U M EA U NIVERSITY ODONTOLOGICAL DISSERTATIONS Abstract N o 30 From the D epartm en t o f Cariology, U niversity o f Umeå, Sweden CONVENTIONAL, MICROFILLED AND HYBRID COMPOSITE RESINS: LABORATORY AND CLINICAL EVALUATIONS Jan W V van Dijken Umeå 1987 CONVENTIONAL, MICROFILLED AND HYBRID COMPOSITE RESINS: LABORATORY A N D CLINICAL EVALUATIONS AKADEMISK AVHANDLING som med vederbörligt tillstånd av Odontologiska fakulteten vid Umeå universitet för avläggande av odontologie doktorsexamen kommer att offentligt försvaras i föreläsningssal B, 9 tr By 1 D, Odontologiska kliniken, Umeå, fredagen den 24 april 1987, kl 09.00 av Jan W V van Dijken Leg tandläkare Abstract Dijken van J W V, C onventional, M icrofilled an d H yb rid C om posite Resins: L aboratory and Clinical Evaluations. Abstract N o 30 — ISSN 0345-7532. Three types o f com posite resins, classified as conventional, microfilled and hybrid resins were compared with respect to surface characteristics, effect on the gingival margin, marginal adaptation and clinical durability in anterior cavities. The surface characteristics were studied in in vitro systems by means o f scanning electron microscopy. Fillings prepared in vivo were evaluated regarding surface characteristics, marginal conditions, color stability and the effect on the develop ment o f gingivitis and caries. M icrofilled resins were superior to the conventional and hybrid com posites with regard to the possibility o f obtaining and retaining a sm ooth surface. The number o f porosities varied greatly between the com posites investigated and could not be related to the type or curing m ethod used in their manufacture. Marginal defects in the form o f chip fractures and fractures in the resin parallel to the resin/enamel border were seen more frequently in the microfilled com posite fillings than in the conventional and hybrid resins. The severity o f the defects increased with time. There was a great variation in clinical behaviour within each resin group. The dif ference in surface characteristics between the three com posites did not result in clinically measurable differences in amount o f plaque on and degree o f gingivitis around the com posite fillings neither during a period o f normal home care nor during an experimental gingivitis period. Recurrent caries was the major single reason for replacement. Patients with a greater number o f caries risk factors clearly showed a higher caries increment, especially around com posite fillings. The short comings o f the three com posite resin types indicate that no material as yet meets the demands o f an all purpose material. Key w ords: com posite resin, caries, gingivitis. UMEÅ UNIVERSITY ODONTOLOGICAL DISSERTATIONS Abstract No 30 From the Department o f Cariology, University o f Umeå Sweden CONVENTIONAL, MICROFILLED AND HYBRID COMPOSITE RESINS: LABORATORY AND CLINICAL EVALUATIONS Jan W V van Dijken Umeå 1987 Abstract Dijken van J W V, Conventional, Microfilled and H ybrid Composite Resins: Laboratory and Clinical Evaluations. Abstract No 30 — ISSN 0345-7532. Three types of composite resins, classified as conventional, micro filled and hybrid resins were compared with respect to surface characteristics, effect on the gingival margin, marginal adaptation and clinical durability in anterior cavities. The surface characteristics were studied in in vitro systems by means of scanning electron microscopy. Fillings prepared in vivo were evaluated regarding surface characteristics, marginal conditions, color stability and the effect on the develop ment of gingivitis and caries. Microfilled resins were superior to the conventional and hybrid composites with regard to the possibility of obtaining and retaining a smooth surface. The number of porosities varied greatly between the composites investigated and could not be related to the type or curing method used in their manufacture. Marginal defects in the form of chip fractures and fractures in the resin parallel to the resin/enamel border were seen more frequently in the microfilled composite fillings than in the conventional and hybrid resins. The severity of the defects increased with time. There was a great variation in clinical behaviour within each resin group. The dif ference in surface characteristics between the three composites did not result in clinically measurable differences in amount of plaque on and degree of gingivitis around the composite fillings neither during a period of normal home care nor during an experimental gingivitis period. Recurrent caries was the major single reason for replacement. Patients with a greater number of caries risk factors clearly showed a higher caries increment, especially around composite fillings. The short comings of the three composite resin types indicate that no material as yet meets the demands of an all purpose material. Key words: composite resin, caries, gingivitis. Jan van Dijken, Dept o f Cariology, University o f Umeå, S-901 87 Umeå, Sweden. © Jan W V van Dijken Printed by U m eå Universitets Tryckeri, U m eå 1987 3 CONTENTS PREFACE 4 NOMENCLATURE OF COMPOSITE RESINS 5 INTRODUCTION 6 Background 6 Composition and curing method 8 Properties o£ composite resins 11 polymerization shrinkage 11 polymerization defects 11 water absorption 13 Clinical consequences of the properties surface characteristics adaptation to the cavity wall microleakage techniques to reduce microleakage in vitro caries biocompatibility 13 13 14 15 17 18 20 Clinical evaluations 22 Potential caries risk 24 Summary 25 AIMS 26 METHODS 27 RESULTS 32 GENERAL DISCUSSION 35 GENERAL SUMMARY AND CONCLUSIONS 44 ACKNOWLEDGEMENTS 46 REFERENCES 47 PAPERS 4 PREFACE This thesis is based on the following papers, which will be referred to by their Roman numerals. I. Dijken van JWV, Meurman procedures on surface comparison between JH, Järvinen J. Effect of finishing textures of some resin restoratives. A new and old types of composite resins. Acta Odontol Scand 1980; 38: 293-301. II. Dijken van JWV, composite resins. III. Dijken van JWV, characteristics restorations Ruyter IE, Holland RI. Porosity in posterior Scand J Dent Res 1986; 94: 471-8. Hörstedt and after P, Meurman JH. marginal 3-4 adaptation years. SEM study of surface of anterior resin Scand J Dent Res 1985; 93: 453- 62. IV. Dijken types van of JWV, composite Period 1987; V. Dijken van gingivitis Period 1987; VI. Dijken resin viscous Sjöström van S, Wing K. The effect of different resin fillings on marginal gingiva. J Clin 14: In press JWV, Sjöström around different S, Wing types K. Development of initial of composite resin. J Clin 14: In press. JWV, Hörstedt restorations placed P. Marginal adaptation of composite with or without intermediate low- resin. A SEM investigation. Acta Odontol Scand 1987; In press. VII. Dijken van JWV. A clinical evaluation of anterior conventional, microfiller and hybrid composite resin fillings. A six-year follow-up study. Acta Odontol Scand 1986; 44: 357-67 5 NOMENCLATURE OF COM POSITE RESINS The nomenclature for the resin materials used in dentistry is complex and somewhat illogical. The aim of the following section is to clarify some expressions. A proper definition of a composite material is "a material system composed of a mixture of two or more macro constituents that differ in form and that are essentially insoluble in one another" According (Glenn 1982). to this definition, many materials used in dentistry can be considered as composites. reacted particles aluminium of Glass ionomer cements for example consist of glass polyacrylate connected chains. by a matrix of calcium and In dentistry the term composite resin has been reserved for the methacrylate based resin materials which are polymerized with 50% by free radical initiated polymerization and reinforced at least 50 vol% (=60 wt%) of filler particles. filler resins vol%. is arbitrary (Glenn 1982) The selection of and some of the microfilled have been marketed as composites despite a filler content < 50 In this thesis the term composite is also used for these resins. Three groups of composites can be identified according to their filler content. Conventional composite resins, the first generation of composites, contain relatively large filler (macrofiller) particles such as ground quartz, borosilicate glass or lithium aluminium glass. Most particles range in size 20-50 pm, and the total range is 0.1-150 pm. Microfilled composites contain so called microfine filler particles of pyrolytic silica (SiO^), 0.04 They were developed in 1974 and were marketed at the end of pm. in the range of 0.007-0.14 pm with a mean of the 1970s. Hybrid composites. According "anything of mixed origin". used resins for containing to Websters dictionary a hybrid is In dentistry the term hybrid composite is a blend microfine pyrolitic silica particles. of macrofiller particles and 6 INTRODUCTION Background The first silicate 1985). high cement introduced in 1904 by Steinbock and Richter (Hendriks The popularity compressive cements and tooth-colored filling material available on the market was known their protect of the silicate cements was related to their strength - they were among the strongest inorganic at that time - their physical and esthetic properties, slow release adjacent tooth of fluoride. The fluoride content helped to enamel from caries and was of definite therapeutic value. Many of the silicate restorations, were successful and clinical life times have years (Bowen with the material been reported of up to 20 years, with an average of 4,5 1968, Robinson 1971). However, there were disadvantages silicate which cements which prompted a search for a replacement led to the development of the polymeric anterior restorative resins. Early, attempts employing were made to use resins as a restorative material by methylmethacrylate polymers (MMA), intended for heat-curing crown and bridge applications. The polymer was mixed with a monomer in order to form a material which could be packed into the tooth cavity. The first by Kulzer self-curing dental resins were based on a patent taken out (1943). temperature with by benzoyl The methylmethacrylate was hardened at room bringing a tertiary amine as accelerator into contact peroxide as the catalyst. A redox reaction thus started the polymerization of the monomer (Bauer 1949, Salisbury 1943, 1950). Cold curing resins were widely used from the beginning of the 1950s in Class III and Class V restorations and in Class IV restorations with supplemental technique. manipulated, synthetic retention provided Because of the dental materials. the by apparent market However, very a pins and later by the acid-etch ease with which they could be soon number became of overloaded with problems were quickly manifested clinically. The major problem was a shrinkage of up to 10 % in polymerization. volume during The shrinkage could not be 7 compensated leakage for by allowed pulpal subsequent watersorption. the ingress of bacteria leading to discoloration and inflammation. these restorations brush technique (Nealon 1952) problems Recurrent caries was frequently observed around (Caul and introduced afforded of The resulting marginal Schoonover 1953, Hedegård 1955). The for successive applications of the resin a slight improvement but did not solve the the self-curing resins. The shortcomings of the unfilled resins led to the continued use of the silicate cements. The idea of improving the cold curing resins by mixing them with inorganic filler particles to form composite resins dates back to 1951 (Knock and Glenn). appropriate thermal Paffenberger et al suggested in 1953 that fillers could reduce the polymerization shrinkage and the expansion of the dental resins. The objective was to maximize the ratio of reinforcing filler to resin. Pioneering of work Standards was performed by Bowen (1956) at the National Bureau in Washington. modification of the or BIS-GMA reaction cured BIS-GMA forms is for a better resin a bisphenol in 1962. This resin which was a A and glycidyl methacrylate could be a a 1963, 1965). resin with less polymerization shrinkage and higher 1963). To facilitate the insertion of into cavities the viscosity was reduced by the addition of liquid high was introduced of than MMA (Bowen 1962, resin more search intraorally by a chemical catalysator (Bowen 1962, viscosity the the epoxy resins, known in dentistry as ”Bowens resin” resin, product In dimethacrylates of lower molecular weight. However, too concentration led to undesirable polymerization shrinkage. noteworthy that It until very recently almost all dental composites were based on the BIS-GMA resin. Bowen combined silica powder with the BIS-GMA monomer and achieved a highly loaded (around 70%) restorative. He suggested in 1964 an uneven size distribution for the fillers in order to get maximum packing of the inorganic filler. The addition of filler particles was an improvement. The composites exhibited increased increased modulus of elasticity and hardness. They also absorbed less water and had a compressive lower polymerization shrinkage composites comparison laboratory, seventies. in led They to coefficient tensile strength as well as an ofthermal expansion and less (Glenn 1982). The superior qualities of the with universal gradually and the unfilled resins, at least in the acceptance replaced the of the unfilled resins resins in the and the 8 silicate cements. disadvantages adaptation, adhesion However, as clinical use increased, the of the composites appeared in the form of poor marginal difficulties to tooth in maintaining a polished surface, lack of structure and an esthetic appearance that did not endure. During the obtain a 1970s, microfillers were used as reinforcing particles to more polishable resin. At the end of the 1970s hybrid composite resins were introduced which contained a blend of macro- and microfiller particles, conventional improving glass in an attempt to combine the properties of the and the microfilled materials. composite fillers, Other approaches aimed at resins were the introduction of finer and softer resins with a higher load of particles and the use of resins with porous glass (Bowen & Reed 1976, Ehrnford 1983). A different 1970s, line of development ionomer cement cement). (the official seen at the beginning of the ISO the glass terminology: glass polyalkenoate It is by definition a composite resin but in dentistry it is not referred to as such. successful properties polycarboxylate cementing almost was when a new tooth colored restorative was introduced, crowns the greater cement and of both which was bridges. the silicate cement to acid and the used as a lining material and for The new cement had the strength and translucency of the dental silicate cements, resistance adhesive It was developed in an attempt to combine the attack. It also and showed a appeared to have the and biocompatible properties of the polycarboxylate cements. The filler is released effective is also an aluminosilica glass, from as the silicate set cement cement in containing fluoride which (Forsten 1977b). inhibiting It should be as recurrent caries (van Dijken 1986). Composition and curing method A dental composite consists basically of three parts: the organic matrix, the coupling agent and the inorganic filler. Matrix: The major monomer component used in most of the commercial composite resins is the BIS-GMA or modifications of the molecule. composites Some contain aliphatic or aromatic urethane diacrylate as major 9 monomer component. Diluent monomers are used to facilitate the handling of the material (Lambrechts 1983, Ruyter 1985). Filler: Conventional composite resins contained between 55-60 vol% (=70 wt%) filler particles, while the first microfilled composites had a filler load composite in the range of 17-40 vol% (30-55 wt%). Most hybrid materials contained a total of 75-85 wt% filler of which 7% was pyrolitic silica. The inorganic composites is strontium. a of will most hybrid resins and some conventional glass made radiopaque by incorporation of barium or Pyrolitic particles hybrid filler not composites silica make for and the traditional quartz filler the material radiopaque. During the 1980s, posterior use were introduced, containing smaller filler particles with an average size of 2-5 pm. Initiator - activator: Composite resins can be divided into chemically cured and light-cured resins. The the latter a two-component into two most system commonly by used a the reaction the deeper is initiated. initiator system Simultaneously and the matrix. initiated and the other an The is benzoyl peroxide through a bond is formed In a one-component system the the absorption of light by a In contrast to the chemically cured systems, is not uniform in a light-cured material. materials problems in materials. diketone, produce an the rate It is fastest layers (Cook 1983). Although originally developed as UV light- resulted 1985). monomer and filler is divided illuminated surface and becomes progressively slower in the polymerized health containing In a tertiary aromatic amine. Free radicals are generated is photo-initiator. near paste of the initiator-activator particles polymerization of one polymerization between the The reaction starts when the two components are mixed. activated and one-component system (Buonocore and Davila 1973). portions; activator. former is a two-component system and (absorption associated spectra ca 365 n m ) , the possible with UV radiation (Ham 1983, Pitts 1981) the development and increased use of visible light-cured In these usually composites, blue light is absorbed by an alpha- camphorquinone (absorption peak at 470 nm) (Ruyter In the excited state it reacts with an amine reducing agent to the free radicals. leads to polymerization. This starts a series of reactions which 10 The no light-cured materials have a longer manipulation time and require mixing. stability and This may result in fewer porosities and better color since there is no amine accelerator present. The wavelength the intensity of the light used to cure the resin are important for the result (Kilian 1981). Large variations among different visible light have sources have been shown (Newman 1983). The light-cured resins disadvantages materials are that chemically sensitive to cured resins do not have. The light and polymerization can begin even under an operation light. Additional equipment is necessary and there is a limited cure depth. of the restoration tissue al reactions 1973). with and discoloration (Stanley et al 1972, Spångberg et microfilled advocated curing 2 a to (Ruyter practically mm. and visible depth 1982). realizable Therefore (Buonocore transparent depths are obtained with macrofilled than composites the approximately attain may lead to retention failures, pulp irritation, Greater composites, Incomplete polymerization in the inner part the Davila For the UV-light cured depth of curing was use of a layering technique was 1973). Because the resin is more light which is more intense, these materials of cure of 3-5 mm (Cook 1983). Because of factors as accessibility to the light source and direction of the light the depth of cure is clinically mostly less than that achieved under ideal laboratory conditions. Inhibitor: ensure Inhibitors are added to the filler-monomer mixture to that the composite has an adequate shelf-life. One of the most widely used inhibitors is hydroquinone (Lambrechts 1983). Filler-resin filler bond: during To achieve polymerization a bond either between the polymer and the a semi-porous filler, giving a mechanical bond (Bowen and Reed 1976, Ehrnford 1983) or a silane layer on the used. filler particles giving a chemical bond (Bowen 1962, The composites. to latter is Söderholm hydrolytic the 1963) is most commonly used bond in the commercial (1984) showed debonding of the silane bond due degeneration or slow crack growth and suggested that this could become a major clinical problem. 11 Properties of composite resins Polymerization shrinkage One major which drawback allows restoration. and a of gap polymeric materials is the setting shrinkage to form between the cavity wall and the This permits microleakage of oral fluids containing ions bacterial toxins, giving rise to pulpal reactions, staining of restoration margins and recurrent caries. The incorporation of filler particles in the resins reduced the level of shrinkage, of 1.67 to but various composite materials still exhibit shrinkage 5.68 voi % (Goldman 1983). Microfilled composite resins which contain a relatively high percentage of organic matrix exhibit a larger polymerization shrinkage than the macrofilled composites. The photocured restoration cured resins material. materials contract towards the outer surfaces of the closest to the light source in contrast to the chemically in which shrinkage occurs towards the center of the The shrinkage is also dependent on e.g. the diluent monomer content (Asmussen 1975). Polymerization defects Polymerization marginal gap shrinkage obviously leads to the promotion of a unless a bond is formed between the resin and the tooth structure. When developed during the bond is strong enough, polymerization can the contraction forces cause internal stresses in the composite resin, the enamel or at the material/enamel border. When the internal resin stress exceeds the strength of the bond between tooth and i.e. the cohesive strength, failures in the then cracks in the enamel, cohesive resin, and dentinal gap formation occur (Asmussen & Jörgensen 1972, Jörgensen et al 1975, Öilo & Jörgensen 1977, Fan 1985, van Dijken & Hörstedt 1986, 1987a). Post-operative sensitivity - observed in connection with larger, mostly posterior restorations - is probably a consequence of contraction forces. 12 The recently introduced technique of incremental polymerization of resin fillings and the use of dentin bonding agents did not reduce the shrinkage, measured (Forsten 1984, Jensen 1987a). To cervical at as a reduction in microleakage and gap formation reduce part the Another and the 1985, marginal van Dijken & Hörstedt 1986, gap - especially in the non-etched of the cavity - the application of a low-viscous resin opening of way reducing composite Chan of inlays the gap has the been suggested (Brännström 1984). polymerization shrinkage is by using made either directly or indirectly, polymerized in an oven at 120° C and cemented with a resin. Another per major problem is incomplete polymerization. Between 25 and 60 cent of the dimethacrylate composite resin, Svendsen 1978, Ruyter Asmussen resulting & 1982). These polymerization strengths, methacrylate öysaed authors produces high low creep remain unreacted in the 1982,Vankerckhoven also in showed tensile, values conversion polymerization molecules in a poorly connecting network (Ruyter & and composite temperature that et a transverse low degree of and low surface resins is al 1982, compressive hardness. dependant The on the and the concentration and chemical nature of the initiator and accelerator (Asmussen 1982). A maximal conversion of reactive groups temperature of is seen in the composite inlays cured at a 120°C. An additional factor in a chemically activated system is the adequacy of the mixing of the two pastes. The entrapment of air bubbles reported by during several mixing produces an investigators (Forsten important matrix defect 1977a, Skjörland et al 1982, Reinhardt et al 1982). The porosities are reported to constitute up to 28% of the volume. and wear mostly resistance contain Porosities severely impair surface morphology (Wilder fewer et porosities al than 1984). Photo-activated systems chemically activated systems (Reinhardt et al 1982, Gotfredsen et al 1983). In a photo-activated distribution and system, duration the light intensity, spectral of curing time are influential factors on the degree of polymerization, which decreased, with increased distance from the top surface (Ruyter & Öysaed 1982). The degree clinical of polymerization therefore is an important factor in the performance characteristics (Ruyter & of (McKinney resin restorations, & 1982, Wu de Rijk especially in wear et al 1984), creep öysaed 1982) and color stability (Ruyter & Svendsen 1978). 13 However, 1983) residual or their photo-initiator by-products and amine accelerator (Asmussen are primarily responsible for the color instability of composite resins. Water absorption All composite undergo 1982). gap resins absorb water from the oral environment and hygroscopic expansion (Asmussen & Jörgensen 1972, Bowen et al Asmussen & Jörgensen (1972), around expansion composite restorations could be closed by the hygroscopic of molecules the filling material in non-etched cavities. The water diffuse molecules. showed in vitro that the marginal through the open spaces between the polymer The polymer chains are pressed apart by the uptake of water and the degree of hydratization. The water uptake is restricted by the extent of cross-linking. Porosities enclosed in the material are also filled with the water and total water uptake represents a linear expansion of 0.4-0.8 per cent. The swelling process compensates partly for the setting contraction. Microfilled resins show higher levels of water that absorption a than conventional composites. hydrolytic degradation of It has been suggested the filler-matrix bond in dental composites (Söderholm 1984) is a negative impact of water absorption. Clinical consequences of the properties The composition respect to of the volumetric materials changes, and have the properties, mainly with consequences for the clinical longevity and biocompatibility of the composite restorations. Surface characteristics The structure of the polished surface of the polymerized material is strongly dependent on the size, packing and hardness of the filler in relation to strip cannot the be resin matrix. maintained The smooth surface obtained under the when the restorations are finished 14 (Dennison & Craig 1972). a function of the abrasive finishing techniques composites (Glantz Gavin hard 1975). glass expected surface glaze to nature produced of rough the polishing agent. Most surfaces on conventional & Larsson 1972, Dennison and Craig 1972, Gray and The or Surface roughness following polishing is also softer resin matrix is easily removed leaving the quartz particles protruding. A similar surface can be emerge after toothbrushing (Asmussen 1979). A rough can only be made smooth again temporarily by application of a or Calatrava veneer on et 1976, al the finished Garman et surface (Heath & Wilson 1976, al 1977, Mc Cabe & Caddick 1978, Williams et al 1978, Lambrechts and Vanherle 1983). Several authors accumulation & Stallard have reported that rough surfaces favor the and retention of debris and bacterial plaque (Gildenhuys 1975, Mörmann promote gingivitis, et al 1974, Smales et al 1979). This can recurrent caries and staining of the fillings (von der Fehr et al 1970, Larato 1972, Smales 1975, Smales et al 1979). Because than the the filler particles wavelength homogeneous of material. of microfilled composites are smaller visible light, the composites looked like a The manufacturers stated that these materials are not liable to extrinsic discoloration and that plaque accumulation is minimal. Adaptation to the cavity wall The maintenance of a tight connection between a filling and the cavity wall is dependant on the balance between shrinkage and the strength of bonding between the material and the cavity wall. The establishment of a strong permanent tissues is microleakage reduces highly and bond between desirable. eliminate the a restorative and the hard dental An effective need bonding may prevent for retentive undercuts. This the risk of pulp damage, marginal discoloration and recurrent caries. The nature of a bond can be mechanical or chemical or a combination of both. A mechanical bond is formed by the penetration of the resin into the micro-irregularities technique introduced phosphoric acid restorative to of by etch materials. an enamel Buonocore the enamel etched (1955). prior by means Buonocore to of the used 85% the use of acrylic Silverstone et al (1975) showed that the most 15 even etching patterns were found when solutions of 30-40% phosphoric acid were applied for 60 seconds. Recently, several investigators have shown that etching for 15-20 seconds resulted in proper sealing conditions (Nordenvall 1981, van Dijken and Hörstedt 1986). Initially, enamel etching was made in the placement of pit and fissure sealants. The application restorations, veneering expanded of to hypoplasia include Class III, IV and V and other cosmetic bonding procedures including diastema closure and labial veneering, bonding of orthodontic brackets, periodontal splinting and temporary bridges. Microleakage Marginal permeability has been 75 years. a focus of interest amongst dental investigators for nearly The space between tooth has possible the of fluid, bacteria, molecules or ions in the a restorative material and a prepared cavity wall of a called marginal percolation, marginal leakage and (Going 1972, Kidd 1976a, Browne & Tobias 1986). With the exception of when polycarboxylate- and glass ionomer cements used, wall, passage been microleakage are at the interface between restoration and tooth there is always a gap between the material and the cavity caused partly by the contraction of the mass of material during setting procedure and partly because the material does not adhere to the tooth (Asmussen and Jörgensen 1972, Barnes 1977, van Dijken and Hörstedt 1986). The microleakage can be related to the properties of the filling material itself or be dependent on the procedures used for cavity treatment and handling of the material. Several methods restorations. et al Browne (1955), et can be used to test the sealing properties of Harper (1912) used air pressure and Fraser (1929), Rose al Mårtensen (1983) et for al (1965), Brännström & Nyborg (1971), example used bacterial penetration as a qualitative measure of tightness. However, the penetration of dyes and radioactive al 1962, 1982, caries van was isotopes Christens Dijken studied has been most frequently studied (e.g. Brown et & Mitchell 1966, Going et al 1960, Forsten 1978, 1980). The susceptibility of the gap to artificial in an acidified gel system (Kidd 1976b, Grieve 1973, Grieve & Jones 1980) and the gap itself was observed by means of 16 direct visualization with light microscopy and scanning electron microscopy (Asmussen & Jörgensen 1972, van Dijken and Hörstedt 1986). Unfortunately, obtained the there are considerable variations in the results with the different in vitro methods used. This combined with lack of criteria for when the sign of a gap is of clinical relevance makes an observation made using an in vitro method uncertain (Shortall 1982, Kidd 1985). Microleakage predisposes sensitivity, marginal studies concluded restorations irritation However, and the emanating to discoloration that pulpal silicate Zander tooth from (1951, pulpal and recurrent inflammation cement the fillings materials 1959) and irritation, acrylic resin caused by chemical (Browne Mitchell caries. Earlier under was thermal & (1959) Tobias 1986). proposed that inflammation was due to bacterial ingrowth in the space between cavity wall and leakage restoration. of fluid From in vivo experiments, was accompanied by it appeared that the bacterial growth, unless the material placed in the cavity had persistent antibacterial properties. The presence between the different last of filling and the has been demonstrated in the space cavity materials. wall in cavities filled with Numerous investigations during the years have shown that bacterial irritation is the main cause pulpal damage beneath silicates, acrylic resins, composite resins other restorative materials (e.g. Brännström & Nyborg 1969, 1974, Qvist 1975, 1979, Mejare 1982, Heys or microorganisms restorative 20 and of et al 1979, Tobias et al 1981, 1982, Bergenholtz et al et al 1985, Leidal & Eriksen 1985). Through the reduction elimination reduced 1971, 1980, Brännström & Nordenvall 1978, Brännström et al or of bacterial prevented leakage beneath inflammation has been filled with silicates and (Skogedal Tobias al 1982). Jörgensen et al (1976) suggested that mechanical et in demonstrated teeth teeth. in She the oral greater functional concluded Eriksen pulpal composites forces & cavities 1976, Brännström & Nordenvall 1978, environment bacterial promote leakage. Qvist (1983) leakage around composite fillings in occlusion than in similar cavities in unopposed that functional stress on teeth was the most important factor for penetration of bacteria through leakage. 17 Techniques to reduce microleakage Galan et al (1976) and van Dijken (1980) found that etching the enamel wall reduced but did not eliminate marginal leakage around composites. Eriksen & Buonocore eliminated when (1976) demonstrated that leakage was only the cavity margins were bevelled prior to etching or when the resin was extended into the etched surface enamel adjacent to the cavity fillings in margin. Most studies of microleakage around composite placed with the acid-etch technique, dealt with restorations which the margins were entirely within the enamel rather than with restorations dentin. been that Since in prior observed etches more the to that etching margins both in enamel and cementum or tags of resin can only be achieved when the enamel has etched margins contained long axis etching the of has the prisms, bevelling of cavity been generally accepted. It might be subsurface of the enamel exposed by the bevelling readily than surface enamel. This is one reason why long times are unnecessary. The bevel allows a gradation of color as the composite resin becomes progressively thinner towards the tooth surface (Groper 1971, Roberts & Moffa 1972, Hill & Soetopo 1977) and decreases the occurrence of enamel fractures (Öilo & Jörgensen 1977). Several thus factors adversely impair the penetration of resin into enamel contributing during to conditioning, reaction products, poor bonding. These include rubbing the enamel incomplete removal contamination of of the etching agent and the etched enamel with saliva, blood, gingival fluid or precipitation of water vapor from exhaled air (c.f. van Dijken and Horstedt 1987b). Resin viscosity (Jacobsen et has al also 1977). been There thought to affect resin penetration is a controversy over whether an intermediate resin system of low viscosity, would better penetrate the acid In etched enamel if used prior several in vitro studies to placement of the composite resin. no difference was seen between tag formation from a highly viscous composite resin and from a low viscous bonding Bryant agent 1984, (Jörgensen Barnes & Shimokabe 1975, Asmussen 1977, Martin & 1977), while another study showed that the tags formed with the high viscous composite resins were shorter (Nordenvall 18 1981). Some studies resins have little of bonding if any strength show that the low-viscous effect (Rider & Tanner 1977, Mitchem & Turner 1974, Raadal 1978, Prévost et al 1982) while others indicate an improvement In some in retention (Ortiz et al 1979, Meurman & Nevaste 1975). studies it was observed that the use of a bonding agent reduces microleakage (Galan et al 1976, Qvist & Qvist 1977, