Composite Restoration Esthetics - IneedCE.com
Composite Restoration Esthetics - IneedCE.com
Composite Restoration Esthetics - IneedCE.com
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Earn<br />
2 CE credits<br />
This course was<br />
written for dentists,<br />
dental hygienists,<br />
and assistants.<br />
<strong>Composite</strong> <strong>Restoration</strong><br />
<strong>Esthetics</strong><br />
A Peer-Reviewed Publication<br />
Written by Robert C. Margeas, DDS, FAGD<br />
PennWell designates this activity for 2 Continuing Educational Credits<br />
Publication date: November 2009<br />
Go Green, Go Online to take your course<br />
Review date: March 2011<br />
Expiry date: February 2014<br />
This course has been made possible through an unrestricted educational grant. The cost of this CE course is $49.00 for 2 CE credits.<br />
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<br />
Overall goal: The purpose of this article is to provide dental professionals<br />
with information about the esthetic considerations and<br />
strength of direct <strong>com</strong>posites. Upon <strong>com</strong>pletion of this course, the<br />
clinician will be able to do the following:<br />
1. List and describe the categories of <strong>com</strong>posite resin restorative<br />
materials available and their characteristics and indications for use.<br />
2. List and describe the modes of failure for <strong>com</strong>posite resin<br />
restorative materials.<br />
3. List and describe the shade considerations involved in the<br />
attainment of esthetics in <strong>com</strong>posite resin restorations and the use<br />
of different shading and layering techniques.<br />
4. List and describe the relevance of a smooth surface and gloss as<br />
well as polishability, and factors influencing these.<br />
Abstract<br />
The increased use of direct <strong>com</strong>posite restorations can be mainly<br />
attributed to patient demand for esthetic restorations and the<br />
availability of <strong>com</strong>posites with high strength and excellent esthetics.<br />
While early <strong>com</strong>posites were weak and suitable only for anterior<br />
restorations, current <strong>com</strong>posites are highly esthetic and offer<br />
high strength for their intended purposes. Techniques have also<br />
evolved, with sophisticated bonding techniques and single-shade,<br />
dual-shade, and multilayering techniques to optimize esthetics.<br />
It is important to consider not only the individual case, relative<br />
strength, and esthetics of different types of <strong>com</strong>posites but also the<br />
technique to be used when selecting a restorative material.<br />
Introduction<br />
Direct <strong>com</strong>posite restorative materials offer esthetic solutions for<br />
clinicians and patients. Esthetic solutions must be achieved in<br />
tandem with the functional requirements of strength, volumetric<br />
and morphologic stability, physical <strong>com</strong>patibility with the surrounding<br />
tooth structure, bio<strong>com</strong>patibility, and the ability either<br />
to self-adhere to the tooth surface or to adhere with an adhesive<br />
system for a durable bond at the tooth-restoration interface. Additional<br />
desirable properties include the ability to inhibit biofilm<br />
formation, thereby reducing the load of acidogenic and periodontal<br />
bacteria; stain resistance; and user-friendliness. Ideally, a restorative<br />
material will meet all these requirements, allowing it to be<br />
used for both anterior and posterior restorations. While amalgam<br />
fulfills the physical requirements for direct restorations, 1 is quicker<br />
and easier to place than are esthetic restorative materials, is more<br />
tolerant of moisture, and can now be hybrid-bonded with the use<br />
of amalgam bonding techniques (which has reduced the need for<br />
classical amalgam preparations, although results have been found<br />
to be variable), 2,3 its lack of esthetic results means it is suitable<br />
only for posterior restorations. Its use for posterior restorations<br />
has also gradually declined 4 as patients have be<strong>com</strong>e increasingly<br />
aware of esthetics and want the improved posterior esthetic materials<br />
that have be<strong>com</strong>e available in response to these demands.<br />
Clinicians demand esthetic materials with improved physical and<br />
handling properties. Physical requirements differ for anterior<br />
and posterior restorations. Anterior restorations, especially those<br />
involving incisal edges, require high strength as well as high esthetics.<br />
Posterior restorations have the added requirement of low<br />
wear. Esthetic restorative materials must offer adequate shade<br />
availability, suitable chroma and values, translucency, opacity,<br />
opalescence, fluorescence, a smooth and glossy surface, and stain<br />
and wear resistance.<br />
Development of <strong>Composite</strong> Resins<br />
When first introduced in the 1970s, <strong>com</strong>posite resins were utilized<br />
only for anterior restorations. 5 These early variants were typically<br />
quartz-filled; did not meet the <strong>com</strong>pressive and tensile force<br />
requirements for posterior restorations; and had relatively high<br />
surface roughness, low polishability, poor resistance to staining,<br />
and poor bonding at the tooth-restoration interface, which, in<br />
<strong>com</strong>bination with polymerization shrinkage, resulted in margin<br />
degradation and postoperative sensitivity. The choice of shades<br />
was limited, and the materials, other than being tooth-colored,<br />
offered poor esthetics with little or no differentiation of shading by<br />
fluorescence, translucency, or intended location (such as cervical<br />
shades for cervical restorations). In addition to these disadvantages,<br />
early resin <strong>com</strong>posites were difficult to handle, required manual<br />
mixing of the resin paste (A) and the catalyst (B), were available<br />
only in tubs or syringes of pastes (A and B separately), and were<br />
always self-cured with a limited working time. Over time, the<br />
strength characteristics of <strong>com</strong>posite resins were improved and<br />
the resins were introduced for use in posterior restorations. These<br />
materials were still unsuitable for posterior restorations in which<br />
high <strong>com</strong>pressive strength was required to resist occlusal and<br />
masticatory forces. Wear resistance was also low. Bonding systems<br />
were still primitive in the 1980s, with limited choice in technique.<br />
Self-adhesive systems were not available and there was little choice<br />
in terms of etching methods. The focus was still on enamel etching<br />
and bonding, and early attempts at dentin bonding resulted in<br />
weak bonding to the smear layer and a rapidly degrading bond. 6 It<br />
was also re<strong>com</strong>mended that, after curing of the resin, the enamelrestoration<br />
interface be re-etched and an unfilled resin be placed<br />
over this surface to seal it and help inhibit microleakage and<br />
wear. 7,8 By the 1990s, posterior <strong>com</strong>posite restorations were available<br />
that were better-suited to Class I and Class II restorations. 9<br />
These enabled a more conservative approach during preparation<br />
than amalgam did, and they were used with improved bonding<br />
systems for improved marginal integrity at the tooth-restoration<br />
interface.<br />
Current <strong>com</strong>posite materials (and bonding systems) are vastly<br />
superior to earlier versions. Current materials are available with<br />
several types of fillers, advanced enamel and dentin adhesive systems,<br />
and they offer strength, lower polymerization shrinkage and<br />
stress, wear resistance, and excellent esthetics.<br />
Current <strong>Composite</strong> Restorative Materials<br />
<strong>Composite</strong> resin materials are currently available as microfilled,<br />
