RestorativeDentistry

Louis Mackenzie
Adrian CC Shortall and FJ Trevor Burke

Direct Posterior Composites: A

Practical Guide
Abstract: The restoration of posterior teeth with directly placed resin-bonded composite requires meticulous operative technique in order
to ensure success. Case and material selection; cavity preparation; matrix selection; isolation; bonding; management of polymerization
shrinkage; placement; finishing and curing of posterior composites all present a series of challenges that dentists must master in order
to ensure high-quality, long-lasting restorations. This paper describes and discusses these aspects of the provision of composites for loadbearing situations in posterior teeth.
Clinical Relevance: Successful restoration of posterior teeth with composite is an essential component of contemporary dental clinical
practice.
Dent Update 2009; 36: 7195

Conflicting opinion and a wealth of

contradictory data present difficulties
for dentists in choosing which materials,
instruments and techniques to employ when
considering restoration of posterior teeth
with direct composite.
In some areas of the world, resin
composite is the first (or only) choice for
direct restorations in teeth, with the setting
up of amalgam-free practices and a dental
school which has not taught amalgam
placement techniques for over a decade.1,2
In this respect, although amalgam has
served dentistry for over a century and, if
well placed, may provide restorations which
function beyond 30 years,3 encouraging
clinical outcomes have caused some
clinicians to favour composite, even when

Louis Mackenzie, BDS, General Dental

Practitioner and Clinical Lecturer, Adrian
CC Shortall, DDS, Reader in Restorative
Dentistry and FJ Trevor Burke, DDS,
MSc, MGDS FDS RCS(Edin), FDS RCS(Eng),
FFGDP FADM, Professor of Primary Dental
Care, Primary Dental Care Research
Group, University of Birmingham School
of Dentistry, St Chads Queensway,
Birmingham B4 6NN, UK.
March 2009

restoring large cavities.4 There has been

a consequent decline in the worldwide
use of amalgam over the last decade3
and a concomitant increase in the use of
composite.5
This situation has been brought
about by:
Alleged health concerns and
environmental considerations regarding
amalgam;
The dental professions desire for an

adhesive material that demands less invasive

cavity preparations;6,7
Patient demand for tooth-coloured
restorations in posterior teeth.1,4,6,8,9
With good case selection,
proper adhesion and placement, posterior
composites can provide successful and
predictable restorations1,8 that may match the
appearance of natural teeth (Figure 1).10,11
As a result, it may be considered
that the use of posterior composites is set

Figure 1. (a, b) Occluso-lingual restoration of a lower second molar in Clearfil Majesty (Kuraray, Japan).

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RestorativeDentistry

Figure 2. (ac) Preventive resin restorations in an upper second molar using X-Flow (Dentsply International, Inc York, PA, USA).

Figure 3. (ac) Occlusal restoration of an upper molar in APX (Kuraray, Japan). Unsupported enamel can be retained, after preparation, if composite is
selected.

to increase, alongside improvements in

materials, instruments, dentine adhesion and
restorative techniques.5,10,12 The professions
knowledge and confidence in the use of
posterior composite will be further enhanced
by better and more comprehensive
undergraduate and postgraduate teaching of
the subject.2,5
However, if composite is to
compete truly in terms of prognosis and
longevity, material performance, adhesion
and restorative techniques must be
optimized.11,13

Indications for posterior

composites
Preventive resin restorations

Resin composites may be

considered to be the material of choice for
ultra-conservative restoration of discrete
carious lesions in the fissures of posterior
teeth, where it is impossible to facilitate
effective plaque removal and fissure sealing

72 DentalUpdate

alone is inappropriate. Depending on the

size of the lesion (and the possible need
to seal adjacent, unaffected, fissures),
various protocols have been proposed for
preventive resin restorations14 and have
been demonstrated to produce excellent
long-term results (Figure 2).15
Larger initial lesions

Posterior composites may also

be considered to be the logical choice for
the treatment of more extensive primary
carious lesions, where minimally invasive
techniques can still be applied.1,10 Since
composite may be adapted to any shape
or size of cavity,5 the undermined enamel
that remains after conservative removal
of dentine caries can be retained, where it
will be supported by bonded composite.10
(Figure 3) The resultant, smaller surface
area restoration will be easier to shape
and will be subject to reduced occlusal
loading.9 When composite is used in the
treatment of primary occlusal lesions, such

restorations have been shown to occupy

80% less tooth surface area than a traditional
amalgam restoration.5
Aesthetic restorative dentistry

Although posterior composites

may be used cosmetically, they are generally
employed in the necessary replacement
of missing tooth tissue and any failed
restoration (Figure 4).
Conservative restorations in the aesthetic zone

Direct composite can be used

effectively for the restoration of aesthetically
important teeth,11,13 for example premolars,
where it can also prove to conserve tooth
tissue,1,6 avoiding the need for further tooth
preparation, which may ultimately involve
core build-up and crown preparation (Figure
5).
Cosmetic restorations

Resin composite may be used to

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RestorativeDentistry

Figure 4. (ac) Disto-occlusal restoration of a lower premolar in Clearfil Majesty (Kuraray, Japan).

b
Figure 6. (a, b) Cosmetic replacement of an occlusal amalgam using Filtek Silorane (3M ESPE, St Paul,
MN, USA).

Figure 5. (a, b) Conservative restoration of an

upper first premolar following a buccal cusp
fracture using Filtek Silorane (3M ESPE, St Paul,
MN, USA).

replace failed or unattractive, moderate to

large Class I and II restorations,1 where the
preparation outline form does not place the
margins under direct parafunctional loading
(Figure 6).
Treatment of cracked teeth

The use of direct composite

has been shown to be effective for the
immediate treatment of painful, cracked

74 DentalUpdate

teeth.5,16 The validity of this form of

treatment and the need to provide cuspal
coverage is the subject of debate and
merits further investigation (Figure 7).
Other uses

Resin composite may be used

effectively for the restoration of Class V
cavities17 and for the conservative repair
of indirect restorations. It may also be
used to replace amalgam restorations
implicated in lichenoid reactions and
in cases of proven allergy to metal
restorations.
Worldwide, the acknowledged
range of indications for which directlyplaced composites can be used is
growing, as clinicians confidence and skill
in placing such restorations increases.
Their motivation should also be to

perfect the least invasive methods for the

preservation and repair of teeth throughout
a lifetime.7

Case selection
Patients should have an
acceptable level of oral hygiene, as
restorations formed in resin composite
have been considered to attract greater
levels of pathogenic bacteria than amalgam
restorations.11 Occlusal contact(s) on enamel
may be considered desirable and, ideally,
all cavity margins should be in enamel. In
this respect, a superior prognosis can be
expected from a restoration bonded to an
uninterrupted enamel margin.18
Contra-indications

Posterior composites should

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Figure 7. (ac) Direct composite (Clearfil Majesty Kuraray, Japan) used to relieve symptoms of a cracked lower molar.

be avoided in patients with a high caries

rate that cannot be controlled,13 or where
the tooth to be restored is subject to high
occlusal loads.1
Careful thought should be given
before considering using direct composite
to restore large cavities,19 where cuspal
contacts require restoration and where
cavity margins extend beyond enamel, for
example, in deep proximal boxes.
Posterior composites are contraindicated if meticulous isolation cannot
be guaranteed throughout the operative
procedure, by the use of rubber dam or
other equivalent methods of moisture
control.1
Posterior composites should not
be attempted if there is insufficient surgery
time available to complete the procedure,
as composite placement techniques cannot
be rushed13 and they should be avoided
in proven cases of sensitivity to resin
composite materials and/or adhesives.1
Informed consent

Although one recent, large, fiveyear study reported comparable longevity

of composite to amalgam in Class I and II
restorations,20 patients should be informed
that posterior composites may not last as
long as an amalgam restoration in some
situations and that, in common with
amalgam, the number of restored surfaces
may have a significant effect on survival.1,20
Patients should also be made
aware that:
In some cases, the procedure may
be much longer (2.5 times13) than an
equivalent amalgam restoration;
March 2009

Placement will often require rubber dam

isolation;
The treatment will be more expensive;
Post-operative complications may be
likely if the restoration is not adequately
bonded, adapted and polymerized, or there
is incomplete control of the problems
associated with polymerization shrinkage.

