M

arginal leakage appears to be an inherent short-

coming of all dental restorations.
1-5
Various tech-
niques have been advocated to enhance the marginal
adaptation and reduce the microleakage of composite
restorations. Multilayer techniques, in contrast to bulk
packing methods, have decreased marginal gap forma-
tions.
6,7
The size reduction of the composite material,
the diminution of polymerization shrinkage, and the
enlargement of the free surface area in relation to the
volume are of great importance in this context.
8
The three-
sided light-curing technique enables initial progress in
this direction; it is questionable if other techniques can
maintain better results.
9
While promising results have
been achieved with centripetal buildups, comparative
microleakage tests were not conducted.
10
An important
benefit of this procedure is that a thin proximal layer
placed towards the matrix band is cured before adja-
cent composite increments are applied into the cavity.
This can reduce the V/A ratio, where V is the cavity vol-
ume and A is the area of the cavity walls. When the
whole margin area is first filled with an increment, fewer
contraction gaps at the margins can be expected using
the centripetal technique versus the incremental technique.
Even if such a gap does develop, the next increment is
likely to fill this gap.
In addition to methods, various materials (eg, light-
curing tips, matrix systems) have also been investigated.
11,12
Different experimental designs for microhardness and
marginal analysis can be found in current literature.
13-15
To investigate marginal leakage of dental restorations,
isotope or dye penetration has been used.
16,17
Following
penetration, one mesiodistal section of the restoration
was without a description of the penetration patterns
at the buccal or lingual sides of the restoration.
18,19
Although several investigations of microleakage have been
conducted, most of the investigations involved Class II
COMPARATIVE STUDY OF COMPOSITE RESIN
PLACEMENT: CENTRIPETAL BUILDUP
VERSUS INCREMENTAL TECHNIQUE
Susanne Szep, Dr med dent*
Holger Frank, Dr med dent

Bettina Kenzel, Dr med dent

Thomas Gerhardt, Dr med dent

Detlef Heidemann, Dr med dent habil

ll
Pract Proced Aesthet Dent 2001;13(3):243-250
*Assistant Professor, Department of Operative Dentistry, Johann
Wolfgang Goethe University, Frankfurt am Main, Germany.

Private practice, Offenbach, Germany.

Private practice, Frankfurt am Main, Germany.

Assistant Professor, Department of Operative Dentistry, Johann

Wolfgang Goethe University, Frankfurt am Main, Germany;
private practice, Frankfurt am Main, Germany.
ll
Professor and Chairman, Department of Operative Dentistry,
Johann Wolfgang Goethe University, Frankfurt am Main,
Germany.
Susanne Szep, Dr med dent
Department of Operative Dentistry
Johann Wolfgang Goethe University
Theodor-Stern-Kai 7
D-60590 Frankfurt am Main
Germany
Tel: (011) 49-69-6301-7523
Fax: (011) 49-69-6301-3841
E-mail: S.Szep@em.uni-frankfurt.de
An in vitro study was performed to evaluate the effect of
two different proximal restoration techniques with differ-
ent matrix systems on the marginal seal and microhard-
ness of Class II composite restorations. Results indicated
that the lowest, however, not significantly different,
microleakage was achieved in totally bonded deep
Class II restorations prepared with margins surrounded
by enamel when using transparent matrices and reflective
wedges in combination with the centripetal buildup tech-
nique. Highest surface hardness of composite resin was
related to transparent matrices and reflecting wedges.
Key Words: resin, centripetal, incremental, microleakage,
matrix, microhardness
243
S
Z
E
P
A
P
R
I
L
13
3
C O N T I N U I N G E D U C A T I O N 1 0
cavities in extracted teeth. These specimens were not,
however, mounted in contact with adjacent teeth to ensure
their movement during separation techniques.
17,18
Microhardness analyses in specimens that were irra-
diated from all sides to obtain polymerization with a high
conversion rate in light-curing composite are found in the
literature. In most instances, cavities are simulated with
standardized metal blocks to obtain flat surfaces for
microhardness analysis.
13,14,20
Under clinical conditions,
however, flat restoration surfaces can only be obtained
in exceptional cases. The results, therefore, may not have
reflected the leakage and microhardness pattern of
Class II cavities, which are larger and more complex
under optimized in vivo simulating conditions. Some clin-
ical studies show that a number of hindrances remain in
the attempt to develop an optimal method for placing
composite restorations that will remain intact in the oral
cavity over extended function.
