 

4. List and describe the relevance of a smooth surface and gloss as well as polishability, and factors influencing these. 

Course Evaluation 

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 

1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No 

Objective #2: Yes No Objective #4: Yes No 

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 

If not taking online, mail completed answer sheet to 

Academy of Dental Therapeutics and Stomatology, 

A Division of PennWell Corp. 

P.O. Box 116, Chesterland, OH 44026 

or fax to: (440) 845-3447 

For immediate results, 

go to www.ineedce.com to take tests online. 

Answer sheets can be faxed with credit card payment to 

(440) 845-3447, (216) 398-7922, or (216) 255-6619. 

Payment of $49.00 is enclosed. 

(Checks and credit cards are accepted.) 

If paying by credit card, please complete the 

following: MC Visa AmEx Discover 

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Exp. Date: _____________________ 

Charges on your statement will show up as PennWell 

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 

7. Was the overall administration of the course effective? 5 4 3 2 1 0 

8. Do you feel that the references were adequate? Yes No 

9. Would you participate in a similar program on a different topic? Yes No 

10. If any of the continuing education questions were unclear or ambiguous, please list them. 

___________________________________________________________________ 

11. Was there any subject matter you found confusing? Please describe. 

___________________________________________________________________ 

___________________________________________________________________ 

12. What additional continuing dental education topics would you like to see? 

___________________________________________________________________ 

___________________________________________________________________ 

Please check here if you wish to receive future communications from 

the sponsor of this course, 3M ESPE 

AGD Code 253 

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. 

AUTHOR DISCLAIMER 

Dr. Margeas has been a speaker on behalf of 3M ESPE as well as other composite manufacturers. 

SPONSOR/PROVIDER 

This course was made possible through an unrestricted educational grant from 3M ESPE. 

No manufacturer or third party has had any input into the development of course content. 

All content has been derived from references listed, and or the opinions of clinicians. Please 

direct all questions pertaining to PennWell or the administration of this course to Machele 

Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com. 

COURSE EVALUATION and PARTICIPANT FEEDBACK 

We encourage participant feedback pertaining to all courses. Please be sure to complete the 

survey included with the course. Please e-mail all questions to: macheleg@pennwell.com. 

INSTRUCTIONS 

All questions should have only one answer. Grading of this examination is done 

manually. Participants will receive confirmation of passing by receipt of a verification 

form. Verification forms will be mailed within two weeks after taking an examination. 

EDUCATIONAL DISCLAIMER 

The opinions of efficacy or perceived value of any products or companies mentioned 

in this course and expressed herein are those of the author(s) of the course and do not 

necessarily reflect those of PennWell. 

Completing a single continuing education course does not provide enough information 

to give the participant the feeling that s/he is an expert in the field related to the course 

topic. It is a combination of many educational courses and clinical experience that 

allows the participant to develop skills and expertise. 

COURSE CREDITS/COST 

All participants scoring at least 70% on the examination will receive a verification 

form verifying 2 CE credits. The formal continuing education program of this sponsor 

is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for 

current term of acceptance. Participants are urged to contact their state dental boards 

for continuing education requirements. PennWell is a California Provider. The California 

Provider number is 4527. The cost for courses ranges from $49.00 to $110.00. 

Many PennWell self-study courses have been approved by the Dental Assisting National 

Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet 

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PennWell course has been approved by DANB, please contact DANB’s Recertification 

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