Choosing a posterior composite

In recent years, successful longterm clinical performance of posterior
composites has been attributed to an
improvement in the physical properties
of composite restoratives and improved
effectiveness of dentine-bonding agents.1,4,9
In the UK, there are currently
over 50 different brands of composite resin
on the market and, as a result, it is difficult
for practitioners to make an informed
choice when selecting a material.5 Many
composites have similar constituents and
manufacturers modify their formulation
to optimize their properties and clinical
performance for anterior, posterior or
universal use. Composites which are
advocated for posterior use have a matrix
of resin monomers containing a high
volume (60%) of inorganic filler particles.
This high filler load conveys the fracture
resistance necessary for the loads exerted
on restorations in molars and premolars.5
Posterior composites are usually hybrid
materials, indicating that the filler particles
are a mixture of sizes.9,10
As handling characteristics are
such a critical determinant of success, this
property may be considered to be one

of the most important. When choosing a

composite, the following should be assessed:
How easily can the composite be removed
from the syringe or applied from the
compule?
How easily can the material be adapted
to the floor and walls of the cavity, without
sticking to instruments?
Do individual increments integrate well
(without obvious voids)?
How easily can the material be sculpted to
the correct anatomical form?
How long does it hold its shape before
curing, without slumping?
Does it have a good working time under
ambient lighting conditions?
Other considerations that may be
important are:
Cost;
Whether it is also to be used for anterior
teeth (heavily filled hybrid composites
may compromise aesthetics when used
anteriorly);
Shade range (although some materials
have many shades, a very limited shade range
for posterior teeth may satisfy most dentists
and patients).5
Most materials are available in
syringes and compules. The use of compules
may result in better adaptation,21 provided
that the tip is small enough to be placed
close to the bottom of the cavity.5 Some
operators favour a less viscous material
and use warmers to achieve the handling
characteristics that they prefer. Others
transfer material from a syringe to a fine
transfer tip (which may be lubricated with a
solvent-free resin) to facilitate accurate direct
placement.
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Figure 8. (ac) Examples of two surface restorations in Synergy Duo (Coltne-Whaledent, Switzerland) 79 years post-placement. Despite excellent handling
and aesthetic properties, this material has been superseded by a new nano-technology product.

Packable composites

While the current tendency is to

market materials with increased viscosity,
very stiff materials may deliver inferior
results, creating voids along cavity walls
and porosities between increments.5,21
When using a packable composite, it has
been suggested that the use of a flowable
composite lining may reduce this tendency.12
Further claims that the consistency of a
composite has a significant effect on contact
tightness have not been substantiated.1,5,22
Clinical trials

Unfortunately, manufacturers
may be driven by market forces to launch
new composites regularly.5 Accordingly, by
the time independent research has revealed
deficiencies, these products may have
been withdrawn.5 Even more annoyingly,
composites with proven excellent long-term
clinical performance may be discontinued
in favour of further innovative materials and
concepts5 (Figure 8).
Even the best laboratory research
is only partially capable of predicting clinical
performance.12 Clinical trials are the ultimate
tool for evaluation, but poor quality data
and lack of standardization can make results
difficult to interpret.12 It has therefore been
recommended that efforts should be made
to meet published standards for improving
the quality of randomized trials,12 as it is
the patient and dentist who will face the
consequences of an underperforming
material.5 It has also been recommended
that, prior to marketing, it is desirable
to evaluate a dental restorative material

76 DentalUpdate

carefully, in-vivo, for at least 2 years (and up

to 4 years)23 to determine its potential clinical
success.12 However, the commercial viability
of such a concept must be questionable.
Choosing an adhesive system

With well over 40 different brands

of adhesive and alternative permutations
of etch, primer and bonding resin being
available, choosing an adhesive system is a
difficult task. Fortunately, virtually all adhesive
systems are compatible with any composite.
Irrespective of the number of bottles, an
adhesive typically contains resin monomers,
curing initiators, inhibitors, stabilizers,
solvents and, sometimes, an inorganic filler.
Each of these components has a specific
function and the chemical formulation
determines, to a large extent, the adhesive
performance.24 It has been demonstrated
that there is a large range in the ability of
general dental practitioners to manipulate
adhesive systems correctly.25 Well-established
3-step etch and rinse adhesive protocols
routinely show reliable and predictable
clinical performance,26,27 and remain the gold
standard method of bonding to dentine.27
However, there is now a tendency towards
marketing adhesives with simplified userfriendly application procedures. While these
two- or one-bottle bonding systems may
save a small amount of clinical time and
offer promising adhesion in the early life
of the restoration, they may prove to be a
false economy in the longer term, failing to
deliver the sustained adhesion desired by
practitioners and patients alike.26,27
As with composite materials,

Figure 9. Mesio-occlusal restoration of a lower

molar at 3 years (Synergy Compact, ColtneWhaledent, Switzerland). Natural contour renders
the restoration undetectable to the casual
observer, despite a shade mis-match and some
marginal chipping.

adhesive systems are frequently replaced

by modified next generation successors,
claimed to be better, without clinical
validation.28

Clinical stages for restorations

using direct posterior
composites
Shade taking

The shade should be taken

before isolation, as teeth may dehydrate and
lighten in colour.11 Shade matching is less of
a concern for posterior composites than with
restorations in anterior teeth and, indeed,
some operators favour a slight mis-match to
assist finishing (Figure 9).5,13 The shade may
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RestorativeDentistry

be taken with the proprietary shade guide,

but greatest accuracy is attained by applying
a test piece of composite to the tooth.10 This
should be cured as there is usually a shadeshift on polymerization.11
Occlusal record

Prior to isolation, articulating

paper should be used to assess the
occlusion in the intercuspal position and
in all excursions.8,13 Careful consideration
of occlusion pre-operatively will facilitate
planning of margin placement,13 reduce
finishing time and enable accurate
reproduction of the occlusal scheme (which
cannot be re-assessed until the rubber dam
is removed). Opposing and adjacent teeth
should be examined. If their position or
contour is likely to compromise successful
restoration, they should be adjusted
appropriately.

Cavity preparation

The main aim of preparation is

to remove diseased tissue only. Access should
be limited to that required to visualize and
remove carious tooth tissue and/or any
previous restoration1,8 and to permit access
for instruments (Figure 10).1 In the UK, the
majority of restorations involve replacement
of old fillings. Here flat floors, definite walls
and undercuts may be present and will

provide resistance form, thereby reducing

stress on the adhesive bond during occlusal
loading. Rounded internal line angles
will aid adaptation of the composite and
further reduce stress concentration.10,12 As
bond strengths of adhesives to enamel are
generally greater than those to dentine and
dentine-bonded interfaces have been shown
to degrade with time,11,24,26,28every effort
should be made to preserve enamel at the
cavity margins, especially on the cervical floor
of boxes.1
No extension into sound fissures
is indicated and a smooth, flowing outline
form, that avoids loading of margins, will
make filling and finishing easier.
Interproximal boxes should
be extended just past the contact point
cervically to allow complete caries removal,
aid matrix placement and permit caries
diagnosis (Figure 11).13 Vertical box margins
may be left in contact, if this does not
compromise matrix placement.
Bevelling is not recommended
occlusally, as this may result in a thin margin
of composite, which could be prone to
fracture under occlusal load. Proximal bevels
are advocated by some to optimize the
marginal seal.29 However, proximal bevels
may be difficult to achieve accurately without
damage to the adjacent tooth.
The use of loupes (+/ light) will
facilitate minimal preparation and caries
removal.13 Care must be taken to avoid all
contact with adjacent teeth,10 which should

Figure 10. (a) Upper premolar with a distal carious

lesion. (b) Initial access. (c) Access sufficient to
assess carious lesion. (d) Cavity preparation
complete. (e) Isolation, wedging and matrix
placement.