(micro)hybrid, and nanofilled <strong>com</strong>posites. Their chemistry is<br />
typically based on bisphenol-a-glycidyl dimethacrylate (Bis-<br />
GMA); however, additive chemistry has been used to reduce<br />
2 www.ineedce.<strong>com</strong>
polymerization shrinkage or stress, and the addition of various<br />
sizes and types of fillers has altered physical and esthetic properties.<br />
Pre-polymerized clusters and increased filler load help reduce<br />
polymerization shrinkage and stress, and increasing filled load also<br />
results in a higher viscosity <strong>com</strong>posite. Each <strong>com</strong>posite type offers<br />
advantages specific to its chemistry. An understanding of these is<br />
necessary to select an appropriate material for clinical procedures.<br />
Microfilled <strong>Composite</strong> Resins<br />
Microfilled <strong>com</strong>posite resins contain crushed particles ranging in<br />
size from 0.04 to 1 micron. The filler particles are typically prepolymerized<br />
particles <strong>com</strong>prised of resin and fumed silica. Filler load<br />
is lower in microfilled <strong>com</strong>posite resins, and internal bonding between<br />
the matrix resin and the prepolymerized filler resin is weak,<br />
resulting in lower strength. This is an important consideration in<br />
stress-bearing areas. The very small particle sizes in microfilled<br />
resins, however, offer excellent esthetics with high polishability<br />
and a long-lasting surface gloss.<br />
Microhybrid/Hybrid <strong>Composite</strong> Resins<br />
Microhybrid <strong>com</strong>posite resins contain silicon dioxide filler with<br />
particles ranging in size from approximately 0.04 up to 0.1 micron,<br />
and glass particle fillers typically range in size from 0.4 to 0.6<br />
micron (400 to 600 nm). These resins lose their high polish over<br />
time with the development of a rougher surface, reducing their<br />
suitability for esthetically demanding cases. They do, however,<br />
offer strong physical properties and are suitable for stress-bearing<br />
restorations. Hybrid resins have slightly larger filler sizes than do<br />
microhybrid resins and essentially behave in the same manner.<br />
Nanofilled <strong>Composite</strong> Resins<br />
Nanofilled <strong>com</strong>posite resins have a high filler load in order to<br />
obtain strength and wear resistance similar to that of microhybrid<br />
<strong>com</strong>posite resins. Nanofilled <strong>com</strong>posite resins contain<br />
smaller particles of filler in the range of 0.02 to 0.1 microns.<br />
One nanofilled <strong>com</strong>posite (Filtek Supreme Plus) contains<br />
nanofiller particles that are approximately 0.02 microns in<br />
diameter, sintered into nanoclusters of 0.6 to 1.4 microns that<br />
contain zirconia/silica particles, in order to improve physical<br />
characteristics.<br />
Table 1. Indications for <strong>com</strong>posite resins<br />
High-esthetic restorations Stress-bearing restorations<br />
Microfilled X –<br />
Microhybrid – X<br />
Nanofilled X X<br />
Flowable and Packable <strong>Composite</strong>s<br />
Another method of categorizing <strong>com</strong>posite resin restorative<br />
materials is by flow characteristics. Flowable <strong>com</strong>posite resins<br />
have a lower filler load and a low viscosity, enabling them to be<br />
syringed directly into preparations, where they flow and conform<br />
to the preparation margins. The flowable <strong>com</strong>posites are used<br />
extensively as a liner under posterior restorations and are also<br />
used as an initial bulk layer for the sandwich technique, similar<br />
to glass ionomer cements, that is then covered with a microfilled<br />
or nanofilled <strong>com</strong>posite. They are also used in clinical situations<br />
in which heavy stress-bearing is not a requirement. Packable<br />
(universal) <strong>com</strong>posites are denser and can be condensed using<br />
plastic instruments during placement, prior to curing. One<br />
study <strong>com</strong>paring a nanofilled <strong>com</strong>posite resin with and without<br />
an underlying layer of flowable <strong>com</strong>posite after use of a two-step<br />
(total etch) or single-step bonding technique found no statistical<br />
differences in secondary caries, postoperative sensitivity, marginal<br />
discoloration or adaptation, or color at a two-year recall.<br />
Both techniques were found to be clinically successful. 10 Packable<br />
<strong>com</strong>posites have been found to be clinically successful over<br />
multiple-year analyses. 11<br />
While clinical function and longevity of esthetic <strong>com</strong>posites<br />
are the first prerequisites, optimizing esthetics is desirable and increasingly<br />
demanded by patients for all direct <strong>com</strong>posite restorations.<br />
Surface smoothness, polishability, luster (surface gloss), and<br />
specific shade attributes and techniques all play important roles in<br />
the achievement of optimal esthetics.<br />
Optimizing <strong>Esthetics</strong> in <strong>Composite</strong>s<br />
The esthetics of <strong>com</strong>posite restorations is influenced by the shape<br />
and contouring of the restoration, which must mimic the natural<br />
tooth in order to provide a natural appearance. In the case of posterior<br />
restorations, the use of sectional matrices has considerably<br />
simplified the achievement of functional and esthetic contours.<br />
Beyond the requirements of contour and shaping, and the use<br />
of an appropriate technique that avoids moisture contamination<br />
and utilizes an appropriate bonding system, esthetics is determined<br />
by the availability and appropriate selection of shade(s)<br />
– the fluorescence and translucency, value (degree of lightness or<br />
darkness), chroma (intensity of the shade), hue, ability to offer<br />
a chameleon effect, polishability, wear resistance, retention of<br />
gloss and polish, and technique. Each of these plays a role in<br />
developing and maintaining optimal esthetics.<br />
Table 2. Factors in optimized <strong>com</strong>posite esthetics<br />
Shape and contour mimicking natural dentition<br />
Functional and esthetic contours<br />
Use of an appropriate technique<br />
Avoidance of moisture contamination<br />
Use of an appropriate bonding system<br />
Selection of appropriate shade(s)<br />
Polishability of the restorative material<br />
Wear resistance<br />
Retention of gloss and polish<br />
www.ineedce.<strong>com</strong> 3
Shades and Shade Selection<br />
<strong>Composite</strong> resin systems are available with multiple shades. The<br />
number of available shades depends on the brand selected and<br />
typically includes a number of shades in the VITA A, B, C, and D<br />
ranges to cover the hues, chroma, and values that will be required<br />
for natural-looking direct <strong>com</strong>posite restorations. Shades are also<br />
available and categorized by translucency and opacity. Regardless<br />
of the technique used, if teeth are stained, the staining should be<br />
removed prior to selecting a shade(s). Shade selection also should<br />
occur prior to placement of a rubber dam, since this will affect<br />
perception of color due to color perception interference with the<br />
rubber dam and because a desiccated tooth appears whiter than a<br />
moist or wet tooth.<br />
Opacity and Translucency<br />
Different shades offer greater or lesser opacity, opalescence, and<br />
translucency. Opacity is an important property for <strong>com</strong>posites,<br />
offering flexibility by enabling the creation of many shades,<br />
ranging from very translucent, which is required for incisal edges<br />
and outer multilayering, to highly opaque, which is required for<br />
the body of a restoration replacing dentin. 12 Opacity is essential<br />
for deeper restorations and restorations with a darker pulpal<br />
