Position Paper

The use of resin-based composite in children

Kevin J. Donly, DDS, MS Franklin Garca-Godoy, DDS, MS
Dr. Donly is professor and postdoctoral program director, Department of Pediatric Dentistry,
Dental School, University of Texas Health Science Center, San Antonio, Tex; Dr. Garca-Godoy is
assistant dean of clinical sciences, College of Dental Medicine, Nova Southeastern University, Ft. Lauderdale, Fla.
Correspond with Dr. Donly at [email protected]

Abstract
Resin-based composites are an integral component of contemporary pediatric restorative
dentistry. They can be utilized effectively for preventive resin restorations, moderate Class
II restorations, Class III restorations, Class IV restorations, Class V restorations and strip
crowns. Tooth isolation to prevent contamination is a critical factor, and high-risk chil-
dren may not be ideal candidates for resin-based composite restorations. Important factors
to consider during composite placement are isolation, polymerization shrinkage and
extent of restoration. When utilized correctly, resin-based composites can provide ex-
cellent restorations in the primary and permanent dentition.(Pediatr Dent.
2002;24:480-488)
KEYWORDS: RESIN-BASED COMPOSITE, PEDIATRIC RESTORATIVE DENTISTRY

T
he use of resin-based composite is a critical compo- The American Dental Association (ADA) specification
nent of pediatric restorative dentistry. The acid-etch No. 27 for direct filling resins4 classified restorative res-
technique, originally recommended by Buonocore,1 ins as Type Iunfilled and filled resins, and Type
aids in providing retention for esthetic restorations in both IIcomposite resins. According to Lutz et al,5 almost all
the primary and permanent dentition. Problems associated filled restorative resins consist of three-dimensional combi-
with the initial resin-based composites have been addressed nations of a minimum of 2 chemically different materials
to create contemporary resin materials that wear better, have with a surface interfacial phase. The 3 phases are: (1) ma-
better color stability and maintain intact restorations for a trix phase; (2) surface interfacial phase; and (3) the dispersed
desired length of time. phase.
In addition, each resin must include an accelerator-ini-
Resin-based composite materials tiator system to begin and complete polymerization. For the
The initial resin, bis-GMA, was developed by Bowen2 and chemically cured composite, the accelerator-initiator is usu-
remains the critical backbone of most contemporary resin ally an amine-peroxide system, whereas light-cured
systems. Quartz filler particles were introduced into the resin composites use a diketone-amine system, which is activated
to provide desirable color properties, as well as desirable wear by the intense blue light. In addition, pigment and opaquers
characteristics. These resins demonstrated initial success, but are added to control translucency (value) and shade
color dissipated over time and wear in the posterior dental (chrome). The resin matrix of all composites is a
arches exhibited disappointing restoration outcomes. By dimethacrylate oligomer such as bis-GMA or
treating the filler particles with silane, the particles were urethanediacrylate, and its viscosity is reduced by a low
actually bound within the resin matrix, causing less discol- molecular weight diacrylate. The clinical characteristics are
oration and degradation of resin restorative materials. Filler controlled by appropriate additions of thermochemical and
particles were ground smaller, compared to those utilized photochemical initiators, accelerators and ultraviolet inhibi-
with the original resin-based composites, which allowed for tors. The surface interfacial phase consists of either a bipolar
more filler to be incorporated into the resin matrix and, coupling agent (eg, an organosilane) to bind the organic
subsequently, resulted in better wear of the material. All of resin matrix to the inorganic fillers, or a copolymeric or
these factors have contributed to the contemporary resin- homopolymeric bond between the organic matrix and partial
based composite restorative materials available today.3 organic filler. The degree of interface adhesion and chemi-
cal stability is critical for successful clinical use of any resin.

480 Donly, Garca-Godoy Use of resin-based composite Pediatric Dentistry 24:5, 2002
Contemporary use of resin-based composite Class II restorations
Resin composite has been shown to be effective as a Class
Preventive resin restorations II restorative material in both the primary and permanent
Although caries has decreased, it is still the most prevalent dentition. The studies cited were clinical studies with a
infectious disease. Water fluoridation, patient education, minimum longevity of 3 years for the primary dentition 12-14
fluoridated dentifrices, oral rinses and professionally applied and 4 years for the permanent dentition,15-30 standards set
topical fluorides have significantly reduced decay, however by the American Dental Association (ADA) for full accep-
the occlusal surfaces of teeth remain the most caries-suscep- tance as a restorative material. The ADA Statement on
tible surface. Data indicates that greater than 80% of Posterior Resin-Based Composites clearly states recommen-
dentistry provided in a contemporary dental practice is at- dations for Class II restorations are associated with
tributed to pit and fissure caries.6,7 preparations that do not include restoration margins exhib-
Preventive resin restorations were introduced by iting heavy occlusal wear.31 This can be interpreted as two
Simonsen and play an important role in the practice of con- or three surface restorations that do not extend beyond the
temporary pediatric dentistry.8 The use of contemporary line angles of the proximal surfaces of the teeth, which in-
resin-based composites, due to bonding properties and ac- clude cusp replacement. Clinical trials, from which the ADA
ceptable wear resistance, allows for the cavity preparation recommendations were derived, were well-controlled trials
to be minimized to include only caries-affected tooth struc- that had good tooth isolation via rubber dam, sound enamel/
ture. The traditional extension for prevention recommended dentin cavity preparation walls and preparations that re-
for amalgam preparations is not necessary with resin resto- mained conservative (approximately one-third to one-half
rations, due to the ability to place a sealant material over the buccolingual intercuspal width).32
caries-susceptible pits and fissures which were not part of Therefore, in the primary dentition, Class II resin com-
the preparation during caries removal. The overwhelming posite restorations would be recommended for preparations
success of the preventive resin restoration makes it the treat- that do not extend beyond the proximal line angles. Obvi-
ment of choice for occlusal pit and fissure caries if the tooth ously, exceptions can be made, particularly if the tooth is
can be adequately isolated.8-10 expected to exfoliate within 1 to 2 years.
Caries can be removed effectively with the use of air abra-
sion or with standard dental burs in dental handpieces. Both Indirect resin composite restorations
of these techniques allow for caries to be removed conser- Direct resin composite restorations have received signifi-
vatively, with tooth preparation extending only as far as cantly more attention than indirect resin composite
caries progression. Likewise, both techniques for tooth restorations. This is due to the extended time necessary to
preparation must be followed with the acid-etch technique place an indirect restoration, potential laboratory expense
for an adequate bond to the enamel surface.11 Should prepa- and the need to prepare the tooth according to guidelines
rations extend very minimally into enamel, sealant can be associated with inlays and onlays. These factors have lim-
flowed onto the prepared and acid-etched surface. Simonsen ited the popularity of indirect resin restorations. However,
termed this as a Group A preventive resin restoration. studies have demonstrated the clinical success of these type
Preparations that extend substantially into enamel or of restorations in both the primary and permanent denti-
even into dentin, but are limited to pits and fissures, can tions.33-35 Indirect resin restorations offer the advantages of
have a resin-based composite placed to replace lost tooth more complete polymerization of the resin, alleviate stresses
structure and then a sealant placed over the entire occlusal associated with resin polymerization shrinkage that occurs
surface for prevention of future caries. Although this con- when direct resin restorations are placed and provide a
servative approach is frequently termed microdentistry, highly esthetic final restoration. Although these restorations
the concept was originally presented by Simonsen as a are not widely utilized, they can be an effective technique
Group B preventive resin restoration. Flowable resin com- and dentists may use their clinical judgement in deciding
posites have been recommended for these types of instances where indirect restorations would be preferred.
restorations. Dentists must be aware of the filler content of
the flowable resin, which can range from 45% to 75%. Ar- Clinical factors
eas of teeth, such as pits and fissures, can have almost any
resin used because these resins do not need great wear resis- Risk assessment
tance. As preparations extend to areas where functional Risk assessment is an important factor when any restorative
occlusion causes wear, a more heavily filled resin compos- material is chosen.36-38 Questions that need to be asked are:
ite is appropriate. Once caries has extended to the point that (1) What is the caries history of the patient? (2) How many
a bur larger than a size 2 round bur is necessary for caries caries lesions are present? (3) What type of oral hygiene is
removal, a conservative resin composite restoration can be present? (4) Is enamel demineralization noted at the free
placed. Simonsen refers to these resin composite restorations gingival margin of the anatomical crown? (5) What is the
as Group C preventive resin restorations. likelihood of the patient returning for routine preventive

Pediatric Dentistry 24:5, 2002 Use of resin-based composite Donly, Garca-Godoy 481
dental care? (6) Can the tooth be isolated? (7) How large is structure. Adapting the glass ionomer cement to the den-
the restoration going to be? (8) Is the tooth primary or per- tin of the cavity preparation eliminates the need for a dentin
manent? and (9) What are the desires of the parents and bonding adhesive. Unfilled bis-GMA bonding agent will
patient? bond to the glass ionomer cement base/liner, and then resin-
These questions merely offer a simplistic overview of risk based composite can be placed, polymerized and the final
assessment. Children that are at high risk, denoted by the restoration contoured and polished.
previous questions 1 to 5, are not good candidates for resin
restorations unless these factors can be modified. Likewise, Cavosurface preparation margins
teeth that cannot be isolated or restorations that are exten- The enamel cavosurface margins should be beveled to in-
sive should have restorative materials other than resins crease the surface area and to remove the aprismatic layer
considered. of enamel.53 The bevel should be placed on the entire length
of the cavosurface margin. The aprismatic layer will not etch
Restoration placement time well and may leave islands of unetched enamel that can
Research has indicated that the placement time of resin- act as pathways for bacterial leakage and/or reduce resin
based composite restorations is significantly longer than the bond strength to the enamel.54
placement of amalgam restorations.39 The lack of coopera-
tion of a child may determine that a resin-based composite Polymerization shrinkage
is not the material of choice. Resin polymerization shrinkage has been a problem associ-
ated with resin-based composite restorations since the
Tooth isolation development of bis-GMA resin.55-56 Most of the resin-based
Isolation of a tooth to prevent contamination is critical dur- composite systems available have volumetric polymerization
ing the placement of a resin-based composite restoration. shrinkage percentages that range between 1.4% and
Discussion of hydrophilic properties of some resins might 5.67%.55-58 The placement of smaller filler particles within
confuse the clinician as to proper indications and the resin matrix has decreased the amount of unfilled resin
contraindications of resin use. The presence of water may present, thereby decreasing the volumetric polymerization
be possible with the use of some adhesive systems.40 How- shrinkage. Although this has benefited the control of poly-
ever, contamination of the adhesive surface to which the merization shrinkage, the problem remains and will
filled resin-based composite is to be adapted can lead to the continue to be a negative factor until resin composite sys-
inability of the filled resin-based composite to bond to the tems are developed that have negligible shrinkage during
adhesive, potentiating restoration microleakage and subse- polymerization.
quent failure. The introduction of newer resin polymerization systems,
such as the plasma arc curing units, lasers and pulse-delay
Adhesive dentin bonding halogen light systems, makes it necessary to clarify the po-
Swift and Garca-Godoy have provided excellent papers in lymerization of resin.
this issue of the journal on adhesive bonding and clinical For small pit and fissure resin-based composite restora-
utilization to which the reader is referred for clarification. tions, the resin can be cured with most any system without
The reader is referred to their papers for clarification of ad- concern due to the low volume of resin utilized. Some of
hesive systems and appropriate uses in children. It is essential the faster light polymerization systems have a narrow light
that the manufacturers instructions be followed. Dentin spectrum range for polymerization. Therefore, it is impor-
bonding is technique sensitive.41-42 The chemical-cured tant that the resin-based composite being utilized falls within
primer, whether it is present alone in a multibottle system the light spectrum of the polymerization light source.59 As
or with other components in a single-bottle system, must Class I and II restorations are placed, polymerization shrink-
be chemically cured before the light-polymerized bonding age becomes a much more important factor. As the resin is
resin is set. This allows for true dentin bonding to occur polymerized, there is an effective shrinkage of the resin.60-64
and alleviates restoration marginal microleakage. Although Researchers have described this setting reaction, explaining
the dentin can be wet during dentin bonding adhesive place- that the setting rate be retarded to allow the polymer to
ment, the adhesive cannot be wet prior to the placement of adequately flow and dissipate the stress while maintaining
the bis-GMA resin-based composite restorative material. a sufficient bond to tooth structure.65,66 When resin poly-
merizes, there is enough flow within the restorative
Bases/liners material that bonded margins remain intact.
Glass ionomer cement is an appropriate base or liner when This helps explain the desired outcome of the pulse-
resin composite is used as the restorative material.43-48 Cal- delay polymerization technique when halogen lights are
cium hydroxide is much more soluble than glass ionomer used.67,68 Caution must be instituted when using faster po-
cement, an unfavorable property adjacent to resin which has lymerization systems to be sure the resin is not polymerized
hygroscopic properties and makes water available within the so quickly that stresses develop at restoration margins which
restoration.49-52 Glass ionomer cement or resin-modified could lead to marginal fracture and/or postoperative
glass ionomer cement physiochemically bonds to tooth sensitivity. Placing resin in 2-mm increments eliminates this

482 Donly, Garca-Godoy Use of resin-based composite Pediatric Dentistry 24:5, 2002
concern to a great extent and ensures that the light source According to most manufacturers, enamel etching is not
is penetrating the resin adequately to maximize polymer- required for the placement of compomers. Compomers have
ization. shown relatively adequate adhesion to unetched enamel and
Recently, a 1.4% volumetric shrinkage resin-based com- dentin.83-85 However, several laboratory studies have shown
posite was introduced to the market.69 As resins continue a higher bond strength and more intimate marginal adap-
to minimize volumetric shrinkage, placement technique will tation of compomers when the enamel was acid-etched with
become less critical, as long as the polymerization light 35% to 40% phosphoric acid.84,86,87 Compomers are used
source is able to effectively penetrate the resin composite in conjunction with methacylate primers that bond to
depth and isolation to prevent contamination is possible. enamel, dentin and compomer restorative material. Many
Currently, there are no shrink-free polymers for use in den- of these primer bonding agents are acidulated and can etch
tistry, but research is pursuing this goal. A resin-based enamel and dentin if utilized according to manufacturer
composite has been introduced to the marketplace, where instructions. Although the need for acid-etching has been
bis-EMA6 replaces bis-GMA as the resin matrix.70 Due to discussed primarily from data associated with in vitro stud-
the larger bis-EMA6 molecule, polymerization shrinkage ies, the clinical relevance of acid-etching the enamel before
percentage was reduced by approximately 25%. the placement of compomers has not been clearly demon-
strated.
Flowable resin-based composites
Flowable resins range from 45% filler (by weight) to 75% Wear
filler. For this reason, dentists should be aware of resin filler The wear of resin composites was a major concern when the
content so that clinically they may be utilized. The lower traditional resins were marketed. The large filler particle sizes
the filler content, the more the polymerization shrinkage and (50 m) and the lack of these particles becoming chemically
wear expectations.71,72 Although some unfilled resin within integrated with the resin matrix were contributing factors
the restorative system can be prepolymerized to decrease the to high wear rates. The bis-GMA resin matrix would begin
polymerization shrinkage clinically, in general, lower filled to degrade, leaving unsupported filler particles exposed to
resins can be expected to shrink more. In Class I and Class masticating forces. The particles would become dislodged
II restorations this is quite important, for these restorations which was clinically expressed by high wear rates. As par-
require good wear properties and minimal shrinkage upon ticles were ground smaller (1.5 m), it became possible to
polymerization is desired. Therefore, if a flowable resin incorporate a greater percentage of filler particles within the
is desirable to a dentist, a higher filled flowable should be resin matrix and increase abrasion resistance. Likewise, a
used for Class I and II restorations. decrease in resin degradation and increase in abrasion resis-
tance occurred when the glass filler particles were treated
Compomers with silane. This silane treatment allowed filler particles to
Compomers have become available more recently and are become chemically integrated within the resin matrix.
recommended for use as a pediatric dental restorative ma- Although the contemporary resin composites have im-
terial. 73-75 Compomers are actually a cross between proved wear properties, they can still exhibit wear
composite resin and glass ionomer cement and are officially characteristics that are associated with occlusal contact at-
termed polyacid-modified, resin-based composites.76,77 An trition, resin matrix fracture, silane coupling agent
acid-base reaction takes place, although minimal, within the hydrolysis, chemical erosion and the degree of polymeriza-
compomer material when the ion-leachable glass filler par- tion.88-104
ticles and dehydrated polyacid contained in the resin Currently, even smaller filler particle sizes (0.1-1 m) are
composite paste are exposed to water. Usually this water being incorporated into resins. Highly filled, small particle
comes from saliva following restoration placement; there- resins can exhibit the best wear characteristic.32,105 Clinical
fore, visible-light polymerization is necessary to complete trials have demonstrated contemporary resin composites to
the setting reaction. Although an acid-base reaction, which have acceptable wear characteristics which meet the stan-
is typical in the setting of glass ionomer cements, does not dards of the ADA acceptable wear rate of no more than 50
occur during the setting process of compomers, compomers m per year and 250 m over 5 years.106,107 In fact, abrasive
do release fluoride and demonstrate adjacent tooth deminer- wear of many resin composites, as measured at restoration
alization inhibition in vitro.78 The fluoride release from margins, is comparable to that of amalgam at 10 to 20 m
compomers is less than that of glass ionomer cements and per year.20,32,108
in vitro investigation indicates compomers are less effective
to inhibit adjacent tooth demineralization than glass Esthetics
ionomer cements.79 One of the most favorable properties that resin-based com-
The mechanical properties of tensile and flexural strength posite restorations offer is excellent esthetics. Over the last
as well as wear resistance of compomers is superior to that 3 decades, there has been a tremendous improvement for
of glass ionomers but less effective than those of resin com- color stability of composites. Resin degradation and the lack
posites.76,80-82 of particles to be bound within the resin polymer matrix led

Pediatric Dentistry 24:5, 2002 Use of resin-based composite Donly, Garca-Godoy 483
to discoloration of the original resin composites.109 These potential for further improvement. Ideally, resin should have
factors have been addressed with great success and the ex- very minimal or no shrinkage upon polymerization. Future
tent of discoloration with contemporary resin composites resin composites will have this issue addressed, resulting in
is quite minor. Research has demonstrated that resin com- composites that exhibit minimal shrinkage. Complete po-
posite color does not significantly change from baseline to lymerization is an important factor and further research
10 years following restoration placement. Indeed, the color should focus on obtaining maximal polymerization.
of resin restorations is a true advantage and can provide long- Technique sensitivity during resin-based composite
term patient satisfaction.110 placement is perhaps the greatest disadvantage of their uti-
lization. Difficulty in isolating teeth to control moisture and
Finishing and polishing differences between materials marketed makes successful
Following polymerization of the resin composite restorative restoration placement problematic. Properties of the mate-
material, the surface can be contoured to final restoration rial should continually address these problems. Minimal
form with carbide or diamond finishing burs. The restora- long-term clinical data is available for resin-based compos-
tion surface can then be polished with sequential abrasive ite restorations, particularly in primary anterior teeth.
discs, abrasive rubber points and/or diamond abrasive paste. Further clinical trials can provide valuable information.
Polished restorations offer pleasing esthetics as well as com- Finally, dentists must be made aware of the clinical tech-
fort to the patient. After the final restoration contour form nique for material utilization. Educating dentists about
is achieved, a sealant material should be painted over the factors that are critical for restoration success will be of ben-
restoration. This is done for 2 basic reasons. First, the sur- efit for both the profession and patients.
face of the restoration achieves maximal polymerization
because of the close proximity to the light polymerization Recommendations
source.111 The surface of the resin composite restoration is The dental literature supports the use of resin-based com-
altered when finishing and polishing, therefore the new posite with the following indications and contraindications:
final restoration surface should be polymerized to ensure it
has reached maximum setting. The sealant or unfilled resin Indications
fills any microcracks within the surface of the resin, which For all resin-based composite restorations, teeth must be
may have been created during the finishing and polishing adequately isolated to prevent saliva contamination. The
process.112 More highly polymerized restorations have been dental literature supports the use of highly filled resin-based
shown to improve wear characteristics.104 composites in the following situations:
1. small pit and fissure caries where conservative preven-
Hypoplastic enamel tive resin restorations are indicated in both the primary
Children may present with teeth that reveal hypoplastic and permanent dentition;
enamel, often the first permanent molar being affected. 2. occlusal surface caries extending into dentin;
Hypoplastic enamel is difficult to bond to, partially due to 3. Class II restorations in primary teeth that do not ex-
the difficulty in adequately etching the enamel. Mild and tend beyond the proximal line angles;
moderately affected teeth can be treated with resin compos- 4. Class II restorations in permanent teeth that extend ap-
ite. The resin should extend to natural unaffected enamel proximately one-third to one-half the buccolingual
to ensure adequate bonding. Dentin bonding adhesives can intercuspal width of the tooth;
provide additional bond strength to the restoration. Severely 5. Class V restorations in primary and permanent teeth;
hypoplastic teeth are subject to rapid caries development, 6. Class III restorations in primary and permanent teeth;
and often it is necessary to plan treatment of full-coverage 7. Class IV restorations in primary and permanent teeth;
restorations in these circumstances. 8. strip crowns in the primary and permanent dentitions.
Allergic reaction Contraindications
Presently, as supported by information presented at the The dental literature supports that resin-based composites
NIH-NIDR Risk Assessment Consensus Conference for re- not be used in the following situations:
storative materials, resin composites are not considered to 1. where a tooth cannot be isolated to obtain moisture
increase the risk of toxicity or hypersensitivity.113 Degrada- control;
tion of resin composites is so minimal that there is no 2. individuals needing large multiple surface restorations
evidence that the placement of these materials as restoratives in the posterior primary dentition;
is problematic.114 3. high-risk patients that have multiple caries and/or
tooth demineralization, exhibit poor oral hygiene and
Research directions compliance with daily oral hygiene, and when main-
Although contemporary resin-based composites have vastly tenance is considered unlikely.
improved from the original marketed composites, there is

484 Donly, Garca-Godoy Use of resin-based composite Pediatric Dentistry 24:5, 2002
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ABSTRACT OF THE SCIENTIFIC LITERATURE

TRAUMATIC DENTAL INJURIES AND QUALITY OF LIFE IN CHILDREN
The impact of traumatic injuries on the dental, periodontal and facial tissues has been studied exten-
sively. On the other hand, the psychological influence of traumatic oral and facial injuries in children has
not been thoroughly examined. With the purpose of assessing the sociodental impact of untreated fractured
anterior teeth in children, this study included a cross-sectional survey of 3,702 Brazilian schoolchildren aged
9 to 14 years. From the total population, 448 had traumatized permanent anterior teeth; from these, 88
presented untreated enamel and dentin fractures. The study group included 68 children and a matching
control group. An oral examination and an oral impact on daily performances (OIDP) index was used to
evaluate the childrens physical, psychological and social activities: eating, enjoying food, speaking, tooth
cleaning, sleeping and relaxing, smiling, laughing, showing teeth without embarrassment, maintaining usual
emotional state without being irritable, carrying major social role or work and enjoying contact with people.
The findings of the study indicated that children with untreated fractured teeth had a statistically signifi-
cant higher overall OIDP value. In relation to the OIDP components, only speaking and pronouncing clearly
was found not to have a significant difference between the groups; the most significant differences were
found in smiling, laughing and showing teeth without embarrassment and in maintaining an emotional
state without being irritable.
Comments: While the physical effect of oral and facial traumatic injuries in children has been exten-
sively examined, this study claims to be the first one that thoroughly covers their behavioral aspect. In fact,
this study provides significant information on the negative effect of untreated enamel and dentin fractures
on the daily behavior and self-image of children. Considering that behavior is one of the most significant
aspects of pediatric dentistry, this change in research attitude should be widely adopted and emulated for
other aspects of pediatric dentistry. EBG
Address correspondence to Dr. Wagner Marcenes, Department of Epidemiology and Public Health, 1-19
Torrington Place, London WC1 6BT UK (email: [email protected]).
Cortes MIS, Marcenes W, Sheiham A. Impact of traumatic injuries to the permanent teeth on the oral health-
related quality of life in 12- to 14-year-old children. Community Dent Oral Epidemiol. 2002;30:193-198.
34 references

488 Donly, Garca-Godoy Use of resin-based composite Pediatric Dentistry 24:5, 2002