March 2009

Figure 11. Proximal box preparation extended

just below contact point cervically.

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RestorativeDentistry

will all adversely affect adhesion. Careful use

of rubber dam will guarantee isolation and
improve visibility, making the procedure
easier and more predictable.8 In this respect,
recently introduced lip/cheek retractors, such
as Optragate (Ivoclar Vivadent, Leichtenstein)
and Optiview (Kerr Mfg Co, Orange, CA, USA)
may be of value in cavities towards the front
of the mouth.
Tight contacts and natural proximal contour

Figure 12. MODB restoration of an upper premolar (Filtek Silorane, 3M ESPE, St Paul, MI, USA) displaying
anatomically correct proximal contour.

In the past, composite placement

resulted in at least double the number of
open contacts compared with amalgam,31
and this often constituted an instant failure
of the restoration. Good matrix technique
has been shown to be the most important
determinant of contact tightness,1,5,10,12,22
with recently introduced devices helping to
overcome these difficulties.
Matrices must be burnished or
held against the adjacent tooth because,
unlike amalgam, composite will not so readily
push the band out.8 The aim is not just to get
a tight contact, but to recreate embrasure
anatomy and facilitate plaque removal from
interproximal margins (Figure 12).
Wedging

Wedges reduce the risk of cervical

extrusion of composite which, once cured,
is virtually impossible to remove accurately
without damage to adjacent tissues. The
wedge also separates the teeth slightly to
compensate for the thickness of the matrix.
New and improved wedges,
such as Flexi-wedges (Common Sense Dental
Products Inc, Springlake, MI, USA) (Figure
13) help to ensure that the wedge does not
deform the matrix or encroach upon the
contact area.10

Figure 13. Flexi-wedges (Common Sense Dental

Products Inc, Springlake, MI, USA)

be inspected for early cavitated lesions

that may be restored conservatively while
there is direct access. All peripheral stain/
amalgam should be removed as this may
show through the composite. It is advisable
to delay the final decision on choice of
restorative material until cavity preparation is
complete.

Matrices
Figure 14. Sectional matrices (top 3: Garrison
Dental Solutions, Springlake, MI, USA; bottom:
TrioDent, New Zealand).

Sectional matrices and separation rings

Tunnel restorations

Outcomes for restorations using

occlusal tunnel preparations to access
proximal caries for restoration with glass
ionomer have not proved favourable.30 While
composite may prove more successful, as it
offers more support to the overlying marginal
ridge, tunnel restorations remain technically

80 DentalUpdate

Two general types of

contemporary matrix are now available for
use with proximal posterior composites:

demanding and may have a limited life span

when compared to conventional Class II
composites or amalgams.
Moisture control

Blood, saliva and crevicular fluid

Sectional matrices and

separation rings have been shown to give
the best proximal contact areas1,10,11,22 and
are useful for proximal boxes that are not
too wide. These matrices are available in a
number of different sizes (Figure 14). Their
rounded shape enables the creation of tight,
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RestorativeDentistry

Figure 15. Forceps to flex open and apply a

separation ring (G-ring, Garrison Dental
Solutions).

placed on top of the wedge (Figure 16) or

between the wedge and the adjacent tooth
for wider boxes. Two rings are needed for
MOD cavities. They can be orientated so that
they face in opposing directions, or in the
same direction if different tine lengths are
selected.
The ring secures the matrix
and further separates the teeth in order to
improve contact tightness, but care must be
taken to check that the cervical seal has not
been lost after ring placement.8 After filling,
sectional matrices can be peeled back to
reveal interproximal surfaces. This permits
further lateral light curing, which is repeated
after complete removal of the matrix.6 During
this curing, the wedge is left in place to
prevent haemorrhage.
Removal of sectional matrices can
be difficult, as this technique generates very
tight contact points. Wrapping the end of the
matrix around tweezers or using a bespoke
instrument (+/- specialized matrix) expedites
removal (Figure 17).

and tightened with a matched instrument.

Metal matrices are favoured
over clear ones, which are difficult to use as
they are relatively thick, are difficult to insert
through tight contact points and cannot be
burnished.6,10 Despite facilitating proximal
light-curing, clear matrices have not been
shown to enhance margin quality and seal.33
Aids to contact formation

Suitably shaped or specially

designed hand instruments (eg TrimaxAdDent Inc Danbury, Connecticut, USA)
(Figure 20) may be useful in helping to create
tight contacts. They are applied to the first
increment of box composite and push the
matrix against the adjacent tooth (Figure
21). When the composite is cured in this
position (through the light-guide when using
Trimax), it will help to hold the matrix out
while further increments are placed. Such a
technique also divides the first increment
into two halves, reducing the tendency for
the forces of polymerization contraction to
pull on both box walls simultaneously.

Circumferential matrix systems

Figure 16. Composi-tight Gold Matrix System in

place (Garrison Dental Solutions).

Figure 17. Pin Tweezers and Tab Matrix (TrioDent,

New Zealand) facilitate matrix removal (and
placement).

anatomically accurate, contact points that

reduce the need for proximal finishing. They
are placed, using tweezers, with the concave
edge orientated towards the occlusal surface
and the convex side towards the adjacent
tooth. After wedging, a separation ring is
applied to the matrix using designated
forceps (Figure 15). The ring tines can be
March 2009

In larger cavities and those with

wider boxes, circumferential systems may
be used in preference to sectional matrices.
Traditional matrix and holder circumferential
systems often result in anatomically incorrect
restorations, with a flat proximal contour and
contact points too near the marginal ridge.8
New, single use, systems, eg
SuperMat (KerrHawe, Bioggio, Switzerland)
(Figures 18, 19) may be chosen in preference,
as they confer a number of advantages:
Single-use eliminates cross-infection risk
inherent in multi-use matrix systems. In this
respect, the use of matrices, after cleaning
and autoclaving, for more than one patient
must be considered inappropriate practice;32
They are simple to use and make tight
contacts easier to obtain;
On tightening, they impart a more rounded
proximal contour and are less likely to flex
weak cusps;
The matrix tightener can be easily
orientated buccally or palatally/lingually and
will permit wedge placement from any angle;
These systems, rather than interfering with
the rubber dam, help to hold the dam in
place and improve access;
They are cost-effective and can also be
used for amalgam fillings.
Matrices are applied to the tooth

Figure 18. SuperMat matrix and tightener

(KerrHawe, Bioggio, Switzerland).

Figure 19. SuperMat Matrix System in place.

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Figure 20. Trimax composite instrument (AdDent

Inc. Danbury, Connecticut. USA).

Etching

Before etching, the cavity must be

thoroughly washed, dried and inspected for
any debris. Starting with the enamel, etchant
is applied to the whole cavity, and just
beyond the margins10 (Figure 22).
Excessive application of etchant
beyond cavity margins will result in excess
composite adhering to the etched enamel;
this will have to be removed and, when doing
so, the underlying enamel may be damaged,
notwithstanding the time spent removing
the excess composite. When application
to the dentine is complete, it is left for 15
seconds and then rinsed off thoroughly.
With total etch systems, enamel
can be dried to confirm proper etching (it
will appear frosty), but the dentine must be
re-wetted to promote dentine bonding.11
The aim of wet bonding is to leave the cavity
slightly but visibly moist, with no obvious
pooling (Figure 23).
Self-etching adhesives are
applied and then dried to evaporate the
solvent.
Bonding

Since successful bonding is a

fundamental requirement for long-lasting
composites, fastidious attention to the
manufacturers protocols is essential for
each adhesive system.11,13 Mistakes in
application will have serious consequences.
Gentle air drying and/or aspiration are used
to evaporate the solvent6 and leave a thin
uniform layer, coating the entire cavity. If the
adhesive continues to ripple under gentle
airflow, this implies that solvent evaporation
is incomplete, or that excess resin is present.
Pooling can be removed by blotting with

84 DentalUpdate

Figure 21. Initial increment of Ceram X-duo

composite (Dentsply International Inc, York, PA,
USA) has been cured with the Trimax (contact
forming) tip in place.

a micro brush.6 Conversely, any dry areas

should receive further adhesive and be air
dried again. All cavity surfaces should now
appear glossy/shiny (Figure 24). The adhesive
is then light-cured as per manufacturers
instructions.
Polymerization shrinkage

Improvements in modern
materials and adhesive technology have
overcome many of the historical problems
associated with posterior composites,4,6,8
such as poor wear resistance, as well as
practical, technical difficulties, such as contact
formation. Many of the remaining problems
associated with posterior composites are a
direct or indirect result of polymerization
shrinkage.34 On setting, all composites shrink
(on average 2-3% by volume)13 as the matrix
monomer converts to polymer. On shrinking,
stresses are invariably generated within the
material and at the margins; the magnitude
of this stress depends on the composition of
the composite and its ability to flow before
solidification, which in turn is related to the
cavity configuration.35 The Configuration
Factor (C-factor) is the ratio of bonded to
free cavity surfaces. Narrow/deep occlusal
cavities, with only one unbonded surface,
have the greatest C-factor and are therefore
subject to an increased potential for stress
development. 24 The larger the increment of
composite, the greater the total shrinkage
will be; this will again increase the potential
for stress formation.

Figure 22. (a, b) Total etch of disto-occlusal

premolar cavity (and resin-modified glass ionomer
lining).

Figure 23. Moist dentine floor ready for application

of adhesive.

Other factors influencing the

amount of polymerization contraction
stress include: cavity volume;36 the amount
and quality of residual mineralized tooth
tissue (tooth compliance); location of
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RestorativeDentistry

Incremental placement technique

is a well recognized method of reducing the
effects of polymerization shrinkage. Other
suggested methods include:
Use of flowable composite resin as a liner;
Use of other linings/base layers;
Incorporation of macro-fillers (eg ready
made inserts) to reduce the overall volume of
composite;
Alternative light curing regimes.
Flowable composites
Figure 24. Glossy/shiny adhesive layer ready for
light curing.

cavity margins; bond strength of the

adhesive; material composition; and curing
characteristics.
Consequences of polymerization shrinkage

Polymerization shrinkage occurs

towards the walls of the preparation to which
the composite is most strongly bonded. If
contraction forces at the least retentive cavity
margins (those with dentine bond or fragile
enamel) exceed those of the bond strength,
separation may occur at the interface.11,34
Partial or total bond failure
may result in loss of the restoration, postoperative sensitivity or marginal gap
formation, which in turn may allow ingress
of cariogenic bacteria and stain.11 Even if
marginal gaps are not an immediate clinical
problem, the stain that ensues may lead to
premature removal of the restoration due
to subsequent misdiagnosis of secondary
caries37 (Figure 25).
If the bonding interface is
preserved, the contraction forces can be
transmitted to the adjacent enamel and
dentine, causing cusp flexure or fracture
(especially if thin) and/or crazing of the
enamel or fractures in the composite
material.11,13,34
Post-operative pain

Despite improvements in
materials and techniques, post-operative
sensitivity following placement of posterior
composites may arise4,11 if care is not
taken to avoid the problems caused by
polymerization contraction shrinkage or
March 2009

Figure 25. Stained marginal and surface defects

are evident in this restoration at 5 years post
placement. Incomplete control of the forces of
polymerization contraction may have contributed
to loss of marginal integrity.

there are deficiencies in the bonding and/or

placement technique.
Nevertheless, as with any
restoration, a short period of transient
post-operative sensitivity may occur and
patients should be warned of this. A common
mechanism for persistent post-operative
pain results when a debond gap forms
under a restoration and fills with dentinal
fluid (over 24-36 hours). When cold or hot
stimuli cause contraction or expansion of
the fluid in this gap, the consequent, sudden
movement of fluid in the dentinal tubules
causes pain.11,38 Pain in a composite-restored
tooth may also relate to the fact that even
the stiffest hybrid composites are relatively
flexible in comparison to the stiffness of
tooth enamel. Flexure of the material and/
or the tooth that it is bonded to may result
in pressure changes in dentinal tubular fluid
being transmitted to the pulp, giving pain on
chewing (often on release).11,38
Treatment of persistent postoperative sensitivity usually involves removal
of the restoration so, if at all possible, is to
be avoided.11 It has also been demonstrated
that a restoration displaying post-operative
sensitivity within one month of placement
is more likely to have failed at five years,
especially in larger cavities.4

Use of flowable composites as a

lining is the subject of divided opinion.2,5,11,13
It is suggested that a flowable resin with
a lower modulus of elasticity may act as
a stress relaxation buffer,13 deforming to
absorb the tension stress of the overlying
composite,38 during polymerization and postcure.
Use of flowables has also been
advocated to improve composite adaptation
to the cavity.
If a decision is made to use
it, then a thin, uniform layer of maximum
0.5mm thickness is applied to the dentine.
Lighter shades may be employed as these
will cure more easily.10,11 It is applied to boxes
first and any air bubbles are popped with a
probe, before curing (Figure 26).
In this respect, flowable
composites may be best suited for
restoring small cavities in preventive resin
restorations39 (see Figure 2) and for sealing
narrow marginal defects when repairing
existing restorations.
Flowable composites from
different manufacturers show a wide
variation in formulation and offer different

Managing polymerization shrinkage

Development of low shrinkage

composites is an area of vigorous research11
and is the subject of a subsequent paper.

Figure 26. Placement of flowable composite

lining.

DentalUpdate 87

RestorativeDentistry

Open sandwich

viscosities, mechanical properties and radioopacities.

surface in any single increment permits resin

flow on polymerization;38
Incremental technique is a more practical
method. It allows development of proper
anatomy1and aesthetics, enhances control of
marginal overhangs and reduces the need for
finishing;38
Despite promising findings from isolated
clinical trials,41 newer bulk-fill techniques are
generally not recommended 12,38,40as they may
promote formation of marginal gaps, increase
post-operative sensitivity and encourage
incomplete polymerization in deep boxes.42,43
Posterior composites may be
applied directly from a compule (if the
viscosity permits) using the tip in a wiping
motion to adapt the material into the cavity
corners, undercuts and against cavity walls.
Composite may also be applied using hand
instruments.
Precise adaptation of the first
increment to the cavity is a very important
step. This layer is furthest from the light and
should therefore be limited to a maximum
1mm thickness6,11and be cured for a greater
length of time than recommended by the

Here a glass ionomer, RMGI

or chemically cured composite is placed
over the dentine and into the cervical part
of a box. In this respect, the longevity of
restorations has been reported to be reduced
by the use of elastic linings and base
layers.21 Potential benefits must be weighed
against reported increased fracture rates of
restorations overlying such shock absorbing
layers.

Bases and linings

Glass ionomer, resin modified

glass ionomer and chemically cured
composite may also be used as part of
an open or closed sandwich restorative
protocol.
Closed sandwich

Here a resin-modified glass

ionomer (RMGI) lining, eg Vitrebond (3M St
Paul, MN, USA), is placed over pulpal dentine
prior to etching. This will adhere to the
prepared cavity floor and may help to protect
the pulp by sealing deep dentine in an area
where bond strengths may be diminished.4
This, in turn, may lead to a reduction in postoperative sensitivity.1,4,6,11 Vitrebond may also
be used to protect calcium hydroxide pulp
caps from etchant, but should be confined
to as small an area of dentine as is practical
and must be kept well clear of cavity margins,
where it will dissolve over time.

Composite placement

When placing posterior

composites, the use of small increments is
recommended by many authors for insertion
and polymerization, for a number of reasons:
Incremental technique gives a more
effective and uniform polymerization
and reduces total polymerization
shrinkage;1,8,11,38,40
Increments decrease the stress generated
on cavity walls,1,10,38 reducing the potential for
debond gaps and cuspal deflection;40
Increments lower the C-factor ratio. The
wide free surface compared to bonded

Figure 27. (a) Adhesive applied to an occlusal cavity in a lower first molar: (b) mesio-lingual increment; (c) disto-lingual increment; (d) disto-buccal increment;
(e) centro-buccal increment; (f) mesio-buccal increment.