floor/underlying area, in order to prevent shine-through of the<br />
darkened dentin. In extreme cases, opaquers and tinters may be<br />
required. 13 Selecting opaque and/or translucent shades can be<br />
critical for the esthetic out<strong>com</strong>e of an individual case, 14 and more<br />
chromatic shades have been found to be more opaque. 15<br />
Controlling the size and volume of filler particles is a contributing<br />
factor to light-scattering properties and therefore<br />
the perceived color and translucency of <strong>com</strong>posite resins. 16 A<br />
matching of filler size and resin is essential for light transmission<br />
in <strong>com</strong>posite resins and translucency. Translucency increases<br />
as the restorative material be<strong>com</strong>es thinner, irrespective of the<br />
shade used – a consideration when using a multilayering technique.<br />
17 Filler size in <strong>com</strong>posite resins has been found to influence<br />
the transmission and reflection of color, and it results in<br />
variations in translucency and opalescence. Opalescence varies<br />
with the size and amount of the filler. In general, increased filler<br />
load decreases translucency. 18 Nanosized filler particles enable<br />
the transmission of light, resulting in translucency. Their ability<br />
to scatter blue light provides the nanofilled <strong>com</strong>posite with opalescence,<br />
which enhances the lifelike appearance of <strong>com</strong>posite<br />
resin materials.<br />
Table 3. Influence of filler on esthetics and strength<br />
Transmission of light<br />
Reflection of color<br />
Variations in translucency<br />
Variations in opalescence<br />
Low filler is less strong<br />
Viscosity<br />
Single-Shade, Dual-Shade, and Multilayering<br />
Techniques<br />
From a practical perspective, there is a need for <strong>com</strong>posite resin<br />
systems that offer the ability to provide esthetic restorations using<br />
only one shade. Single-shade restorations are simpler and quicker<br />
to place. Single-shade restorations require that the <strong>com</strong>posite be<br />
able to blend in with the surrounding tooth structure through a<br />
chameleon effect, such that the gradation from different areas of<br />
the tooth’s structure to the restoration is not obvious and results in<br />
a natural-looking restoration.<br />
More esthetically demanding clinical situations can require a<br />
dual-shade or multilayering technique to mimic the adjacent tooth<br />
structure. Dual-shade restorative procedures are suited to situations<br />
in which there may be substantial variations in two adjacent<br />
areas – for example, for a darker cervical versus coronal area, or<br />
for a highly translucent and wide incisal edge versus the more<br />
opaque coronal area being restored. When using a dual-shade<br />
technique, the dentin color (body of the tooth) should be selected<br />
first, followed by the enamel shade (and if a translucent shade<br />
is also used, this should be chosen last). Dietschi et al. reported<br />
on a shading concept that <strong>com</strong>pared enamel and dentin shades<br />
with the opacity and specific color of teeth. After <strong>com</strong>paring teeth<br />
with similar chroma (green-red/blue-yellow values), it was found<br />
that only the blue-yellow values varied. Translucency was found<br />
to be relatively constant for dentin, and it increased with age in<br />
enamel. From these conclusions, a simplified dual-layering technique<br />
was developed – the “natural layering concept” – that uses<br />
a universal dentin hue and one of three enamel hues, depending<br />
on the age of the patient (young, adult, and old). 19 Multilayering<br />
techniques are the most time-consuming and <strong>com</strong>plex, requiring<br />
more shades to be used, but they offer the most esthetic solution<br />
for specific cases. The blending effect varies with the size of<br />
the restoration. 20 Advanced layering techniques can also utilize<br />
color tints to modify <strong>com</strong>posite shades, such as for the creation of<br />
hypocalcification-like areas to mimic adjacent teeth with hypocalcifications<br />
where these are not being treated. 21<br />
It is important when using dual- or multiple-shade techniques<br />
to use the same brand of <strong>com</strong>posite and the shade guide<br />
for that <strong>com</strong>posite system. The translucency and shade of <strong>com</strong>posites,<br />
while almost universally using the VITA shade guide<br />
system for labeling purposes, show variation across brands. 22 For<br />
multilayering techniques, the blending effect depends on both<br />
the specific brand of <strong>com</strong>posite and the shades used. 23 Significant<br />
differences in color, translucency, and fluorescence have also<br />
been found between flowable and packable (universal) <strong>com</strong>posites<br />
that were different brands but labeled as the same shades. 24<br />
Curing and polishing change the color and translucency of a<br />
<strong>com</strong>posite resin, again varying by brand and shade. 25,26,27 The<br />
shade guide, not uncured resin, should be used for shade selection.<br />
Alternatively, recently cured resin can be used. 28 It is also<br />
important to consider the availability and quality of light within<br />
the daylight UV spectrum when selecting shades. As the daylight<br />
UV varies, so too does the perceived color of <strong>com</strong>posite resins 29<br />
and teeth. The use of <strong>com</strong>puterized shade guide determination<br />
4 www.ineedce.<strong>com</strong>
through colorimetric analysis, together with the use of multilayering<br />
with nanofilled <strong>com</strong>posites, was found in one study to<br />
result in improved esthetics. 30<br />
In selecting a <strong>com</strong>posite, sufficient shades should be available<br />
in the same brand of <strong>com</strong>posite to satisfy clinical requirements for<br />
single-shade, dual-shade, and multilayering techniques. Either an<br />
accurate match to the VITA Classical shade guide, or an accurate<br />
custom shade guide must be available for the selected <strong>com</strong>posite’s<br />
shade system.<br />
Table 4. Tips for Multilayering Techniques<br />
Use the same brand of <strong>com</strong>posite for all layers<br />
Ensure the amount and quality of daylight is adequate for shade selection<br />
Do not use uncured resin to determine shades<br />
Use the VITA shade guide if the <strong>com</strong>posite system accurately mimics this<br />
Use a custom shade guide if the <strong>com</strong>posite system has custom<br />
shade labeling<br />
Surface Attributes and <strong>Esthetics</strong><br />
Surface smoothness and retention of surface gloss are important<br />
for function and esthetics. 31 A high-gloss, smooth surface reflects<br />
light, giving a more natural appearance. The scattering and absorption<br />
of light on rough surfaces results in a darker, duller appearance.<br />
The initial smoothness of <strong>com</strong>posite resins is influenced<br />
by the filler particle size and the technique used for polishing and<br />
finishing the resin. <strong>Composite</strong> resins with smaller filler particles<br />
are smoother and exhibit greater luster than do larger particle-size<br />
filled resins, thus explaining the greater surface smoothness and<br />
polish seen in both microfilled and nanofilled <strong>com</strong>posite resins.<br />
Nanofilled <strong>com</strong>posite resin containing nanoclusters has been<br />
shown to exhibit high translucency, polishability, and gloss, and its<br />
long-term polish is <strong>com</strong>parable to the characteristics of microfilled<br />
<strong>com</strong>posite resins. Nanofilled translucent shades retained polish<br />
better than did similar microfilled shades. 32,33 Microhybrids are<br />
not as glossy or smooth, but their polishability and esthetics have<br />
been enhanced in recent years. 34<br />
