Effect of posterior resin composite piacement technique on

the resin-dentin interface formed in vivo

Guilherme Carpena Lopes, DDS, MSVLuiz Narciso Baratieri, DDS, MS,
Sylvio Monteiro, Jr, DDS, MS. PhDVLuiz Clvis Cardoso Vieira, DDS, MS,

Objective: The aim of this study was to evaluate the morphology of Ihe resin-dentin interlace tormed in
vivo with two posterior resin composite placement techniques (incremental and bulk). Method and materials: After approval from the patients, 12 Class II cavities with margins in enamel (2.5 x 2.5 x 4.5 mm)
were prepared in caries-free premolars scheduled to be extracted for orthodontic reasons (n = 6). The cavities were restored with Single Bond + Fiitek P60 as a buik condensable technique or Single Bond -i- Fiitek
Z250 as an oblique incremental technique. After 1 week, the teeth were extracted with minimai trauma to
the restored area. After the teeth were sectioned, a poiyvinyi siioxane impression was taken from the
resin-dentin interface to control tor artifacts created during preparation for scanning electron microscopy.
The specimens were subsequentiy processed tor and observed under a scanning electron microscope to
assess gap tormation. Results: The mean percentage ot gap formation was 6,1% tor teeth restored with
the incrementai piacement technique and 18.7% tor teeth restored with the buik piacement technique. The
difference was statistically signiticant. Conclusion: The incremental placement of posterior resin composites may stiii provide better seal than the new buik condensable technique. (Quintessence Int 2004:35:

156-161)
Key words: bulk restoration, gap tormation, incremental restoration, posterior resin compcsite, resindentin interface

CLINICAL RELEVANCE: Placement technique is an important tactor in the success ot posterior resin composite
restorations.

esin shrinkage attributed to polymerization has

been reported as one of the factors directly responsible for marginal leakage at the tooth-restoration interface.' Secondary caries may occur whenever marginal
leakage of restoration allows the interface between the
restoration and tooth to he invaded by bacteria.
However, even when gaps are not located at the cavo-

'Clinical Instructor and Graduate Student, Department of Operative

Dentistry, tjnrversidade Federal de Santa Catarina, Florianpolis, Brazil;
Clinical Protessor, Department of Operative Dentistry, Universidade do Sul
de Santa Catarina, Tubaro, Brasil.
^Professor, Depaitmenl ot Operative Denlislry, Universidade Federal de
Sania Catarina, Florianpolis, Brazil.
Reprint requests; Dr Guiltierme Carpena Lopes, Rja Launndo Janurio
da Silveira No. 947, Apto 34A. Lagoa da Conceio, Flonanpolis, Santa
Catarina, Brazil 88062-200. E-rrail: guiltiermejopes@ig.oom.br
Presented al the 2000 session of the nternatioriat Associalion tor Dentai
Research, Wastiington. DC.

156

surface margin, they may cause clinical problems.^

Deformation of restoration margins and interfaces during chewing may result in a dimensional change of
gaps, which may cause pain because of percolation of
fluids in the dentinai tubules.^ Furthermore, the difference in the coefficients of thermal expansion of tooth
structure and resin composite can lead to diffErent volumetric changes in ihe resin and tooth structure during
temperature changes.^
Several methods have been advocated to minimize
the problems associated with polymerization shrinkage of light-cured resin composites. One of the most
commonly used techniques is incremental insertion or
layering, which allows a more uniform polymerization
and results in a reduction in total shrinkage.' Dentists,
however, prefer simpler placement techniques'' that
are not as time consuming as, for example, incremental layering. Some new packable composites are now
available on the market. Low polymerization shrinkage and higher depth of cure are some proprieties reported hy manufacturers, which could allow these materials to be placed in hulk.s These high-viscosity resin
composites also have a particular handling property
that allows for packing.^
Volume 35. Number 2, 2004

Lopes et al

Some recent dye penetration studies of packable

composites show no difference in microleakage scores,
regardless of placement technique,"-'" However, dye
penetration may only be able to identify' microleakage
where there is marginal failure. This is one of the reasons that scanning electron microscopy (SEM) may be
more appropriate to analyze gap formation. Furthermore, in vivo studies represent the true clinical difficulty of placement restorative materials and involve
the maintenance of pulpal pressure," However, in
vivo techniques introduce the additional difficulty of
atraumatic extraction.
The aim of this study was to evaluate the effect of
posterior resin composite placement techniques (bulk
packable versus traditional incremental technique) on
the sealing ability of Ciass II resin composite restorations placed in vivo.
METHOD AND MATERIALS

The ethics committee of the Universidade Federal de

Santa Catarina School of Dentistry approved the use of
human subjects according to the terms presented in the
protocol. Informed consent was obtained from eacg of
the 6 patients and/or the patients' legal guardians,
A box-type Class II cavity was prepared on each
proximal surface of six premolars (one from each patient) scheduled to be extracted for orthodontic reasons. In total, 12 cavities could be restored. The vitality of the experimental teeth was confirmed by a
thermal vitality test. Local anesthesia with 2% lidocairte with 1:100,000 epinephrine was administered.
The cavities were 2.5 mm wide, 4,5 mm high, and 2,5
mm deep, with occlusal and gingival margins in
enamel. The cavities were prepared with a No, 245
carbide bur (KG Sorensen) mounted in a high-speed
handpiece under air and water coolant. The cavities
were prepared without a peripheral bevel in the box.
After the cavity preparation, a visual examination
was conducted to ensure that dental hard tissue
(enamel and dentin) presented sound characteristics.
The field was isolated with rubber dam, and a metal
matrix band (AutoMatrix, Caulk/Dentsply) was applied to the preparation. The adhesive system (Single
Bond, 3M Dental) was applied according to the manufacttirer's instructions.
One cavity in each tooth (n = 6) was restored with
Filtek P60 (3M Dentai), placed with a bulk condensing
technique. 3 of each placed mesially and thre of each
placed distaUy. The bulk restorations were irradiated for
40 seconds with an XL 1500 curing unit (3M Dental)
with a light output of 400 mW/cm^, After removal of
the matrix, additional light curing was performed from
the lingual and the facial directions for 40 seconds.
Quintessence International

The other six cavities were restored with Filtek

Z250 (3M Dental), placed with an oblique Incremental technique in three layers. Each increment was irradiated with the XL 1500 curing unit for 40 seconds.
The finishing procedures were carried out with fine
diamond burs (Brasseler) and sandpaper strips (3M
Dental),
After 1 week, the teeth were carefully extracted
with minimal trauma to the restored area. The roots
were immediately removed by diamond bur sectioning
under water. The teeth were cross sectioned mesiodistay through the center of the restoration with a diamond-impregnated copper disk (South Bay Technology) in an oil-cooled low-speed cutting machine
(Isomet. Buehler),
A polyvinyl siloxane impression (President,
Coltene/Whaledent) was taken of the resin-dentin interface to control for artifacts created during the
preparation for SEM, The specimens were subsequently fixed in 2.5% glutaraldehyde in 0,1-M sodium
cacodylate huffer at pH 7,4 for at least 12 hours at
4''C, After fixation, the teeth were rinsed ivith 20 mL
of 0,2-M soditim cacodylate buffer at pH 7,4 for 1
hour with three changes, followed by distilled water
for 1 minute. They were dehydrated in ascending
grades of ethanol (25;o for 20 minutes, 50".!) for 20
minutes, 75 for 20 minutes, 9O''/o for 30 minutes,
and lOO^b for 60 minutes). After the final ethanol
step, the specimens were dried by immersion in hexamethyldisilazane for 10 minutes'^ and air dried at
room temperature.
The specimens were then embedded in self-curing
epoxy resin and stored for 12 hours. After setting, the
epoxy casts were pohshed with waterproof sificon carbide papers of decreasing abrasiveness (420, 600, and
1,000 grit) and polished to a high gloss with soft fissue
disks vvith increasingly fine diamond suspensions to a
particle size of 1 pm. The specimens were washed,
dried, demineralized in 6 N of hydrochloric acid for 30
seconds, and deproteinized in 2% sodium hypochlorite
for 10 minutes. After drying, the specimens were sputter coated with gold-palladium by means of a Polaron
E-5000 sputter coater (Polaron), and observed under a
Phihps XL 30 SEM (Philips Electric),
RESULTS

The enamel-resin interface did not show any gap formation. The dentin-resin interface formed gaps above
the hybrid layer in three specimens prepared with the
bulk placement technique (Figs la and lb) and five
specimens prepared with the incremental placement
technique (Fig 2). Table 1 shows the percentage of gap
formation of all specimens.
157

 Lopes et al

Fig l a Class II cavity restored with the bulK placement technique (Filtek and P60) A gap naa formed Sequence ot the resin-dentin interface of a cavity restored witii ttie bull* placement technique.

For the restorafions placed with the oblique incremental technique (Filtek and Z250), the mean gap formation was 6,1%, For restorations placed with the
bulk technique (Filtek and P60), the mean gap formation was 18.7%. A t test revealed that the incremental
placement technique resuUed in a significantly lower
percentage of gap formafion than did the hulk condensadon technique.

DISCUSSION
Fig 1b Gap formed at the resm-dentii inle'-ace of a
cavity restored with the Puik placement rechnique.