88 DentalUpdate

March 2009

RestorativeDentistry

manufacturers (x2). Subsequent increments

should be 2 mm or less, and touch only one
wall, to create a more favourable C-factor.11,13
The use of the correct amount of composite
will minimize finishing.11,13 Each increment is
cured for a time, at least, in accordance with
the manufacturers instructions.
While various protocols have
been proposed for layered placement
of composite in posterior cavities,40 no
individual incremental technique has been
demonstrated as consistently superior in
terms of minimizing the adverse effects of
polymerization and post-cure stress44,45and
optimizing marginal seal.46 Three variations
of the basic oblique-layering technique are
described:
Successive cusp build-up;
Separate dentine and enamel build-up;
Separate dentine and enamel build-up
using an index.

Successive cusp build-up

Here individual cusps are restored

one at a time (Figure 27), up to the level of
e
the occlusal enamel. Small sloping increments
are applied to each corner of the cavity in
turn and manipulation is kept to a minimum,
to avoid folding voids into the material.
This method, while initially time consuming,
can greatly reduce finishing time by careful
attention to progressive reconstruction of
natural morphology.11

Separate dentine and enamel build-up

Here sloping increments are again

applied to cavity walls (and cured in turn)
g
h
but only to the level of the amelo-dentinal
junction (ADJ) occlusally (Figure 28). Final
enamel increments are then applied. Careful
control of the final layer will again reduce
the finishing stage.8,11 Some operators (if
agreeable to the patient) place composite pit
and fissure stain before placement of the final
layer.8 An alternative method of achieving a
more natural appearance is to use a dark (eg
A4) shade of composite for the bulk of the
restoration and a translucent or light shade for
the enamel increment(s).
Figure 28. (a) Occlusal amalgam LR6. (b) Prepared cavity. (c) Adhesive layer (over localized, very thin,
Vitrebond lining). (d) Lingual dentine restored. (e) Buccal dentine restored. (f) Enamel restored. (g)
Occlusal contacts recorded. (h) Finished restoration.
Separate dentine and enamel build-up using an
index

This variation can be used when

restoring a carious tooth with an intact
occlusal surface. After dam placement, a preMarch 2009

operative impression is taken of the occlusal

surface (a number of materials, including

translucent ones, may be used for this

purpose). Once layered dentine restoration
DentalUpdate 89

RestorativeDentistry

Figure 29. (a) Isolation. (b) Pre-operative impression of the occlusal surface (silicone putty is used here). (c) Impression must record morphology accurately. (d)
Access to lesion. (e) Cavity preparation complete. (f) Incremental restoration up to ADJ. (g) Final increments of composite applied and silicone index seated
over the unset material. (h) Minimal excess to be removed before curing. (i) Finished restoration requires no occlusal adjustment.

is complete, the impression material is

used to aid precise adaptation of the
final enamel increment(s) (Figure 29).
With careful control of the amount of
composite used, this technique may
completely eliminate the finishing
stage.11

90 DentalUpdate

Instruments for composite placement

A multitude of specialized
instruments are now available for use with
posterior composites, designed to simplify
placement and shaping.13
It is vital that they are kept
spotless and unscratched, in order to prevent

composite sticking to them. The use of a

small selection of favoured instruments will
improve efficiency and it may be advisable
to keep a special set of instruments for
composite only (Figure 30).
The use of adhesives to lubricate
instruments is not recommended, as they
March 2009

RestorativeDentistry

contain solvents that will degrade the

properties of the restorative material.

Light curing

Various alternative regimes have

been proposed for light curing, including
soft-start, ramp, step, pulse and pulse delay.
The clinical significance of these protocols
is the subject of debate6 and may have a
limited effect on polymerization shrinkage
and therefore stress formation.31 It is
generally accepted that:
The light tip should be placed as close to
the cavity as possible;11
While composite cannot realistically be
over-cured (2540% remains un-reacted),
care must be taken not to overheat the
pulp, or to waste time;
Lighter shades will cure more readily than
dark shades, which absorb more light;10,11
Light units should be metered
regularly6,11,13,47 as low intensity light still
looks bright. Separate radiometers may be
expected to offer greater accuracy than
those built-in to curing lights;
Care must be taken to prevent premature
polymerization by the overhead chair light.6

Figure 30. (a) P.K.T 2 (b) P.K.T 3 (both instruments are available from many dental and technical suppliers).
(c, d) Multi-function composite instrument (Garrison Dental Solutions, Springlake, MI USA).

Shaping/finishing/polishing

The best mechanical properties

of set composite are to be found just
below the surface, close to the light source,
but where polymerization has not been
inhibited by oxygen. Gross adjustments
are therefore contra-indicated unless
the clinician plans to re-light-cure on
completion of finishing. A dark-curing
phase follows application of the light
and early finishing (<3minutes) has been
shown to affect microleakage significantly.11
Therefore, a delay in finishing, for as long
as is practical, will be beneficial. Heavy,
immediate finishing will also increase
the potential for formation of white-line
fractures around the restoration. It is
believed that these are related to enamel
fractures occurring 1050 m from the
margin of the restoration. To help reduce
their prevalence, an even longer delay in
final finishing (>24 hours) will give the
composite time to absorb water (and
undergo hygroscopic expansion), relieving
stresses at the bonded interface.
Despite best efforts, slight
adjustments are usually necessary and an
array of specialized diamond and tungsten
March 2009

Figure 31. Bertolotti Top-Spin diamonds (Pollarddental, CA, USA). Specialized composite finishing
burs for accurate shaping of fissures and fossae.

carbide burs are available to facilitate

this8,11,13 (Figure 31). They should be applied
intermittently with light pressure and water
spray to prevent overheating.6 The use of
loupes will facilitate removal of excess6
and reduce the risk of damage to marginal
enamel (Figure 32).
A variety of polishing discs are
available (Figure 33). These may be used to
impart a smooth surface and are especially
useful for marginal ridges, where they are
less likely to damage adjacent teeth. Discs
may be followed by rubber or silicone discs/
cups/points or brushes, which may be
impregnated with particles that impart a
high shine. Again, discs and polishers should
be used intermittently and with water
cooling, if necessary, to combat excessive
temperature rise.
Surface sealers, eg Biscover

Figure 32. Occlusal restoration in an upper first

molar at 2 years (Synergy Duo, Coltne-Whaledent,
Switzerland). Finishing bur marks are evident
on the palatal cusps, adjacent to the restoration
margin.

(Bisco Inc, Schaumburg, Illinois, USA), may be

applied to seal surface defects and further
improve texture and aesthetics.8 (Their
application will also permit an additional
curing cycle.)
Practising posterior composites

Carefully recording which

materials and techniques have been
employed will enable a long-term clinical
audit of restorations. In-vitro practice on
extracted teeth is a useful method of testing
new materials and perfecting techniques13
(Figure 34).
DentalUpdate 93

RestorativeDentistry

14.

15.

16.
Figure 33. Super-snap finishing and polishing discs (Shofu Dental Corporation, San Marcos, CA, USA).

a
Acknowledgment

Louis Mackenzie would like to

thank David Mason and Julie Thomas of J+S
Davis Ltd for their support in the conception
of this paper.

References
1.
2.

3.
4.
5.
6.

c
7.
8.
9.

10.

Figure 34. (ac) Extracted teeth (here set in silicone

putty) can be used to test adhesive systems and
composites and to practise techniques.

11.

12.

Conclusion
Posterior composites, while time
consuming and demanding, can yield great
patient and dentist satisfaction. Learning and
mastering techniques is well worth the effort.

94 DentalUpdate

13.

Ritter AV. Posterior composites revisited.