Polishing <strong>Composite</strong>s<br />
<strong>Composite</strong>s can be polished using two-step or one-step systems.<br />
These can include the use of silicon tips, Sof-Lex discs, rubber<br />
cups, and polishing pastes and liquid polishers. Polishing<br />
<strong>com</strong>posites has been found to achieve the greatest improvement in<br />
surface gloss within five seconds of polishing. 35 One-step polishing<br />
systems are suitable for nano<strong>com</strong>posite polishing (Filtek<br />
Supreme Plus (or XT outside of US); Grandio; CeramX; Premise;<br />
and Tetric EvoCeram) as well as flowable restorative materials;<br />
polishing results in a more stain-resistant surface. 36,37 Surface<br />
sealants have been re<strong>com</strong>mended for use following finishing<br />
and polishing in order to impart the smoothest surface. 38 It has<br />
also been found that removing the outer surface layer during<br />
polishing helps stain resistance. 39 The optimal polisher depends<br />
on the specific <strong>com</strong>posite. 40<br />
Table 5. Surface smoothness and polisher<br />
Filtek<br />
Supreme<br />
Plus<br />
Mylar PoGo OptraPol One Gloss<br />
Smoother Smoother Rougher Rougher<br />
Grandio Smoother Smoother Rougher Rougher<br />
Tetric Less rough Roughest Less rough Less rough<br />
EvoCeram<br />
Premise No significant differences<br />
CeramX No significant differences<br />
Source: Ergucu et al. Operative Dentistry, 2007.<br />
It is therefore important to follow the manufacturer’s re<strong>com</strong>mendations<br />
for specific <strong>com</strong>posites.<br />
Wear Resistance and Surface Roughness<br />
Over time, surface roughness develops in response to abrasion (as<br />
well as acid erosion) of <strong>com</strong>posite surfaces. In vitro three-surface<br />
wear testing and simulated cycles of toothbrushing are used to<br />
measure the anticipated susceptibility of <strong>com</strong>posite resins to intraoral<br />
abrasion from mastication or toothbrushing. In one study,<br />
in vitro–simulated toothbrushing resulted in rougher surfaces in<br />
microfilled and microhybrid <strong>com</strong>posites than it did in packable<br />
<strong>com</strong>posites, <strong>com</strong>pomers, and resin-modified glass ionomers. Polishing<br />
<strong>com</strong>posite resins at recall appointments can help to reduce<br />
surface roughness that has developed and to impart a smooth<br />
surface. 41 Both the amount of surface wear and mechanism of wear<br />
over time have been found to differ among resins. Surface roughness<br />
is also positively correlated with staining of <strong>com</strong>posites. 42<br />
Very small particles contained in microfilled resins result in<br />
an even wear pattern and thus retention of a smoother surface.<br />
The <strong>com</strong>bination of nanofillers around nanoclusters results in<br />
removal during wear of the very small nanofilled particles that<br />
are packed in the nanocluster surface, again resulting in a more<br />
even pattern of wear and a smoother surface. Scanning electron<br />
micrographs (SEM) have demonstrated the removal of individual<br />
small nanofiller particles from larger zirconia-silica nanoclusters. 43<br />
In contrast, SEMs of microhybrid resins show larger defects at the<br />
surface following wear, proposed to be due to the removal of larger<br />
individual particles that leave voids and a less even pattern of wear,<br />
resulting in a rougher surface than observed with microfilled and<br />
nanofilled <strong>com</strong>posites. 44<br />
Figure 1. Scanning electron micrographs of <strong>com</strong>posite fillers<br />
Nanofiller<br />
Courtesy of Dr. Jorge Perdigao<br />
Hybrid filler<br />
www.ineedce.<strong>com</strong> 5
Surface wear results in loss of gloss followed by loss of the layer<br />
below the gloss. In vitro data indicates that the microhardness of a<br />
nanofilled <strong>com</strong>posite is higher than that of microfilled <strong>com</strong>posites,<br />
attributable to the filler. 45<br />
The aging of esthetic restorative materials results in surface<br />
changes and therefore changes in the light-scattering absorption<br />
properties of glass ionomers, modified glass ionomers, <strong>com</strong>pomers,<br />
and resin <strong>com</strong>posites. 46 Aging of flowable <strong>com</strong>posites has also<br />
been found to result in more color changes <strong>com</strong>pared to universal<br />
<strong>com</strong>posites. 47 Accelerated in vitro aging was found in one in vitro<br />
study to result in the loss of translucency but not to affect opacity<br />
of <strong>com</strong>posite resins. 48<br />
Bacterial Considerations<br />
A smooth, glossy appearance is also important to reduce the potential<br />
for bacterial adhesion and the accumulation of biofilm. In<br />
vitro studies have found amalgam to be bactericidal and to inhibit<br />
the formation of biofilm. 49,50 The converse has been found with<br />
resin-based restorative materials, although, interestingly, the experimental<br />
addition of microparticulate silver to <strong>com</strong>posite resin<br />
material has been found in vitro to have a bactericidal effect as<br />
well as to inhibit bacterial adhesion. 51 These findings increase the<br />
importance of selecting a material that both achieves and retains<br />
a smooth surface. 52 In vitro studies on packable resin <strong>com</strong>posites,<br />
<strong>com</strong>pomers (polyacid-modified <strong>com</strong>posite resins), and glass ionomer<br />
cements found no antibacterial properties for these materials,<br />
while one found a minimal effect for a few days with <strong>com</strong>posite<br />
resin. 53,54,55,56 In the case of the packable <strong>com</strong>posites tested, newly<br />
polymerized resin would actually support the development of<br />
biofilm, and one study found that bacteria formed a dense biofilm<br />
on <strong>com</strong>posite resin. 57,58<br />
Combining Strength and <strong>Esthetics</strong><br />
While predictable and reliable esthetics is important, this must<br />
not result in <strong>com</strong>promised functionality. Microfilled resins are<br />
highly esthetic, suitable for anterior restorations in low stressbearing<br />
restorations. Microhybrid and nanofilled <strong>com</strong>posites are<br />
suitable for stress-bearing restorations. Some variability in the<br />
mechanical properties of different nanofilled <strong>com</strong>posites has been<br />
found in in vitro testing. 59<br />
Beun et al. <strong>com</strong>pared the mechanical properties of nanofilled,<br />
microhybrid, and microfilled <strong>com</strong>posites. The nanofilled <strong>com</strong>posites<br />
had an elastic modulus and physical properties at least<br />
equivalent or better than those of universal <strong>com</strong>posite and superior<br />
to those of microfilled <strong>com</strong>posite. 60 One study <strong>com</strong>paring the<br />
properties of nanofilled <strong>com</strong>posite resin containing nanoclusters<br />
and microfilled and hybrid resin <strong>com</strong>posites found that nanofilled/nanocluster<br />
<strong>com</strong>posites offered physical characteristics and<br />
strength <strong>com</strong>parable to those of microhybrid <strong>com</strong>posites. Physical<br />
characteristics measured and <strong>com</strong>pared included wear resistance –<br />
also a factor in esthetics, <strong>com</strong>pressive and diametral strengths, and<br />
fracture resistance. 61 The same nanofilled <strong>com</strong>posite was found in<br />
other in vitro testing to have higher diametral tensile strength than<br />
did microhybrid <strong>com</strong>posites. 62<br />
Latest Developments in <strong>Composite</strong> Resins<br />
Recent developments in <strong>com</strong>posite resin technology have included<br />
reductions in polymerization shrinkage and in polymerization<br />
stress. These have been achieved through increased filler loads<br />