4,21,22
Provided the prepa-
ration margins are surrounded by enamel, most multi-
layer placement techniques can achieve adequate results
in marginal adaptation of composite materials.
16,18,23
Deeper cavities with gingival floors that end in dentin
constitute a challenge for the adhesive mechanism.
24,25
Figure 1. One hundred ninety-two composite restorations were placed for marginal seal analysis and divided into eight
equal groups of 24 specimens.
244 Vol. 13, No. 3
Practical Procedures & AESTHETIC DENTISTRY
n=96 caries-free human molars mounted in models in contact position
n=192 cavities
n=96 cavities surrounded by enamel (E)
n=48 cavities
incremental (I)
n=48 cavities
centripetal (C)
n=48 cavities
incremental (I)
n=48 cavities
centripetal (C)
EIM
n=24
metal
matrix
+
wooden
wedge
EIT
n=24
trans-
parent
matrix
+
reflective
wedge
ECM
n=24
metal
matrix
+
wooden
wedge
ECT
n=24
trans-
parent
matrix
+
reflective
wedge
DIM
n=24
metal
matrix
+
wooden
wedge
30DIT
n=24
trans-
parent
matrix
+
reflective
wedge
DCM
n=24
metal
matrix
+
wooden
wedge
DCT
n=24
trans-
parent
matrix
+
reflective
wedge
thermocycling, methylene blue diffusion, embedded in resin, 2 bucco-oral sections

n=96 cavities surrounded by dentin (D)
One purpose of this investigation was to create an
experimental design that allows (under simulated in vivo
conditions) the examination of different restorative tech-
niques (incremental versus centripetal technique) for the
approximal box of Class II cavities. This study also exam-
ined the effect of an opaque matrix system versus a trans-
parent matrix/wedge on the marginal seal of composite
restorations. In addition, the Vickers hardness of the
approximal surfaces of composite restorations was mea-
sured under simulated clinical conditions, but in a differ-
ent experimental arrangement.
Materials and Methods
Specimen Preparation
One hundred sixty unrestored, extracted molar teeth free
of caries and fracture lines were randomly divided in
two experimental designs: 96 specimens were used for
the evaluation of the marginal seal (Figure 1), and 64
teeth were employed for the evaluation of surface micro-
hardness of composite restorations (Figure 2). Once the
specimens were cleaned with pumice and water, they
were mounted in silicone models in proximal contact with
other specimens, which ensured the movement of teeth
during separation techniques that simulated clinical con-
ditions. Teeth were divided into two groups according
to the following specifications: in the first group, the gin-
gival floor was surrounded by enamel, in the second
group by dentin. Each tooth was prepared with two
Class II cavities using parallel buccal and lingual walls
on the occlusal aspect and in the proximal boxes.
The preparations were cut with a diamond bur
(#6837 KR, Brasseler USA, Savannah, GA) in a high-
speed handpiece with water coolant. The finishing pro-
cedure was performed in a similar fashion. After six
preparations, a new bur was used. To ensure as much uni-
formity among the preparations as possible, a periodontal
probe was utilized as a guide: the depth of the gingival
floors of the preparations was estimated from 4.5 mm
(Group 1) to 7.5 mm (Group 2); the pulpal floor extended
3 mm into dentin; all proximal extensions were estimated
at 6 mm for both groups. No bevels were prepared. After
the preparations were completed, the teeth were randomly
assigned to eight groups of 24 teeth each. The teeth in
all groups were restored with a hybrid composite resin
(Herculite XRV, Kerr/Sybron, Orange, CA) using the total-
etch technique as recommended by the manufacturer.
The combination of composite insertion technique and the
matrix system varied with each group. Each layer
was subjected to a 40-second exposure to the curing unit
(Elipar II, Espe, Norristown, PA). Prior to each use of this
curing unit, a curing radiometer (Demetron/Kerr, Karlsruhe,
Germany) was employed to measure light output in the
400 nm to 500 nm wavelength range. The measured light
intensity varied from 800 mW/cm
2
to 1000 mW/cm
2
.
Incremental Technique
In the groups EIM, EIT, DIM, and DIT, the composite resin
was placed with an incremental technique: the first layer
of composite resin was placed on the gingival floor, the
second and third layers were placed diagonally, and
the last increment was used to complete the filling in the
occlusal portion of the cavity (Figure 3). The incremental
technique in cavities with a depth of 4.5 mm was per-
formed in the following sequence: 1.5 mm + 2 mm + 1 mm.