Masters Esthet Dent 2008; 20: 5765.
Lynch CD, Shortall ACC, Stewardson D,
Tomson PL, Burke FJT. Teaching posterior
composite resin restorations in the United
Kingdom and Ireland: consensus view of
teachers. Br Dent J 2007; 203: 183187.
Osborne JW. Amalgam: dead or alive? Dent
Update 2006; 33: 9498.
Hayashi M, Wilson NHF. Failure risk of
posterior composites with post-operative
sensitivity. Operative Dent 2003; 28: 681688.
Roeters JJ, Shortall ACC, Opdam NJM. Can a
single composite resin serve all purposes? Br
Dent J 2005; 199: 7379.
Davidson DF, Suzuki M. A prescription for the
successful use of heavy filled composites
in the posterior dentition. J Can Dent Assoc
1999; 65: 256260.
Roeters JJ. Extending indications for directly
bonded composite restorations: a clinicians
view. J Adhes Dent 2001; 3: 8187.
Javaheri D. Placement technique for direct
posterior composite restorations. Pract
Proced Aeshet Dent 2001; 13: 195200.
Hickel R, Manhart J. Longevity of restorations
in posterior teeth and reasons for failure.
J Adhes Dent 2001; 3: 4564.
Lopes GC, Viera LCC, Araujo E. Direct
composite resin restorations: a review
of some clinical procedures to achieve
predictable results in posterior teeth. J Esthet
Rest Dent 2004; 16: 1931.
Summitt JB, Robbins JW, Hilton TJ, Schwartz
RS, Santos JD. Fundamentals of Operative
Dentistry: A Contemporary Approach. Illinois,
USA: Quintessence Books, 2006; 289339.
Krmer A, Franklin G-G, Frankenberger R.
Evaluation of resin composite materials. Part
II: In vivo investigations. Am J Dent 2005; 18:
7581.
Burke FJT, Shortall ACC. Successful
restoration of load-bearing cavities in
posterior teeth with direct-replacement

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resin-based composite. Dent Update 2001; 28:

388398.
Hassall DC, Mellor AC. The sealant restoration:
indications, success and clinical technique.
Br Dent J 2001; 191: 358362.
Houpt M, Fuks A, Eidelman ED. The
preventive resin (composite resin/sealant)
restoration: nine year results. Quintessence Int
1994; 25: 155159.
Opdam NJ, Roeters JJ, Loomans BA,
Bronkhorst EM. Seven year clinical evaluation
of painful cracked teeth restored with a
direct composite restoration. J Endod 2008;
34: 808811.
Peumans M, De Munck J, Van Landuyt KL
et al. Restoring cervical lesions with flexible
composites. Dent Mater 2007; 23: 749754.
Szep S, Frank H, Kenzel B, Gerhart T,
Heidemann D. Comparative study of
composite resin placement: centripetal
build-up versus incremental technique.
Pract Proced Aesthet Dent 2001; 13: 243250.
Poon EC, Smales RJ, Yip KH. Clinical
evaluation of packable and conventional
hybrid posterior resin-based composites:
results at 3.5 years. J Am Dent Assoc 2005;
136: 15331540.
Opdam NJM, Bronkhorst EM, Roeters JJ,
Loomans BA. A retrospective clinical study
on longevity of posterior composite and
amalgam restorations. Dent Mater 2007; 23:
28.
Opdam NJ, Roeters JJ, Joosten M, Veeke O.
Porosities and voids in class I restorations
placed by six operators using a packable or
syringable composite. Dent Mater 2002; 18:
5863.
Peumans M, Van Meerbeek B, Asscherickx K,
Simon S, Abe Y, Lambrecchts P, Vanherie G.
Do condensable composites help to achieve
better proximal contacts? Dent Mater 2001;
17: 533541.
Opdam NJM, Bronkhorst EM, Roeters JJ,
Loomans BA. Longevity and reasons for
failure of sandwich and total-etch posterior
composite resin restorations. J Adhes Dent
2007; 9: 469475.
Van Landuyt KL, Snauwaert J, De Munck J,
Peumans M, Yoshida Y, Poitevin A et al.
Systematic review of the chemical
composition of contemporary dental
adhesives. Biomaterials 2007; 28(26):
37573785.
Bouillaguet S, Degrange M, Cattani M,
Godin C, Meyer JM. Bonding to dentin
achieved by general practitioners. Schweiz
Monatsschr Zahnmed 2002; 112: 10061011.
Peumans M, Kanumilli P, De Munck J, Van
Landuyt KL, Lambrecchts P, Van Meerbeek
B. Clinical effectiveness of contemporary
adhesives: a systematic review of current
clinical trials. Dent Mater 2005; 21: 846881.
De Munck J, Shirai K, Yoshida Y et al. Effect of
water storage on the bonding effectiveness
of 6 adhesives to class 1 cavity dentin.
Operative Dent 2006; 30-1: 456465.
Van Dijken JWV, Sunnegrdh-Grnberg K,
Lindberg A. Clinical long-term retention

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29.

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of etch and rinse and self-etch adhesive

systems in non-carious cervical lesions. A
13 year evaluation. Dent Mater 2007; 23:
11011107.
Opdam NJ, Roeters JJ, Kuijs R, Burgersdijk RC.
Necessity of bevels for box only Class II
composite restorations. J Prosthet Dent 1998;
80: 274279.
Weigand A, Attin T. Treatment of proximal
caries lesions by tunnel restorations. Dent
Mater 2007; 23: 14611467.
Cunningham J, Mair LH, Foster MA, Ireland RS.
Clinical evaluation of three posterior
composite and two amalgam restorative
materials: 3-year results. Br Dent J 1990; 169:
319323.
Lowe AH, Burke FJT, McHugh S, Bagg J. A
study of blood contamination of Siqveland
matrix bands. Br Dent J 2002; 192: 4345.
Demarco FF, Cenci MS, Lima FG,
Donassollo TA, Andr DA, Leida FL. Class
II composite restorations with metallic
and translucent matrices: 2-year follow-up
findings. J Dent 2007; 35: 231237.
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light-cured composite resins: influence of
material and photoactivation mode.
Dent Mater 2007; 23: 911920.
Alomari Q, Ajlouni R, Omar R. Managing

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the polymerisation shrinkage of resin

composite restorations: a review. S Afr
Dent J 2007; 62: 1216.
Braga RR, Boaro LC, Karoe T, Azeredo CL,
Singer JM. Influence of cavity dimensions
and their derivatives (volume and c-factor)
on shrinkage stress development and
microleakage of composite restorations.
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of a restoration based on in-vivo marginal
quality evaluation. J Adhes Dent 2007; 9
(Suppl 1): 117120.
Lopes GC, Baratieri LN, Monteiro S,
Viera LCC. Effect of posterior resin
composite placement technique on the
resin-dentin interface formed in vivo.
Quintessence Int 2004; 35: 156160.
Gallo JR, Burgess JO, Ripps AH, Walker RS,
Bell MJ, Turpin-Mair JS et al. Clinical
evaluation of 2 flowable composites.
Quintessence Int 2006; 37: 255231.
Tjan AHL, Bergh BH, Lidner C. Effect of
various incremental techniques on the
marginal adaptation of class II composite
resin restorations. J Prosthet Dent 1992; 67:
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performance evaluation of a packable

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posterior composite in bulk-cured

restorations. J Am Dent Assoc 2006; 137:
7180.
Lazarchik DA, Hammond BD, Sikes CL,
Looney SW, Rueggeberg FA. Hardness
comparison of bulk-filled/transtooth and
incremental-filled/occlusally irradiated
composite resins. J Prosthet Dent 2007; 98:
129140.
Pokus LT, Placido E, Cardoso PE. Influence
of placement techniques on Vickers and
Knoop hardness of class II composite resin
restorations. Dent Mater 2004; 20: 726732.
Pfeifer CS, Ferracane JL, Sakaguchi RL, Braga RR.
Factors affecting polymerisation stress in
dental composites. J Dent Res 2008; 87:
10431047.
Park J, Chang J, Ferracane J, Lee IB. How should
composite be layered to reduce shrinkage
stress: incremental or bulk filling? Dent Mater
2008; 24: 15011505.
Ghavamnasiri M, Moosavi H, Tahvildarnejad N.
Effect of centripetal and incremental methods
in class II composite resin restorations on
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DentalUpdate 95

The Good Equipment guide

Direct Restorations Louis Mackenzie 2015
Posterior composites

Anterior composites

Magnification
Loupes (+ light) (2.4-2.5 x magnification) www.orascoptic.com

Renamel (microfill composite) www.cosmedent.com

(Enlighten U.K)
Miris 2 (Hybrid composite) (Layering) www.coltene.com
Composite instrument (Microfil Green) www.Almore.com
Composite brushes #2/3 www.cosmedent.com
Silicone finishers (FlexiPoints) www.cosmedent.com
LED Light-curing unit (Valo) www.optident.co.uk
Radiometer (LCU testing) various
Composite finishing bur kit 4092.314 www.kometdental.co.uk
Visionflex diamond finishing strips www.kometdental.co.uk
Diatech diamond finishing strips www.coltene.com
Super-snap finishing and polishing discs www.shofu.com
Enamelize composite polishing paste www.cosmedent.com
Gingival retraction kit www.optident.co.uk
PTFE tape
Sticktech (FRC-RBB framework) www.gc.com

Photography
Intra-oral camera
Digital SLR:
Macro lens / Ring flash / Mirrors / Retractors / Contraster
www.dentalphotographyinpractice.com
Anaesthesia
Topical anaesthetic www.optident.co.uk
Articaine LA (Septanest) www.septodont.co.uk
Tooth preparation
Aquacut quattro (Air abrasion) www.velopex.com
Intracoronal brushes www.optident.co.uk
FenderWedges www.directadental.com
Microprep burs www.kometdental.co.uk (West one dental)
Pear-shaped diamond bur (cavity prep) www.diatech.com
Rose-head stainless steel burs various
T.C burs Jet 1169/170 www.claudiusash.co.uk
End cutting diamond burs www.diatech.com
Hand excavator LM 63-64/65-66 Xsi www.js-davis.co.uk
Enamel hatchet (various)
Gingival margin trimmers www.js-davis.co.uk
Mesial 1.2 LM 125-126 XSi / Distal 1.2 LM 121-122 XSi
Matrix systems
Composi-tight 3D Sectional matrix kit www.optident.co.uk
Pin Tweezers (matrix removal) www.triodent.com
SuperMat Matrix kit www.kerrdental.co.uk
SuperMat Matrix bands (2182) www.kerrdental.co.uk
Trimax contact forming instrument www.optident.co.uk
Perform contact forming instrument www.optident.co.uk
Materials
Vitrebond (RMGI) (indirect pulp cap) www.3M.co.uk
Etch and rinse adhesive (XP Bond) www.dentsply.co.uk
Self-etching primer and adhesive (SE Bond) www.js-davis.co.uk
Universal adhesive (ScotchBond Universal) www.3M.co.uk
Fissure sealant (Fissurit) (Voco) www.voco.com
Majesty Flow www.js-davis.co.uk
Majesty esthetic (Hybrid)(Kuraray) www.js-davis.co.uk
SDR (Bulk-fill flowable composite) www.dentsply.co.uk
SonicFill (Bulk-fill) www.kerrdental.co.uk
Biscover - Composite sealant www.optident.co.uk
Fibreposts (Radix Fibrepost kit) www.dentsply.co.uk
Biodentine (direct pulp cap) www.septodont.com
Shaping & Finishing
Garrison composite instrument TN009 www.optident.co.uk
Composite shaping instrument CW 102 www.coltene.com
Bertolotti Top-spin diamonds Size T2/T3 (F/ SF/UF)
(Phone USA) 001(805) 495-5222
Composite finishing burs 860 (bullet) 852 (short needle) 801
(small round) www.diatech.com

Isolation
Hygenic rubber dam kit www.coltene.com
Rubber dam (Blue/med/non-latex) www.perfectionplus.com
Rubber dam clamps (12A/13A) www.coltene.com
Plastic rubber dam frame DTE20/5554 www.qedendo.co.uk
Dam stabilizing cord (Wedjets) www.coltene.com
Amalgam
Amalgam removal bur FG S1158 XY www.trihawk.com
AutoMatrix kit www.dentsply.co.uk
Flexiwedges www.optident.co.uk
Tytin Amalgam www.kerrdental.co.uk
Amalgam condensers www.js-davis.co.uk
1.0-1.5mm LM 340-360 / 1.2-2.0mm LM 350-380 /
1.8-2.5mm LM 370-390
Frahms Carver 62004006 www.dentsply.co.uk
P.K.T 3 burnisher various
Hollenback carver (Flexichange) www.dentsply.co.uk
Discoid-Cleoid Carver LM 731-732 www.js-davis.co.uk
Amalgam burnisher LM 31-32 www.js-davis.co.uk
Panavia F 2.0 luting resin (Bonded amalgam + RBB) (Kuraray)
www.js-davis.co.uk
Resinomer amalgam bonding resin www.optident.co.uk
References
Textbooks www.quintpb.co.uk

Summitts Fundamentals of Operative Dentistry: A Contemporary

approach. Fourth Edition; 2013
Manauat J, Salat A. Layers: An atlas of composite resin stratification; 2013
Hugo B. Esthetics with resin composite: Basics and techniques; 2009

Papers

Mackenzie L, Shortall ACC, Burke FJT. Direct posterior composites: A

practical guide. Dent Update. 2009 Mar;36(2):71-80
Mackenzie L, Burke FJT, Shortall AC. Posterior composites: A practical
guide revisited. Dent Update. 2012 Apr;39(3):71-95
Mackenzie L, Parmar D, Burke FJT, Shortall AC. Direct Anterior composites:
A practical guide. Dent Update. 2013 May; 40(4):297-317

Online CPD
www.dentaljuce.com

RestorativeDentistry

Louis Mackenzie
FJ Trevor Burke and Adrian CC Shortall

Posterior Composites: A Practical

Guide Revisited
Abstract: Direct placement resin composite is revolutionizing the restoration of posterior teeth. Compared to amalgam, its use not only improves
aesthetics but, more importantly, promotes a minimally invasive approach to cavity preparation. Despite the benefits, the use of composite to
restore load-bearing surfaces of molar and premolar teeth is not yet universally applied. This may be due to individual practitioner concerns over
unpredictability, time and the fact that procedures remain technique sensitive for many, particularly with regard to moisture control, placement
and control of polymerization shrinkage stress. New materials, techniques and equipment are available that may help to overcome many of these
concerns. This paper describes how such techniques may be employed in the management of a carious lesion on the occlusal surface of an upper
molar.
Clinical Relevance: Direct posterior composite is the treatment of choice for the conservative restoration of primary carious lesions.
Dent Update 2012; 39: 211216

Detection and diagnosis

A Class I carious lesion (ICDAS
3)1 was detected in the mesial pit of an upper
second molar (Figure 1). The lesion was
diagnosed as active with respect to enamel
cavitation exposing dentine. In addition the
patients dietary habits, oral hygiene measures
and the presence of active lesions elsewhere
indicated the need for operative intervention.

Isolation
Placement of direct restorations
in the molar regions can present difficulty
with regard to moisture control. Use of rubber
dam with a single hole and a versatile winged
molar clamp (Hygenic 12A, Coltne-Whaledent,
Switzerland)) provided rapid isolation, which
Louis Mackenzie, BDS, General Dental
Practitioner and Clinical Lecturer,
FJ Trevor Burke, DDS, MSc, MGDS
FDS RCS(Edin), FDS RCS(Eng), FFGDP
FADM, Professor of Primary Dental Care,
Primary Dental Care Research Group and
Adrian CC Shortall, BDS, DDS, Reader
in Restorative Dentistry, University of
Birmingham School of Dentistry, St
Chads Queensway,Birmingham B4 6NN,
UK.
April 2012

Figure 1. A cavitated Class I carious lesion in an

upper second molar.

was completed (Figure 2) by flossing the dam

through the mesial contact point. The speed
with which this technique achieves isolation
and promotes a comfortable experience for
the patient and a predicable outcome for
the operator cannot be overemphasized.
Although the vast majority of practitioners do
not routinely use rubber dam,2 the isolation of
a single tooth for an occlusal restoration is a
perfect starting point for those wishing to learn
and refine rubber dam techniques.

Occlusal template
As carious demineralization had

Figure 2. Isolation.

left the occlusal surface virtually intact, in

this case a template was used to facilitate
provision of an anatomically accurate final
restoration. Fabrication of a template
may be achieved using a pre-operative
impression gained by injecting a small
amount of a clear polyvinyl siloxane material
(Memosil 2, Heraeus Kulzer, Germany) onto
the occlusal surface3,4 (Figure 3). After
waiting for the material to partially set, finger
pressure (Figure 4) was applied to accurately
capture the occlusal morphology. Once set,
the template was removed (Figure 5) and
the mesial surface marked with a felt pen to
assist orientation when reapplied later.
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RestorativeDentistry

Figure 3. Template material injected on to the

occlusal surface.

Figure 6. Access to lesion.

Figure 9. Etched cavity after washing/drying.

undercut cavity forms. Etching was further

optimized by agitating the etchant with an
appropriate instrument.

Wash and dry

Figure 4. Template material adapted to capture
occlusal morphology.

Figure 7. Cavity preparation complete.

Figure 5. Pre-operative template.

Figure 8. Acid etch applied.

Access
Using a small round bur, access
to the carious lesion was gained through
the cavitated pit and extended only to allow
visualization and assessment of underlying
dentinal caries. (Figure 6).

Minimally invasive preparation

Using appropriate burs, peripheral
caries excavation was carried out to remove
soft carious dentine and fragile overhanging
enamel only. Pulpal caries was then excavated
using a hand excavator and extended only
until there was moderate resistance to gentle

212 DentalUpdate

excavation5,6,7 (Figure 7).

Removal of only irreversibly
demineralized tooth tissue is a fundamental
aim of contemporary caries management,57
as it maximizes the amount of residual healthy
tooth tissue59 and improves the prognosis for
long-term pulpal health by minimizing trauma
to the dentine/pulp complex.57

Etching
Phosphoric acid (37% ) was used
to etch the whole cavity and 1mm beyond the
margins (Figure 8).
Etch 37 (Bisco Inc, Schaumburg,
IL, USA) was chosen as it flows easily into

After 15 seconds the etchant was

thoroughly washed off. The cavity was then
dried with gentle airflow, taking care not to
desiccate the dentine. The aim is to achieve a
visibly moist dentine cavity floor (and walls)
with no obvious pooling of water.9 When total
etch adhesive systems are employed, careful
control of dentine moisture is essential for
optimization of adhesion and prevention of
post-operative sensitivity. While the frosty
appearance of enamel walls is a reassuring
sign that a predictable enamel bond (and
thus marginal seal) will be achieved (Figure
9), it may also signal an increased likelihood
of over dry dentine. If dentine desiccation is
suspected it may be rehydrated with water,9
applied using an appropriate brush.

Adhesive
Adhesive (XP Bond, Dentsply
International Inc, York, PA,USA) was applied to
the whole cavity and just beyond the margins,
using a Microbrush (Microbrush international
Grafton, US). Gentle airflow was then used
until no ripples were evident. This reduced the
likelihood of adhesive pooling and confirmed
that the solvent had evaporated. The adhesive
was then light-cured for 40 seconds with the
light tip as close to the cavity as possible. The
cavity was inspected to ensure that a uniform
glossy/shiny adhesive layer coated the entire
cavity9 (Figure 10).

April 2012

RestorativeDentistry

one increment has a significant time-saving

benefit;11
The technique is easy to learn and simple
to use;11
The SDR layer was then lightcured for 20 seconds.

Placement (Enamel layer)

Figure 10. Adhesive applied.

Figure 13. Enamel increment of hybrid

composite applied.

A single increment of a traditional

hybrid composite was then placed over the
layer of SDR, which is not designed to restore
right up to the occlusal surface as a result of:
Inferior optical properties conveyed by the
materials translucency;
Wear resistance lower than that of a
conventional hybrid composite.
Care was taken to apply just the
right amount of hybrid material (Figure 13) to
minimize excess and prevent under fill that
would increase the tendency for poor marginal
adaptation and void formation.

Use of the template

Figure 11. Bulk-fill restoration of dentine layer
using SDR.

Figure 14. Template re-applied to adapt final

composite increment.

Figure 12. SDR compule.

Figure 15. Composite light-cured through

template

Placement (dentine layer)

In this case, the entire dentine
layer was restored in one increment, using
a flowable composite designed for this
purpose ( SDR, Smart Dentine Replacement,
Dentsply International Inc, York, PA, USA)
(Figure 11).
SDR (Figure 12) is an innovative
flowable posterior composite offering a
number of potential benefits with regard to
reducing placement technique sensitivity:
Flowable consistency and self-levelling
April 2012

property optimizes marginal adaptation into

undercut cavities;
Cannula delivery obviates the need for
instrumentation, thus reducing the tendency
for marginal voids and layers between
increments;
Translucency of the material facilitates
depth of cure up to 4 mm in one increment;
Reported low polymerization shrinkage
stress10 reduces the risk of post-operative
sensitivity that is usually associated with bulkfill techniques;
Restoration of the majority of the cavity in

To facilitate adaptation and

shaping of the final increment, the preoperative occlusal template was applied to the
unset material (Figure 14). The light tip was
then firmly applied to the translucent template
during a (minimum) 60 second light cure
(Figure 15).
This technique has three main
benefits:4
Application of the template may reduce
the potential for oxygen inhibition of the
polymerization reaction occurring on the
surface of the restoration;
The morphology of the original occlusal
surface is accurately reproduced;
A significant amount of time may be saved
when this technique is employed. (Although
this may be cancelled out by the time taken to
make the template3).

Light cure
Once the template was removed
the restoration received a further 60 seconds
light-cure to maximize polymerization
(Figure 16).

Excess removal
The restoration was inspected
for marginal excess (Figure 17), which was
easily removed from unetched enamel using a
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RestorativeDentistry

With patient consent,

photographic images taken before, during
and after operative procedures may be
used as a powerful motivational tool to
help explain the disease process when
encouraging patients to reduce their caries
risk and to demonstrate the benefits of
modern minimally invasive dentistry.

References
Figure 16. Further light-curing.

Figure 19. Completed restoration.

Figure 17. Minimal excess for removal.

Figure 20. Review.

Review
At review (interval based on
caries risk or, as in this case, need for further
dentistry) all aspects of the completed
restoration were studied (Figure 20).
Figure 18. Occlusal check.

sharp hand instrument. (Note: Careful volume

estimation of the final increment will reduce
or even eliminate this stage).

Occlusal check
Articulating paper was used
to confirm that the restoration conformed
precisely to the patients pre-existing occlusal
scheme, in both the intercuspal position and
all excursions (Figure 18).

Finished restoration
The restoration was inspected
(Figure 19). At this stage the surface may be
refined, polished or coated with a solventfree surface sealer, depending on operator
preference.9

216 DentalUpdate

Discussion
Direct posterior composite
restorations offer many benefits
to both patient and dentist that
go far beyond the fact that the
restorations are tooth-coloured.
New materials, equipment and techniques
will continue to improve the quality,
predictability and success of direct
composite restorations. Such methods will
also promote minimally invasive caries
management, maximizing the amount of
tooth tissue preserved. This will increase
the longevity, not of just the fillings placed,
but of the teeth that they restore.
Precise notation of the
materials employed during each restorative
procedure will provide each dentist with
an invaluable evidence base for the longterm audit of their successful operative
techniques.

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April 2012