and novel chemical technology. Polymerization shrinkage, and<br />
therefore stress, has been reduced through the use of siloranering-based<br />
chemistry 63 as well as by increasing conversion rate<br />
of the monomer. 64 Direct reduction of polymerization stress<br />
has now also been achieved through the use of a polymerization<br />
modulator to reduce stress. A recent development has improved<br />
esthetics in a high-strength, esthetic nanofilled <strong>com</strong>posite.<br />
Changes in the synthesis of nanoclusters in nanofilled <strong>com</strong>posite<br />
resin have demonstrated improved polish retention and handling,<br />
while maintaining wear resistance, in in vitro testing. The<br />
same material has fracture toughness equal to that of the upper<br />
range of other <strong>com</strong>posites, as well as high flexural strength. 65<br />
The cases below illustrate the use of this new nanofilled/<br />
nanocluster <strong>com</strong>posite for single-shade and multilayering techniques.<br />
Case Studies<br />
Case 1. Multi-layering technique<br />
The patient presented with an old, worn and defective <strong>com</strong>posite.<br />
After discussion, it was decided to replace the Class IV <strong>com</strong>posite.<br />
The old <strong>com</strong>posite was removed, followed by etching of the<br />
enamel and dentin, rinsing and drying, then use of the bonding<br />
agent. The <strong>com</strong>posite (Filtek TM Supreme Ultra universal <strong>com</strong>posite)<br />
was then layered for optimal esthetics, using a thin layer of<br />
WE, followed by A1 to create a ‘dentin replacement layer’ at the<br />
lobes. This was followed by application of grey translucent shade<br />
between the lobes and B1 enamel shade. The final restoration was<br />
polished using a Sof-Lex disc, followed by a cup brush and polish<br />
for an esthetic, high gloss smooth surface finish.<br />
Figure 2. Old, worn <strong>com</strong>posite restoration<br />
Figure 3. Old <strong>com</strong>posite removed<br />
6 www.ineedce.<strong>com</strong>
Figure 4. Etchant applied<br />
Figure 9. Final, polished restoration<br />
Figure 5. Bonding agent applied<br />
Figure 6. Thin layer of WE against impression template<br />
Case 2. Single-shade restoration<br />
In this case the patient presented with a carious DO lesion, visible<br />
unaided as well as radiographically. The patient preferred an esthetic<br />
<strong>com</strong>posite restoration. After removing the carious enamel and dentin,<br />
the tooth was first etched, rinsed and dried, and then the adhesive<br />
layer applied. Shade A3 body was then used and the <strong>com</strong>posite<br />
resin syringed directly into the preparation. The <strong>com</strong>posite was then<br />
packed into the tooth and light-cured. Finishing of the restoration<br />
was achieved using a fine diamond for fine occlusal contouring, followed<br />
first by a Sof-Lex disc and then a brush cup and polish.<br />
Figure 10. Carious DO lesion<br />
Figure 7. Cured lingual wall of WE<br />
Figure 11. Etchant applied<br />
Figure 8. Application of B1 enamel<br />
Figure 12. Adhesive applied<br />
www.ineedce.<strong>com</strong> 7
Figure 13. Nanofilled, nanocluster <strong>com</strong>posite, shade A3, syringed into<br />
preparation<br />
Figure 14. Packing of <strong>com</strong>posite into preparation<br />
Figure 15. Final, esthetic single-shade posterior restoration<br />
Summary<br />
Esthetic <strong>com</strong>posite restorations have gained popularity with patients<br />
and increased usage by clinicians. During the development<br />
of <strong>com</strong>posite restorations, several categories have been developed.<br />
Current <strong>com</strong>posites can be categorized as microfilled, (micro)<br />
hybrid, and nanofilled, as well as flowable and packable. Recent<br />
developments in <strong>com</strong>posite technology have resulted in improved<br />
physical characteristics and improved esthetics, without <strong>com</strong>promising<br />
strength. Each type of <strong>com</strong>posite offers different physical<br />
and esthetic characteristics that must be considered when selecting<br />
a <strong>com</strong>posite and technique for individual cases.<br />
References<br />
1 Roulet JF. Benefits and disadvantages of tooth-coloured alternatives to<br />
amalgam. J Dent. 1997;25(6):459-73.<br />
2 Setcos JC, Staninec M, Wilson NH. Bonding of amalgam restorations:<br />
existing knowledge and future prospects. Oper Dent. 2000;25(2):121-9.<br />
3 Mahler DB, Engle JH. Clinical evaluation of amalgam bonding in Class<br />
I and II restorations. J Am Dent Assoc. 2000;131(1):43-9.<br />
4 Burke FJ. Amalgam to tooth-coloured materials--implications for<br />
clinical practice and dental education: governmental restrictions and<br />
amalgam-usage survey results. J Dent. 2004;32(5):343-50.<br />
5 Small BW. Direct resin <strong>com</strong>posites for 2002 and beyond. Gen Dent.<br />
2002;50(1):30-3.<br />
6 Eliades GC, Caputo AA, Vougionklakis A. Composition, wetting<br />
properties and bond strength with dentin of six new dentin adhesives.<br />
Dent Mater. 1985; 1:170–6.<br />
7 Wilson EG, Mandradjieff M, Brindock T. Controversies in posterior<br />
<strong>com</strong>posite resin restorations. Dent Clin North Am. 1990 ;34(1):27-44.<br />
8 Leinfelder KF. Using <strong>com</strong>posite resin as a posterior restorative material.<br />
J Am Dent Assoc. 1991;122(4):65-70.<br />
9 Leinfelder KF. Using <strong>com</strong>posite resin as a posterior restorative material.<br />
J Am Dent Assoc. 1991 Apr;122(4):65-70.<br />
10 Efes BG, Dörter C, Gömeç Y, Koray F. Two-year clinical evaluation of<br />
ormocer and nanofill <strong>com</strong>posite with and without a flowable liner. J<br />
Adhes Dent. 2006;8(2):119-26.<br />
11 Kiremitci A, Alpaslan T, Gurgan S. Six-year clinical evaluation of<br />
packable <strong>com</strong>posite restorations. Oper Dent. 2009;34(1):11-7.<br />
12 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in<br />
advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.<br />
13 Dias WR, Pereira PN, Swift EJ Jr. Maximizing esthetic results in<br />
posterior restorations using <strong>com</strong>posite opaquers. J Esthet Restor Dent.<br />
2001;13(4):219-27.<br />
14 Ikeda T, Sidhu SK, Omata Y, Fujita M, Sano H. Colour and translucency<br />
of opaque-shades and body-shades of resin <strong>com</strong>posites. Eur J Oral Sci.<br />
2005;113(2):170-3.<br />
15 Yu B, Lee YK. Influence of color parameters of resin <strong>com</strong>posites on<br />
their translucency. Dent Mater. 2008;24(9):1236-42. Epub 2008 Mar<br />
28.<br />
16 Lee YK. Influence of scattering/absorption characteristics on the color<br />
of resin <strong>com</strong>posites. Dent Mater. 2007 ;23(1):124-31. Epub 2006 Feb<br />
17.<br />
17 Kamishima N, Ikeda T, Sano H. Color and translucency of resin<br />
<strong>com</strong>posites for layering techniques. Dent Mater J. 2005;24(3):428-32.<br />
18 Lee YK. Influence of filler on the difference between the transmitted<br />
and reflected colors of experimental resin <strong>com</strong>posites. Dent Mater.<br />
2008;24(9):1243-7. Epub 2008 Mar 17.<br />
19 Dietschi D, Ardu S, Krejci I. A new shading concept based on natural<br />
tooth color applied to direct <strong>com</strong>posite restorations. Quintessence Int.<br />
2006;37(2):91-102.<br />
20 Paravina RD, Westland S, Imai FH, Kimura M, Powers JM. Evaluation<br />
of blending effect of <strong>com</strong>posites related to restoration size. Dent Mater.<br />
2006;22(4):299-307. Epub 2005 Aug 8.<br />
21 Chalifoux PR. <strong>Composite</strong> tints: mixing <strong>com</strong>posite materials to alter<br />
color and techniques to simulate hypocalcification and craze lines.<br />
Compend Contin Educ Dent. 2004;25(8):583-4, 586, 588 passim; quiz<br />
592, 613.<br />
22 Yu B, Lee YK. Translucency of varied brand and shade of resin<br />
<strong>com</strong>posites. Am J Dent. 2008;21(4):229-32.<br />
23 Paravina RD, Westland S, Kimura M, Powers JM, Imai FH. Color<br />
interaction of dental materials: blending effect of layered <strong>com</strong>posites.<br />
Dent Mater. 2006;22(10):903-8. Epub 2005 Dec 27.<br />
24 Yu B, Lee YK. Differences in color, translucency and fluorescence<br />
between flowable and universal resin <strong>com</strong>posites. J Dent. 2008<br />
Oct;36(10):840-6. Epub 2008 Jul 14.<br />
25 Lee YK, Lim BS, Rhee SH, Yang HC, Powers JM. Color and<br />
translucency of A2 shade resin <strong>com</strong>posites after curing, polishing and<br />
thermocycling. Oper Dent. 2005;30(4):436-42.<br />
26 Lee YK, Lim BS, Rhee SH, Yang HC, Powers JM. Changes of optical<br />
properties of dental nano-filled resin <strong>com</strong>posites after curing and<br />
thermocycling. J Biomed Mater Res B Appl Biomater. 2004;71(1):16-<br />
21.<br />
27 Lee YK, Lim BS, Rhee SH, Yang HC, Powers JM. Changes of optical<br />
properties of dental nano-filled resin <strong>com</strong>posites after curing and<br />
8 www.ineedce.<strong>com</strong>
thermocycling. J Biomed Mater Res B Appl Biomater. 2004;71(1):16-<br />
21.<br />
28 Sidhu SK, Ikeda T, Omata Y, Fujita M, Sano H. Change of color<br />
and translucency by light curing in resin <strong>com</strong>posites. Oper Dent.<br />
2006;31(5):598-603.<br />
29 Lee YK, Kim JH, Ahn JS. Influence of the changes in the UV <strong>com</strong>ponent<br />
of illumination on the color of <strong>com</strong>posite resins.<br />
J Prosthet Dent. 2007;97(6):375-80.<br />
30 Milnar FJ. Selecting nanotechnology-based <strong>com</strong>posites using<br />
colorimetric and visual analysis for the restoration of anterior dentition:<br />
a case report. J Esthet Restor Dent. 2004;16(2):89-100.<br />
31 Koupis NS, Marks LA, Verbeeck RM, Martens LC.Review: finishing<br />
and polishing procedures of (resin-modified) glass ionomers<br />
and <strong>com</strong>pomers in paediatric dentistry. Eur Arch Paediatr Dent.<br />
2007;8(1):22-8.<br />
32 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in<br />
advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.<br />
33 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in<br />
advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.<br />
34 Morgan M. Finishing and polishing of direct posterior resin restorations.<br />
Pract Proced Aesthet Dent. 2004;16(3):211-7.<br />
35 Heintze SD, Forjanic M, Rousson V. Surface roughness and gloss of<br />
dental materials as a function of force and polishing time in vitro. Dent<br />
Mater. 2006;22(2):146-65.<br />
36 Ergücü Z, Türkün LS, Aladag A. Color stability of nano<strong>com</strong>posites<br />
polished with one-step systems. Oper Dent. 2008;33(4):413-20.<br />
37 Ozel E, Korkmaz Y, Attar N, Karabulut E. Effect of one-step polishing<br />
systems on surface roughness of different flowable restorative materials.<br />
Dent Mater J. 2008;27(6):755-64.<br />
38 Attar N. The effect of finishing and polishing procedures on the<br />
surface roughness of <strong>com</strong>posite resin materials. J Contemp Dent Pract.<br />
2007;8(1):27-35.<br />
39 Ergücü Z, Türkün LS, Aladag A. Color stability of nano<strong>com</strong>posites<br />
polished with one-step systems. Oper Dent. 2008;33(4):413-20.<br />
40 Ergücü Z, Türkün LS. Surface roughness of novel resin <strong>com</strong>posites<br />
polished with one-step systems. Oper Dent. 2007;32(2):185-92.<br />
41 Neme AL, Frazier KB, Roeder LB, Debner TL. Effect of prophylactic<br />
polishing protocols on the surface roughness of esthetic restorative<br />
materials. Oper Dent. 2002;27(1):50-8.<br />
42 Lu H, Roeder LB, Lei L, Powers JM. Effect of surface roughness<br />
on stain resistance of dental resin <strong>com</strong>posites. J Esthet Restor Dent.<br />
2005;17(2):102-8; discussion 109.<br />
43 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in<br />
advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.<br />
44 Ibid.<br />
45 Barros BACD, Lopes GC, Baratieri LN, Araujo E. Surface microhardness<br />
of different resin <strong>com</strong>posites. IADR; Abstact 0574;2004.<br />
46 Lee YK, Lim BS, Rhee SH, Yang HC, Lim YK. Changes in scattering<br />
and absorption properties of esthetic filling materials after aging. J<br />
Biomed Mater Res B Appl Biomater. 2007;80(1):131-9.<br />
47 Yu B, Lee YK. Comparison of the color stability of flowable and<br />
universal resin <strong>com</strong>posites. Am J Dent. 2009;22(3):160-4.<br />
48 Lee YK, Lu H, Powers JM. Changes in opalescence and fluorescence<br />
properties of resin <strong>com</strong>posites after accelerated aging. Dent Mater.<br />
2006 Jul;22(7):653-60.<br />
49 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial<br />
analysis of amalgam and <strong>com</strong>posite resins. J Dent. 2007;35(3):201-6.<br />
50 Willershausen B, Callaway A, Ernst CP, Stender E. The influence of<br />
oral bacteria on the surfaces of resin-based dental restorative materials:<br />
an in vitro study. Int Dent J. 1999;49(4):231-9.<br />
51 Bürgers R, Eidt A, Frankenberger R, Rosentritt M, Schweikl H, Handel<br />
G, Hahnel S. The anti-adherence activity and bactericidal effect of<br />
microparticulate silver additives in <strong>com</strong>posite resin materials. Arch<br />
Oral Biol. 2009;54(6):595-601. Epub 2009 Apr 16.<br />
52 Quirynen M, Bollen CM. The influence of surface roughness and<br />
surface-free energy on supra- and subgingival plaque formation in<br />
man. A review of the literature. J Clin Periodontol. 1995;22(1):1-14.<br />
53 Matalon S, Slutzky H, Weiss EI. Surface antibacterial properties of<br />
packable resin <strong>com</strong>posites: part I. Quintessence Int. 2004;35(3):189-<br />
93.<br />
54 Matalon S, Weiss EI, Gozaly N, Slutzky H. Surface antibacterial<br />
properties of <strong>com</strong>pomers. Eur Arch Paediatr Dent. 2006;7(3):136-41.<br />
55 Slutsky H, Weiss EI, Lewinstein I, Slutzky S, Matalon S. Surface<br />
antibacterial properties of resin and resin-modified dental cements.<br />
Quintessence Int. 2007;38(1):55-61.<br />
56 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial<br />
analysis of amalgam and <strong>com</strong>posite resins. J Dent. 2007;35(3):201-6.<br />
57 Matalon S, Slutzky H, Weiss EI. Surface antibacterial properties of<br />
packable resin <strong>com</strong>posites: part I. Quintessence Int. 2004;35(3):189-<br />
93.<br />
58 Willershausen B, Callaway A, Ernst CP, Stender E. The influence of<br />
oral bacteria on the surfaces of resin-based dental restorative materials:<br />
an in vitro study. Int Dent J. 1999;49(4):231-9.<br />
59 Mota EG, Oshima HM, Burnett LH Jr, Pires LA, Rosa RS. Evaluation<br />
of diametral tensile strength and Knoop microhardness of five<br />
nanofilled <strong>com</strong>posites in dentin and enamel shades. Stomatologija.<br />
2006;8(3):67-9.<br />
60 Beun S, Glorieux T, Devaux J, Vreven J, Leloup G. Characterization<br />
of nanofilled <strong>com</strong>pared to universal and microfilled <strong>com</strong>posites. Dent<br />
Mater. 2007;23(1):51-9.<br />
61 Mitra SB, Wu D, Holmes BN. An application of nanotechnology in<br />
advanced dental materials. J Am Dent Assoc. 2003;134(10):1382-90.<br />
62 Lopes GC, Zucco J, De Lucca C, Baratieri L, Vieira L. Diametral tensile<br />
strength of micro-hybrid <strong>com</strong>posite resins. IADR; Abstact 0585;2004.<br />
63 Ilie N, Jelen E, Clementino-Luedemann T, Hickel R. Lowshrinkage<br />
<strong>com</strong>posite for dental application. Dent Mater J. 2007;26(2):149-55.<br />
64 Bracho-Troconis C, Rudolph S, Boulden J, Wong N. Conversion vs.<br />
Shrinkage of N’Durance, Dimer Acid based Nanohybrid <strong>Composite</strong>.<br />
IADR. 2008, Rotonto July 1-4. Abstract 1812.<br />
65 Kobussen GA, Craid BD, Halvorson RH, Doruff MC, Bigham WS.<br />
Optical Properties of an Experimental Highly Aesthetic <strong>Composite</strong><br />
Restorative. IADR 2009, April 1 –3, Miami. Avstract 1508.<br />
Author Profile<br />
Robert C. Margeas, DDS, FAGD<br />
Dr. Margeas graduated from the University of Iowa College<br />
of Dentistry in 1986 and <strong>com</strong>pleted his AEGD residency<br />
the following year. He is currently an adjunct professor in<br />
the department of Operative Dentistry at the University of<br />
Iowa. He is Board Certified by the American Board of Operative<br />
Dentistry. He is a Diplomate of the American Board of Aesthetic<br />
Dentistry , a Fellow of the Academy of General Dentistry and International<br />
Team of Oral Implantologists (ITI). He has written numerous articles on<br />
esthetic and implant dentistry, and lectures and presents hands-on courses<br />
nationally and internationally on those subjects. He serves on the Editorial<br />
Advisory board of Inside Dentistry, Compendium, and is a contributing<br />
editor to Dentistry Today and Oral Health in Canada. Dr. Margeas maintains<br />
a full-time private practice focusing on <strong>com</strong>prehensive restorative and<br />
implant dentistry in Des Moines, Iowa.<br />
Disclaimer<br />
Dr. Margeas has been a speaker on behalf of 3M ESPE as well as<br />
other <strong>com</strong>posite manufacturers.<br />
Reader Feedback<br />
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www.ineedce.<strong>com</strong> 9
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Questions<br />
1. Esthetic solutions for restorations must be<br />
achieved in tandem with _______________.<br />
a. the functional requirements of strength<br />
b. physical <strong>com</strong>patibility with the surrounding tooth<br />
structure<br />
c. volumetric and morphologic stability<br />
d. all of the above<br />
2. The use of amalgam for posterior restorations<br />
has _______________ in recent years.<br />
a. gradually increased<br />
b. remained the same<br />
c. gradually decreased<br />
d. increased dramatically<br />
3. Early <strong>com</strong>posite resins _______________.<br />
a. were typically quartz-filled<br />
b. did not meet the <strong>com</strong>pressive and tensile force requirements<br />
for posterior restorations<br />
c. had high surface roughness and low polishability<br />
d. all of the above<br />
4. Early posterior <strong>com</strong>posite materials were<br />
_______________.<br />
a. suitable for anterior restorations<br />
b. suitable for posterior restorations<br />
c. suitable for indirect restorations<br />
d. all of the above<br />
5. <strong>Composite</strong> resin is currently available as<br />
_______________ <strong>com</strong>posite.<br />
a. microfilled<br />
b. microhybrid<br />
c. nanofilled<br />
d. all of the above<br />
6. The addition of various sizes and types of<br />
fillers has altered the _______________<br />
properties of <strong>com</strong>posites.<br />
a. physical<br />
b. esthetic<br />
c. genetic<br />
d. a and b<br />
7. Microfilled <strong>com</strong>posite resins<br />
_______________.<br />
a. contain crushed filler particles, typically prepolymerized<br />
and <strong>com</strong>prised of resin and fumed silica<br />
b. have a lower filler load than microhybrid <strong>com</strong>posite<br />
resins<br />
c. offer high polishability and excellent esthetics<br />
d. all of the above<br />
8. Microhybrid <strong>com</strong>posite resins<br />
_______________.<br />
a. develop a rougher surface over time<br />
b. offer strong physical properties<br />
c. are suitable for stress-bearing restorations<br />
d. all of the above<br />
9. Nanofilled <strong>com</strong>posite resins have high filler<br />
loads in order to obtain _______________<br />
similar to that of microhybrid <strong>com</strong>posite<br />
resins.<br />
a. strength and wear resistance<br />
b. wear and elasticity<br />
c. elasticity and esthetics<br />
d. none of the above<br />
10. Flowable <strong>com</strong>posite resins _______________.<br />
a. have lower filler loads than packable <strong>com</strong>posites<br />
b. flow and conform to the preparation margins<br />
c. have a high viscosity<br />
d. a and b<br />
11. One study <strong>com</strong>paring restorations using<br />
nanofilled <strong>com</strong>posite resin found those<br />
_______________ of flowable <strong>com</strong>posite to be<br />
clinically successful.<br />
Questions<br />
a. those with an underlying layer<br />
b. those without an underlying later<br />
c. those with and without an underlying layer<br />
d. none of the above<br />
12. The value of a <strong>com</strong>posite shade refers to the<br />
_______________.<br />
a. use of hues<br />
b. degree of lightness or darkness<br />
c. the opacity of the shade<br />
d. none of the above<br />
13. Chroma refers to the _______________.<br />
a. color of a shade<br />
b. opalescence of a shade<br />
c. intensity of a shade<br />
d. none of the above<br />
14. If teeth are stained, the staining should be<br />
removed _______________ selecting a shade.<br />
a. prior to<br />
b. at the same time as<br />
c. after<br />
d. any of the above<br />
15. Selecting a shade while a rubber dam is on<br />
the teeth can affect the choice of shade due to<br />
the _______________.<br />
a. altered color perception because of the influence of the<br />
rubber dam itself<br />
b. altered appearance of dessicated teeth<br />
c. altered number of teeth that are visible<br />
d. a and b<br />
16. Opacity in a <strong>com</strong>posite _______________.<br />
a. enables the creation of many shades ranging from<br />
opaque to highly translucent<br />
b. is higher in more chromatic shades<br />
c. is essential for deeper restorations<br />
d. all of the above<br />
17. Selecting _______________ shades can<br />
be critical for the esthetic out<strong>com</strong>e of an<br />
individual case.<br />
a. opaque<br />
b. translucent<br />
c. opaque and/or translucent<br />
d. none of the above<br />
18. The size and volume of filler particles in a<br />
<strong>com</strong>posite resin _______________.<br />
a. contributes to light-scattering properties<br />
b. influences the perceived color<br />
c. influences the perceived translucency<br />
d. all of the above<br />
19. Nanosized filler particles _______________.<br />
a. enable the transmission of light<br />
b. scatter blue light<br />
c. enhance the lifelike appearance of <strong>com</strong>posite resin<br />
materials<br />
d. all of the above<br />
20. In general, increased filler load<br />
_______________ translucency.<br />
a. increases<br />
b. decreases<br />
c. does not affect<br />
d. mimics<br />
21. Single-shade restorations _______________.<br />
a. require that the <strong>com</strong>posite be able to blend in with the<br />
surrounding tooth structure<br />
b. are quicker and simpler to place than dual or multiple<br />
shade restorations<br />
c. are rarely practical<br />
d. a and b<br />
22. When using a dual shade technique, the<br />
_______________ color should be selected<br />
first, followed by the _______________ shade<br />
and then, if used, the translucent shade.<br />
a. enamel; dentin<br />
b. dentin; enamel<br />
c. cementum<br />
d. none of the above<br />
23. Multilayering techniques _______________.<br />
a. require the most shades<br />
b. are the most time-consuming and <strong>com</strong>plex<br />
c. offer the most esthetic solution for specific cases<br />
d. all of the above<br />
24. It is important when using dual- or multipleshade<br />
techniques to use _______________ for<br />
that <strong>com</strong>posite system.<br />
a. the same brand of <strong>com</strong>posite<br />
b. the same brand shade guide<br />
c. the same brand matrix<br />
d. a and b<br />
25. Shade selection for a <strong>com</strong>posite can be<br />
determined using _______________.<br />
a. the shade guide or uncured resin<br />
b. uncured or cured resin<br />
c. the shade guide or cured resin<br />
d. the shade guide for a glass ionomer<br />
26. A high-gloss, smooth surface<br />
_______________.<br />
a. reflects light<br />
b. results in an appearance that is not as dark or dull as a<br />
rough surface<br />
c. gives a more natural appearance<br />
d. all of the above<br />
27. The <strong>com</strong>bination of nanofillers around<br />
nanoclusters has been shown to result in<br />
_______________.<br />
a. a more even pattern of wear<br />
b. a rougher surface<br />
c. a smoother surface<br />
d. a and c<br />
28. In vitro data indicates that the<br />
microhardness of a nanofilled <strong>com</strong>posite<br />
is _______________ that of microfilled<br />
<strong>com</strong>posites.<br />
a. higher than<br />
b. the same as<br />
c. lower than<br />
d. a or c<br />
29. A smooth, glossy surface can reduce the<br />
potential for _______________.<br />
a. bacterial removal<br />
b. bacterial adhesion<br />
c. bactericidal activity<br />
d. viral removal<br />
30. Each type of <strong>com</strong>posite offers<br />
_______________ properties that must be<br />
considered when selecting a <strong>com</strong>posite and<br />
technique for an individual case.<br />
a. the same physical and different esthetic<br />
b. the same physical and esthetic<br />
c. different physical and the same esthetic<br />
d. different physical and esthetic<br />
10 www.ineedce.<strong>com</strong>
ANSWER SHEET<br />
<strong>Composite</strong> <strong>Restoration</strong> <strong>Esthetics</strong><br />
Name: Title: Specialty:<br />
Address:<br />
E-mail:<br />
City: State: ZIP: Country:<br />
Telephone: Home ( ) Office ( )<br />
Requirements for successful <strong>com</strong>pletion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all<br />
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<br />
you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822<br />
Educational Objectives<br />
1. List and describe the categories of <strong>com</strong>posite resin restorative materials available and their characteristics and<br />
indications for use.<br />
2. List and describe the modes of failure for <strong>com</strong>posite resin restorative materials.<br />
3. List and describe the shade considerations involved in the attainment of esthetics in <strong>com</strong>posite resin restorations and<br />
the use of different shading and layering techniques.<br />
4. List and describe the relevance of a smooth surface and gloss as well as polishability, and factors influencing these.<br />
Course Evaluation<br />
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.<br />
1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No<br />
Objective #2: Yes No Objective #4: Yes No<br />
2. To what extent were the course objectives ac<strong>com</strong>plished overall? 5 4 3 2 1 0<br />
3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0<br />
If not taking online, mail <strong>com</strong>pleted answer sheet to<br />
Academy of Dental Therapeutics and Stomatology,<br />
A Division of PennWell Corp.<br />
P.O. Box 116, Chesterland, OH 44026<br />
or fax to: (440) 845-3447<br />
For immediate results,<br />
go to www.ineedce.<strong>com</strong> to take tests online.<br />
Answer sheets can be faxed with credit card payment to<br />
(440) 845-3447, (216) 398-7922, or (216) 255-6619.<br />
Payment of $49.00 is enclosed.<br />
(Checks and credit cards are accepted.)<br />
If paying by credit card, please <strong>com</strong>plete the<br />
following: MC Visa AmEx Discover<br />
Acct. Number: ______________________________<br />
Exp. Date: _____________________<br />
Charges on your statement will show up as PennWell<br />
4. How would you rate the objectives and educational methods? 5 4 3 2 1 0<br />
5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0<br />
6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0<br />
7. Was the overall administration of the course effective? 5 4 3 2 1 0<br />
8. Do you feel that the references were adequate? Yes No<br />
9. Would you participate in a similar program on a different topic? Yes No<br />
10. If any of the continuing education questions were unclear or ambiguous, please list them.<br />
___________________________________________________________________<br />
11. Was there any subject matter you found confusing? Please describe.<br />
___________________________________________________________________<br />
___________________________________________________________________<br />
12. What additional continuing dental education topics would you like to see?<br />
___________________________________________________________________<br />
___________________________________________________________________<br />
Please check here if you wish to receive future <strong>com</strong>munications from<br />
the sponsor of this course, 3M ESPE<br />
AGD Code 253<br />
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.<br />
AUTHOR DISCLAIMER<br />
Dr. Margeas has been a speaker on behalf of 3M ESPE as well as other <strong>com</strong>posite manufacturers.<br />
SPONSOR/PROVIDER<br />
This course was made possible through an unrestricted educational grant from 3M ESPE.<br />
No manufacturer or third party has had any input into the development of course content.<br />
All content has been derived from references listed, and or the opinions of clinicians. Please<br />
direct all questions pertaining to PennWell or the administration of this course to Machele<br />
Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.<strong>com</strong>.<br />
COURSE EVALUATION and PARTICIPANT FEEDBACK<br />
We encourage participant feedback pertaining to all courses. Please be sure to <strong>com</strong>plete the<br />
survey included with the course. Please e-mail all questions to: macheleg@pennwell.<strong>com</strong>.<br />
INSTRUCTIONS<br />
All questions should have only one answer. Grading of this examination is done<br />
manually. Participants will receive confirmation of passing by receipt of a verification<br />
form. Verification forms will be mailed within two weeks after taking an examination.<br />
EDUCATIONAL DISCLAIMER<br />
The opinions of efficacy or perceived value of any products or <strong>com</strong>panies mentioned<br />
in this course and expressed herein are those of the author(s) of the course and do not<br />
necessarily reflect those of PennWell.<br />
Completing a single continuing education course does not provide enough information<br />
to give the participant the feeling that s/he is an expert in the field related to the course<br />
topic. It is a <strong>com</strong>bination of many educational courses and clinical experience that<br />
allows the participant to develop skills and expertise.<br />
COURSE CREDITS/COST<br />
All participants scoring at least 70% on the examination will receive a verification<br />
form verifying 2 CE credits. The formal continuing education program of this sponsor<br />
is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for<br />
current term of acceptance. Participants are urged to contact their state dental boards<br />
for continuing education requirements. PennWell is a California Provider. The California<br />
Provider number is 4527. The cost for courses ranges from $49.00 to $110.00.<br />
Many PennWell self-study courses have been approved by the Dental Assisting National<br />
Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet<br />
DANB’s annual continuing education requirements. To find out if this course or any other<br />
PennWell course has been approved by DANB, please contact DANB’s Recertification<br />
Department at 1-800-FOR-DANB, ext. 445.<br />
RECORD KEEPING<br />
PennWell maintains records of your successful <strong>com</strong>pletion of any exam. Please contact our<br />
offices for a copy of your continuing education credits report. This report, which will list<br />
all credits earned to date, will be generated and mailed to you within five business days<br />
of receipt.<br />
CANCELLATION/REFUND POLICY<br />
Any participant who is not 100% satisfied with this course can request a full refund by<br />
contacting PennWell in writing.<br />
© 2009 by the Academy of Dental Therapeutics and Stomatology, a division<br />
of PennWell<br />
Customer Service 216.398.7822