158

The initial polymerization shrinkage of resin composites, the different coefficients of thermal expansion of
this material, and dental hard tissues and adhesion
problems of cervical areas are the essential factors responsible for marginal leakage at the proximal aspect'^
and gap formation at the resin-dentin interface of
resin composite restorafions. Volumetric polymerizaVolume 35, Number 2, 2004

Lopes el al

Fig 2 Class II cavity restored with the incremental placement teclinique (Fiftek and Z250). There is no gap formation. Sequence of trie
tesin-dentir interface ot a cavity restored by incrementat piacement technique.

tion shrinkage can reach 2.6% to 7.1% on light-cured

composites."'^ The incremental technique for insertion and polymerizafion of resin composites is advocated by many authors. ^^"^^ Layering resin composite
has been sbown to reduce the stresses generated on
cavity walls.^'
The reason for the lesser amount of gap formation
with the incremental technique in the present study
may be a result of the low configuration factor (C-factor).^ The wide free surface permits resin to fiow during polymerization. Consequently, minimal shrinkage
occurs within each increment. In general, the C-factor
of a Class II resin composite restoration is in the range
of 1.0 to 2.0 when the bulk technique is used." The incremental technique can greatly reduce the C-factor of
the preparation. Incremental restoration techniques
actually lower the C-factor to less than 1.0, because
there is usually almost as much free surface as bonded
surface in any single increment.^'
Quintessence internaticnal

TABLE 1 Gap percentage by placement technique

and resin composite
Specimen
1
2
3
4
5
6
Mean

Incremental
Z250 (%)

Bulk
P60 (%

0.0
6.7
0.0
0.0
7.4
2Z.4
6,1

0.0
17.3
23.8
35.4
18,9
26.9
18.7

The incremental technique can incorporate air bubbles. Alster et a P have shown that the stress relief in
thin resin increments is proportional to the amount of
resin porosity. The oxygen present in the air voids also
159

 LoDes et al

contributes to stress reduction.^-" Tbe role of air incorporation in the stress relief of resin composite seems
to be important and should be investigated furtber.
Altbough tbe incremental layering tecbnique bas
been widely advocated for reduction of polymerization
sbrinkage, reports and recent finite element analyses
now dispute this tbeory.^^'^^ In one of tbese studies, it
was concluded that layering resin composites results
in bigher overall sbrinkage stress and deformation of
remaining bard tissue walls.-^ Tbe autbors pointed out,
bowever, tbat tbe incremental tecbnique still has some
advantages over bulk placement, sucb as improved
marginal adaptation and wetting,-' wbicb was, in part,
confirmed in tbe present study.
Tbe incremental placement technique is still regarded as tbe most practical for otber reasons as well.
This procedure provides enbanced control of overbangs in tbe lateral margins prior to curing^^ and a
more effective^^ and uniform cure.^^
The present results are in agreement witb recent researcb conducted in vivo, in wbicb tbere was signifcantly more gap formation at tbe dentin-restoration
interface, and postoperative sensitivity, after bulk
placement tban after restorations were applied in layers.'' In botb studies, neither tecbnique resulted in a
perfectly sealed interface between tbe restoration and
tbe tootb structure. Tbe bigh modulus of elasticity of
tbe bybrid resin composites probably could not relieve
tbe stress produced during polymerization. Furtber investigations should be conducted in vivo with an intermediate layer of tlowable resin composite, because
the use of a low-modulus resin composite may increase the flexibility of the bonded assembly and may
act as stress-relaxation buffers, absorbing tbe tension
stress induced by polymerization of tbe resin composite placed over tbe resin.^"'^^

CONCLUSION
Within tbe limitations of tbis short-term study, it is
concluded that tbe placement tecbnique is an important factor wben posterior teetb are restored witb
resin composites. Tbe incremental placement of posterior composites stili provides better seal than does tbe
new bulk condensation technique.

REFERENCES
1. Neiva IF, de Andrada MAC, Baratieri LN, Monteiro S Jr,
Ritter AV. An in vitro study of effect of restorative technique
on marginal leakage in posterior composites. Oper Dent
1998;23:282-289.

160

Opdam NJM, Rocters FJM, Peilzer AJ, Verdonschot EH.

Marginal integrity and postoperative sensitivity in Class II
resin composite restoration in vivo. J Dent 1998;25;
555-562.
BuUard RH, Leinfelder KP, Russell CM. Effect of coefficient
of thermal expansion on microleakage. J Am Dent Assoc
1988,116;871-874.
Opdam NJM, Peilzer A], Roeters JJM, Smale I. Class I occlusai composite resin restorations: in vivo post-operative
sensitivity, wall adaptation and microleakage. Am J Dent
1998;11:229-234.
Manhart J, Kunzelmann K-H, Chen HY, Hickel R.
Mechanical properties and wear hehavior of light-cured
packable composite resins. Dent Mater 2000;16;33-40.
Fortin D, Vargas MA. The spectrum of composites; New
techniques and materials. J Am Dent Assoc 2000;131:
26S-30S.
Affleck MS, Denehy GE, Vargas MA, Setien VJ.
Microleakage with incremental vs. bulk placement utilizing
condensable composites [abstract 393]. J Dent Res 1999;
78:155.
Paler TA, Mazer RB. Marginal adaptation of condensable
composite restorative [abstract 392]. J Dent Res 1999;78:
154.
Miranda WG Jr, Nunes MP, Cardoso PEC, Santos J]P.
Microleakage of condensable composite resins with a flowable composite [abstract 1603]. J Dent Res 1999;78:306.
Moldovan S, Monoghan P, Seghi R. Therm o stressed microleakage of hybridized Class II esthetic dental restorations [abstract 2265]. J Dent Res 1999;78:389.
Pashley DH. In vitro simulations of in vivo bonding conditions. Am J Dent 1990;4:237-240.
Perdiglo J, Lambrechts P, Van Meerbeek B, Vanherle G,
Lopes AB. Pield emission SEM comparison of four post-fisation drying techniques for human dentin. J Biomed Mater
Res 1996:29:1111-1120.
Schuckar M, Geurtsen W. Proximo-cervical adaptation of
Class Il-composite restorations after thermoeycling: a quantitative and qualitative study. J Oral Rehabil 1997;24:
766-775.
DeGee A), Davidson CL, Smith AA. Modified dilatometer
of continuous recording of volumetric polymerization shrinkage of composite restorative materiais. | Dent 1981;9:
36-42.
Feilzer AJ, DeGee AJ, Davidson CL. Curing contraction of
composites and glass ionomer cements. J Prosthet Dent
1988;59:297-300.
16. Eick JD, Welch PH, Polymerization shrinkage of posterior
composite resin and its possible influence on postoperative
sensitivity. Quintessence Int 1986;17:103-lll.
Hassan K, Mantc F, List G, Dhuru V. A modified incremental filling technique for Class II composite restorations. J
Prosthet Dent 1987;58:153-156.
18. Hilton TJ. Direct Posterior Composite Restoration, fn:
Schwartz RS, Summit JB, Robbins JW {eds). Fundamentals
of Operative Dentistry-A New Contemporary Approach.
Chicago: Quintessence, 1996:207-228.
Lsche GM. Marginal adaptation of Class II composite fillings: Guided polymerization vs. reduced light intensity. J
Adhesive Dent 1999;l:31-39.

Volume 35, Number 2. 2004

 Lopes et al

20. Tlan AHL, Bergh BH. Lidner C. Effect o various incrementa! techniques on the marginal adaptation of Class 11 composite resin restorations. ] Prosthet Dent 1992;67:62-66.
21. Lutz F. Krejci 1, Barbakow F. Quahty and durability of marginal adaptation in bonded composite restorations. Dent
Mater 1991:7:107-113.
22. Feiizer AJ, De Gee AJ, Davidson CL. Setting stress in resin
composite in relation to the configuration of the restoration.
Dent Res 1987 ;66:1656-1639.
23. Carvaiho RM. Pereira JC. Yoshiyama M. Pashiey DH. A review of polymerization contraction: the influence of stress
development versus stress relief. Oper Dent 1996:21:17-24.
24. Alster D, Feiizer AJ, DeGee AJ, Mol A. The dependence of
shrinkage stress reduction on porosity concentration in thin
resin layers. J Dent Res 1992;71:1619-1622.
25. Versluis A. Douglas WH. Cross M. Sakaguchi RL. Does an
incremental filling technique reduce polymerization shrinkage stresses? J Dent Res 1996;75:871-878.
26. VTmkler MM, Katona TR, Paydar NH. Finite element stress
analysis of three fifling techniques for Class V light-cured
composite restorations. J Dent Res 1996:75:1477-1483.

OlFED.org

27 Baratieri LN, Ritter AV, Perdigao J, Felippe tA. Direct posterior composite resin restorations: current concepts for the
technique. Pract Periodont Aesthet Dent 1998;10:
875-886.
28. Versluis A, Tanthirojn D. Douglas WH. Do dental composites always shrink toward the light? J Dent Res 1998;77:
1435-1445.
29. lap AUJ, Wang HB, Siow KS, Gan LM. Polymerization
strength of visible-light-cured composites. Oper Dent
2000;25:98-103.
30. Kemp-Scholte CM. Davidson CL. Complete marginal seal
of Class V resin composite restorations effected by increasedflexibility.J Dent Res 1990;69:1240-1243.
31. Van Meerbeek B, Lambrechts P, lnokoshi S, Braem M,
Vanberie G. Factors affeeting adhesion to mineralized tissues. Oper Dent 1992;17:111-124.

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