For cavities with a depth of 7.5 mm, the following
sequence was used: 1.5 mm + 2 mm + 2 mm + 2 mm.
P P A D 245
Szep

Figure 2. One hundred twenty-eight direct resin restorations were placed for microhardness analysis and subsequently
divided into eight groups of 16 specimens.
n=96 caries-free human molars embedded in resin and sectioned
n=128 cavities
n=64 cavities surrounded by enamel (E)
n=32 cavities
incremental (I)
n=32 cavities
centripetal (C)
n=32 cavities
incremental (I)
n=32 cavities
centripetal (C)
EIM
n=16
metal
matrix
EIT
n=16
trans-
parent
matrix
ECM
n=16
metal
matrix
ECT
n=16
trans-
parent
matrix
DIM
n=16
metal
matrix
DIT
n=16
trans-
parent
matrix
DCM
n=16
metal
matrix
DCT
n=16
trans-
parent
matrix
Microhardness analysis

n=64 cavities surrounded by dentin (D)
Centripetal Technique
In the groups ECM, ECT, DCM, and DCT, the hybrid resin
was placed in a centripetal technique: a first layer of resin
(1 mm thick) was placed towards the matrix band, and
the subsequent increments (2 mm thick) were applied hori-
zontally towards the occlusal area of the cavity (Figure 3).
Since the same number of increments was used for buildup
(depending on the depth of the cavities), this investiga-
tion evaluated the layering technique used.
Opaque Matrix System
In the groups EIM, ECM, DIM, and DCM, a 0.05-mm
Tofflemire metal matrix band (Orbis Dental, Offenbach,
Germany) and a No. 15 in a retainer with wooden
wedges were applied to the specimens. Each increment
of composite for these specimens was cured only from
the occlusal side with visible light for 40 seconds.
246 Vol. 13, No. 3
Practical Procedures & AESTHETIC DENTISTRY
Mean, Standard Deviation (SD), Minimum (Min), Maximum (Max), and
Median Values of Marginal Penetration (%) Including the Gingival Aspects of the Cavity.
Group No. Mean SD Min Max Median Significance to No.
EIT 1 59.39 36.37 0 100 61.42 2, 8
DIT 2 89.31 16.36 50 100 100.00 1, 3, 7
ECT 3 52.37 26.58 0 100 51.98 2, 8
DCT 4 68.71 25.41 24.4 100 72.65
EIM 5 75.83 35.25 0 100 100.00
DIM 6 69.03 38.06 0 100 100.00
ECM 7 54.25 45.70 0 100 60.17 2, 8
DCM 8 92.42 21.91 22.4 100 100.00 1, 3, 7
Numbers of groups indicate statistically significant difference (alpha = 0.05, Kruskal-Wallis Multiple-Comparison Z-Value Test).
Figure 3. Schematic representation of the technique used:
incremental technique (I) versus centripetal technique (C).
Following removal of the matrix system, the restorations
were cured for 40 seconds from the buccal and occlusal
aspects for both techniques.
Transparent Matrix/Wedge System
In the groups EIT, ECT, DIT, and DCT, a precontoured
0.05-mm transparent matrix band (Nr.773, Hawe Neos,
Bioggio, Switzerland) in a retainer was applied with
reflective wedges. Each increment of composite was
cured with visible light for 40 seconds. With the incre-
mental technique, the first layer was cured indirectly
through the light wedge; the second and third layers
were polymerized from the buccal and oral direction
in order to ensure that the shrinkage vectors were directed
toward the cavity margins. The last increment was
polymerized from the occlusal aspect. With the cen-
tripetal technique, the first layer was polymerized from
occlusal direction, the second layer through the light
wedge, the third and fourth layers from the buccal and
occlusal direction as previously described, and last layer
from the occlusal aspect. Following the removal of the
matrix system, no postcuring was performed for the defin-
itive restoration.
All restorations were finished immediately after
placement with fluted carbide burs, soft polishing disks
(Sof-Flex, 3M Dental, St. Paul, MN), and silicon polish-
ing under water coolant. Plastic finishing strips were used
for the finishing of the interproximal surface. Postcuring
was not performed.
I C
Distal view Buccal view
Table 1
Evaluation of Marginal Seal
The specimens were removed from their mounting and
thermocycled for 5000 cycles (5C to 55C) with a
dwell time of one minute at each temperature. After
thermocycling, two coats of colored fingernail varnish
were applied to all specimens, excluding the restora-
tion margins of 1.5 mm.
Microleakage was assessed with 2% methylene blue
diffusion for 24 hours at 37C. The teeth were then
embedded in a self-curing, transparent epoxy resin, longi-
tudinally sectioned with a diamond saw in a buccolingual
direction at the approximal box of the restoration, and
dye penetration was evaluated by light microscopy at
32 magnitude. The gingival margins of the embedded
specimens in transparent resin were marked from the
mesiodistal view for the first section. From here, two
sections of 500 m were obtained with a mean loss
of 280 m per section. Microleakage was calculated
in percent of the total length of the gingival margins of
the cavity.
Evaluation of Surface Hardness
Sixteen teeth of each group were embedded in resin
and sectioned on the approximal sides to receive a par-
allel plane area. This flat surface was necessary to facil-
itate Vickers hardness tests. Afterwards, different cavities
with already described sizes were prepared into the
specimens. A strip of the matrix band used (transparent
or metal) was glued (UHU hotglue, Bhl, Germany) to
the resin blocks without forming marginal gaps between
the prepared cavities and the matrix band. Restorations
were applied, as previously described (Figure 2), and
all curing procedures were performed from the occlusal
surface of the cavity. After curing, the matrix band was
removed, no postcuring technique was used, and the
Vickers hardness of the planed approximal composite
surfaces was measured with microhardness meter at a
load of 0.3 kg for 30 seconds. The Vickers hardness
was measured on the approximal composite surface
24 hours following resin placement. Six measurements
were made at predetermined, regularly distributed sites
in the cervical area of the approximal surface. The val-
ues were evaluated by light microscopy at 200 mag-
nitude. Hardness was calculated by dividing the applied
load by the surface area of the indentation.
Statistical Analysis
The mean values and standard deviations were calculated
for each group. Data were analyzed with nonparametric
statistics; the Kruskal-Wallis Multiple- Comparison Z-Value
Test including the Bonferroni Correction were used
with alpha = 0.05 for statistical analysis of the results.
Results
Evaluation of Marginal Seal
The results of the dye penetration of the various groups
of composite restorations were recorded (Table 1).
Marginal microleakage or its absence was observed in
P P A D 247
Szep
Mean, Standard Deviation (SD), Minimum (Min), Maximum (Max), and Median Values of
Vickers Hardness Values for Proximal Surfaces of Different Groups.
Group No. Mean SD Min Max Median Significance to No.
EIT 1 64.48 4.55 55.78 75.52 63.87 5-8
DIT 2 62.47 5.32 61.94 73.67 64.78 5-8
ECT 3 64.59 4.34 54.73 74.33 64.10 5-8
DCT 4 59.56 4.77 51.24 70.45 58.20 5-8
EIM 5 42.65 4.18 32.41 52.43 42.80 1- 4,8
DIM 6 41.80 5.69 31.92 52.43 43.57 1- 4,8
ECM 7 41.95 4.89 33.95 55.62 40.29 1- 4,8
DCM 8 31.56 4.46 22.86 42.80 30.98 1- 7
Numbers of groups indicate statistically significant difference (alpha = 0.05, Kruskal-Wallis Multiple-Comparison Z-Value Test
and Bonferroni Test).
Table 2
each group evaluated in this study. Each restoration
demonstrated marginal microleakage on the gingival
wall. Highest values were found in the groups DCM
(92.42%) and DIT (89.31%), which were significantly
different from the groups EIT (59.4%), ECM (54.26%),
and ECT (52.37%). Since buccolingual sections were
obtained in order to encompass the entirety of the cervi-
cal shoulder in the buccolingual direction, the method of
sectioning may have influenced the results obtained. An
occasional high standard deviation was observed as a
result of the either perfect seal or high values of pene-
tration that were obtained in this evaluation.
Evaluation of Surface Hardness
The results of the microhardness measurements were listed
(Table 2). For all groups investigated, there was a strong
correlation between increased microhardness and the
use of transparent matrices. When transparent matrices
were used, no statistically significant correlation was
found between the use of the incremental technique ver-
sus centripetal technique or of the location of the cavity
preparation. For the group DCM (opaque matrix system
in combination with the centripetal technique in deep
cavities), a significant decrease in microhardness val-
ues was noted compared with all seven possible groups.
Discussion
As a composite resin material undergoes polymerization
shrinkage, the force of this shrinkage may exceed the bond
strength of the material to tooth structure.
26
Shrinkage-free
resins that would permit the placement of perfectly
adapted and sealed restorations are not yet available.
Factors allowing the optimization of the marginal adap-
tation of composite resin restorations can be found in the
composite resin material, cavity preparation, and place-
ment technique. A multistep insertion technique, in combin-
ation with transparent matrices and reflective wedges,
has been designed to enhance the marginal quality of
Class II composite restorations.
8
In addition, the marginal
adaptation can be significantly improved by the use of a
buildup base material that reduces the size of the compos-
ite restoration, thus increasing the free surface-to-volume
ratio.
27,28
Based on these facts, and in combination with
various parameters previously described, a comparison
was made between the centripetal and incremental tech-
niques. It was found that the centripetal technique showed
better marginal adaptation in cavities prepared in enamel
than did the common incremental technique. Several
authors have indicated that one of the most important
principles for incremental placement is to reduce the V/A
ratio by applying the first increment to only one cavity
wall.
29
Other reports have indicated that the applica-
tion of composite in oblique layers resulted in fewer
contraction gaps at the margins.
30,31
There has been dis-
agreement concerning the relative merits of apical oblique
versus coronal oblique incremental patterns, although dif-
ferences between these are of less significance than the
need for incremental rather than single-bulk technique.
32
In the present study, it was found that neither the
technique nor the matrix band material had statistical sig-
nificant influence in the marginal microleakage. Only the
preparation depth influenced the results. Eakle and Ito
reported that significantly less leakage occurred under
gingival margins when the proximal box ended on
enamel than when it terminated on cementum.
19
The same
behavior was found in this study, where the highest
microleakage value in the enamel-surrounded groups
75.83% penetration (EIM), as opposed to the highest
value of 92.42% (DCM) in deeper cavities. Numerous
researchers noted that neither of the one-bulk incremental
placement techniques was able to produce consistently
leak-free margins, even on etched enamel.
17,19
Through the use of the centripetal technique, the
V/A ratio could be reduced. This differed from the incre-
mental technique, where the complete apical area of the
cavity was filled with the first layer of composite resin
material. In the incremental technique, this first layer had
less contact with the lateral walls than did the resin in
the first layer of the centripetal buildup technique.
Alternatively, the first layer of the centripetal technique
had no contact to the pulpoaxial walls and thus had less
tendency to contract toward this wall and away from the
cervical floor during polymerization. In the proximal box,
the polymerization shrinkage tended to pull this first
248 Vol. 13, No. 3
Practical Procedures & AESTHETIC DENTISTRY
horizontal increment away from the cervical margin. The
second layer of the incremental technique, which was
a diagonal layer, was not able to cover the first portion
in the cervical area, which did occur with the second
layer of the centripetal buildup technique.
In deep cavities, the dentin adhesive material was
unable to inhibit dye penetration. Lui et al determined
that the worst marginal adaptation of restorations was
found in the cervical area and attributed to the effect of
polymerization shrinkage, inadequate adaptation of non-
condensable resin, difficulty of placement at the proxi-
mal box, and shrinkage toward the light source.
23
In the
present study, this behavior was only registered in groups
EIM, ECM, and DCM. It is, however, surprising that all
cavities in the Lui study were filled with different tech-
niques and in different depths yet always with metal matri-
ces and wooden wedges. Wooden wedges, when
properly used, enhance the adaptation to the cavity walls
and provide firm contact areas and anatomical proximal
contours.
33
Scherer et al registered that restorations made
with transparent matrices and reflective wedges exhib-
ited less microleakage than those delivered with opaque
matrices and wooden wedges.
25
Furthermore, Lutz et al
proved that the concept of directing the polymerization
shrinkage vectors toward the margins of a cavity by using
light-reflective wedges with reflective cores was efficient.
28
In another study,
12
it was shown that the worst mar-
ginal qualities were obtained in cavities filled with com-
posite in a one-step technique and with opaque wedges
and matrices (62.2% excellent margins) in contrast to
composite fillings with transparent matrices and laterally
reflecting wedges (79.4% excellent margins). The values
were not significantly different. In that study, however,
the cavities were placed in a one-bulk technique and
opaque matrices were only cured from the occlusal direc-
tion. No postcuring was performed following the replace-
ment of the opaque matrices and wooden wedges. In
the present study, only the restorations delivered with
metal matrix bands were postcured. For this purpose,
postcuring was performed for 40 seconds from the buc-
cal and occlusal aspects. The additional use of reflec-
tive wedges in the proximal area during the postcuring
period was not investigated in this study, as the authors
believed that a postcuring situation with reflective wedges
in the proximal area would not accurately reflect the dif-
ferences in the aforementioned techniques.
A statistically significant increase in microhardness
was obtained in all groups treated with transparent matri-
ces and reflective wedges. This could be attributed to
the higher degree of conversion and crosslinking of the
resin.
13,34
There is also a correlation between the curing
light intensity and the depth of cure.
von Beetzen et al investigated the microhardness of
composite restorations and determined that the Herculite
composite material, also used in this study, was char-
acterized by Vickers values that ranged from 44 HV to
59.8 HV, depending on the polymerization technique.
13
In the experimental set-up of their investigation, stan-
dardized Class I I cavities in brass blocks were filled with
composite in 2.5-mm increments, which were then cured
for 60 seconds from the occlusal aspect of the cavity.
Plastic matrix bands were used and, after the increments
had been cured from the occlusal aspects, no postcur-
ing was done as in the present study. Although higher
values (59.8 HV) were obtained when using a trans-
parent cone for the polymerization,
13
comparable values
were also achieved for the restorations using both metal
matrices (42.65 HV for group EIM) and transparent matri-
ces (64.48 HV for group EIT) in the current investiga-
tion. This is due to the 1.5-mm increments in this study,
the preparation of extracted teeth rather than metal blocks,
and the use of an additional curing unit. Questions were
raised, however, regarding the examination of surface
hardness conducting different polymerization procedures,
as in evaluation of the marginal seal. In the experimen-
tal design of microhardness analysis, the different matrix
bands were glued to the flat surface of the specimen.
Although securing and utilization of different wedges was
not conducted in this investigation, it would be interest-
ing, to do this in further investigations. A postcuring poly-
merization technique, which could have improved the
results, was also rejected.
P P A D 249
Szep
Conclusion
The authors concluded that none of the insertion tech-
niques and matrix bands used in this study were able to
prevent extensive microleakage at the cervical margins
of Class I I composite restorations. The marginal integrity
of composite resins placed in cavities ending in enamel
and restored with the centripetal technique and trans-
parent matrices was not statistically different from those
filled in the incremental technique in combination with
either reflective or wooden wedges.
Cavities prepared with their marginal aspects in
dentin showed no significant differences in their micro-
leakage behavior either in dependence of the matrix
band material nor of the placement technique. In deep
cavities, the lowest microleakage values (although not
statistically significant) were obtained when the centripetal
technique was used in combination of transparent matri-
ces. The preparation depth significantly influenced the
results, with less leakage observed in margins located
within the enamel. The results also determined that the
highest mean hardness values for composite resin restora-
tions were achieved using transparent matrices.
Acknowledgment
The authors declare no financial interest in any of the
products cited herein.
References
1. Bergenholtz G, Cox CF, Loesche WJ, Syed SA. Bacterial leak-
age around dental restorations. Its effect on the pulp. J Oral
Pathol 1982;11(6):439-450.
2. Brannstrom M. Communication between the oral cavity and the
dental pulp associated with restorative treatment. Oper Dent
1984;9(2):57-68.
3. Cheung GS. Reducing marginal microleakage of posterior com-
posite resin restorations: A review of clinical techniques. J Prosthet
Dent 1990;63(3):286-288.
4. Eriksen HM, Pears G. In vitro caries related to marginal leak-
age around composite resin restorations. J Oral Rehabil 1978;
5(1):15- 20.
5. Qvist V. Correlation between marginal adaptation of compos-
ite restorations and bacterial growth in cavities. Scand J Dent
1980;88:296-300.
6. Navarro Majo JL. Marginal adaptation of posterior resins: Effect
of hygroscopic expansion and layer placement technique on
Class I I and V fillings. Stoma (Lisb) 1991;2:47-48.
7. Saunders WP, Strang R, Ahmad I. Effect of composite resin place-
ment and use of an unfilled resin on the microleakage of two
dentin bonding agents. Am J Dent 1990;3(4):153-156.
8. Lutz F, Krejci I, Oldenburg TR. Elimination of polymerization
stresses at the margins of posterior composite resin restorations:
A new restorative technique. Quint Int 1986;17(12):777- 784.
250 Vol. 13, No. 3
Practical Procedures & AESTHETIC DENTISTRY
9. Krejci I, Sparr D, Lutz F. Three-layer light hardening procedure with
traditional composites for Black Class II restorations. Quintessenz
1987;7:1217-1229.
10. Bichacho N. The centripetal build-up for composite resin poste-
rior restorations. Pract Periodont Aesthet 1994;6(3):17-23.
11. Cvitko E, Denehy G, Boyer DB. Effect of matrix systems and
polymerization techniques on microleakage of Class II resin com-
posite restorations. Am J Dent 1992;5(6):321-323.
12. Lutz F, Krejci I, Barbakow F. The importance of proximal curing
in posterior composite resin restorations. Quint Int 1992;23(9):
605-607.
13. von Beetzen M, Li J, Nicander I, Sundstrm F. Microhardness
and porosity of Class 2 light-cured composite restorations cured
with a transparent cone attached to the light-curing wand. Oper
Dent 1993;18(3):103-109.
14. Simonsen RJ, Kanca J. Surface hardness of posterior composite
resins using supplemental polymerization after simulated occlusal
adjustment. Quint Int 1986;17(10):631- 633.
15. Unterbrink GL, Muessner R. Influence of light intensity on two
restorative systems. J Dent 1995;23(3):183-189.
16. Hinoura K, Setcos JC, Philips RW. Cavity design and placement
techniques for Class 2 composites. Oper Dent 1988;13(1):12-19.
17. Shahani DR, Menezes JM. The effect of retention grooves on
posterior composite resin restorations: An in vitro microleakage
study. Oper Dent 1992;17(4):156-164.
18. Donly KJ, Wild TW, Jensen ME. Posterior composite Class II
restorations: In vitro comparison of preparation designs and restora-
tion techniques. Dent Mater 1990;6(2):88-93.
19. Eakle WS, Ito RK. Effect of insertion technique on microleak-
age in mesio-occlusodistal composite resin restorations. Quint
Int 1990;21(5):369-374.
20. Neo JC, Denehy GE, Boyer DB. Effects of polymerization tech-
niques on uniformity of cure of large-diameter, photo-initiated com-
posite resin restorations. J Am Dent Assoc 1986;113(6):905-909.
21. Fuks AB, Chosack A, Eidelman E. Assessment of marginal leak-
age around Class II composite restorations in retrieved primary
molars. Pediatr Dent 1990;12:24-27.
22. Opdam NJ, Roeters J J, Kuijs R, Burgersdijk RC. Necessity of
bevels for box only Class II composite restorations. J Prosthet
Dent 1998;80(3):274-279.
23. Lui JL, Masutani S, Setcos JC, et al. Margin quality and microleak-
age of Class II composite resin restorations. J Am Dent Assoc
1987;114(1):49-54.
24. Dietschi D, De Siebenthal G, Neveu-Rosenstand L, Holz J. Influence
of the restorative technique and new adhesives on the dentin
marginal seal and adaptation of resin composite Class II restora-
tions: An in vitro evaluation. Quint Int 1995;26(10):717-727.
25. Scherer W, Caliskan F, Kaim J M, et al. Microleakage com-
parison in opaque and transparent matrix systems. Gen Dentistry
1989;37(6):482-484.
26. Lambrechts P, Braem M, Vanherle G. Buoncore memorial lec-
ture: Evaluation of clinical performance for posterior composite
resins and dentin adhesives. Oper Dent 1987;12:53- 78.
27. Aboushala A, Kugel G, Hurley E. Class II composite resin restora-
tions using glass-ionomer liners: Microleakage studies. J Clin
Pediatr Dent 1996;21(1):67-70.
28. Lutz F, Krejci I, Luescher B, Oldenburg TR. Improved proximal
margin adaptation of Class II composite resin restorations by
use of light-reflecting wedges. Quint Int 1986;17(10):659-664.
29. Davidson CL. Resisting the curing contraction with adhesive com-
posites. J Prosthet Dent 1986;55(4):446-447.
30. Hansen EK. Effect of cavity depth and application technique on
marginal adaptation of resins in dentin cavities. J Dent Res 1986;
65(11):1319-1321.
31. Hansen EK, Asmussen E. Comparative study of dentin adhesives.
Scand J Dent Res 1985;93(3):280-287.
32. Bryant RW. Direct posterior composite restorations: A review. 2.
Clinical technique. Aust Dent J 1992;37(3):161-171.
33. Eli I, Weiss E, Kozlovsky A, Levi N. Wedges in restorative den-
tistry: Principles and applications. J Oral Rehabil 1991;18(3):
257- 264.
34. Kanca J. Visible light activated composite resin for posterior use:
A comparison of surface hardness and uniformity of cure. Update.
Quint Int 1985;16(10):687- 690.
1. As composite resin materials undergo polymerization
shrinkage, the force of this shrinkage may exceed the
bond strength of the composite material to tooth struc-
ture. Shrinkage-free resins are available that permit the
placement of perfectly adapted and sealed restorations.
a. Both statements are true.
b. Both statements are false.
c. The first statement is true, the second statement is false.
d. The first statement is false, the second statement is true.
2. The centripetal technique incorporated:
a. Polymerization of the first layer from the occlusal direction.
b. Polymerization of the second layer through the light
wedge.
c. Polymerization of the third and fourth layers from the
buccal and occlusal directions.
d. All of the above.
3. According to the literature, the achievement of clinically
flat restoration surfaces can be obtained in most
instances. This statement is:
a. True.
b. False.
4. Following comparison of the centripetal technique to the
incremental technique, all of the following conclusions
were drawn EXCEPT:
a. Extensive microleakage was prevented by all of the
insertion techniques and matrix bands evaluated.
b. The highest mean hardness values for composite resin
restorations were achieved using transparent matrices.
c. No significant differences could be noted between the
microleakage behavior of cavities prepared with their
marginal aspects in dentin.
d. The placement technique or type of matrix band utilized
for restoration did not significantly affect the marginal
integrity of the composite resin restorations.
5. A significant microhardness increase was observed in
the groups treated with transparent matrices and reflec-
tive wedges. This difference was attributed to the higher
degree of conversion and crosslinking of the resin.
a. Both statements are true.
b. Both statements are false.
c. The first statement is true, the second statement is false.
d. The first statement is false, the second statement is true.
6. When the whole margin area is initially filled with an
increment:
a. Development of a gap cannot be filled with the next
consecutive incremental layer.
b. Fewer contraction gaps can be expected at the margins
using the incremental technique versus the centripetal
technique.
c. Fewer contraction gaps can be expected at the margins
using the centripetal technique versus the incremental
technique.
d. All of the above.
7. The centripetal technique demonstrated enhanced
marginal adaptation in cavities prepared in enamel
compared to the traditional incremental technique.
This statement is:
a. True.
b. False.
8. The incremental technique incorporated:
a. Indirect curing of the first layer through the light wedge.
b. Polymerization of the second and third layers from the
buccal and oral directions.
c. Polymerization of the final increment from the occlusal
aspect.
d. All of the above.
9. The dentin adhesive material was unable to inhibit dye
penetration in deep cavities. The worst marginal adapta-
tion of restorations was found in the cervical area and
attributed to the effect of polymerization shrinkage.
a. Both statements are true.
b. Both statements are false.
c. The first statement is true, the second statement is false.
d. The first statement is false, the second statement is true.
10. According to the aforementioned case report, the:
a. Utilization of the incremental technique facilitated reduc-
tion of the cavity volume to area of the cavity walls ratio.
b. Utilization of the centripetal technique facilitated reduc-
tion of the cavity volume to area of the cavity walls ratio.
c. Utilization of the centripetal technique facilitated mini-
mized contact of the first layer with the lateral walls
compared to the resin in the first layer of the incremental
buildup technique.
d. All of the above.
To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete as follows:
1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3) Clip answer sheet from the page and mail
it to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section.
The 10 multiple-choice questions for this Continuing Education (CE) exercise are based on the article Comparative study of composite resin
placement: Centripetal buildup versus incremental technique by Susanne Szep, Dr med dent, Holger Frank, Dr med dent, Bettina Kenzel,
Dr med dent, Thomas Gerhardt, Dr med dent, and Detlef Heidemann, Dr med dent habil. This article is on Pages 243-250.
Learning Objectives:
This article describes the effects of two different proximal restoration techniques with different matrix systems on the marginal seal and micro-
hardness of Class II composite restorations. Upon reading this article and completing this exercise, the reader should:
Understand the importance of limiting microleakage in Class II restorations.
Be able to describe the utilization of the centripetal and incremental buildup techniques.
CONTINUING EDUCATION
(CE) EXERCISE NO. 10
C
E
CONTINUING EDUCATION
10
252 Vol. 13, No. 3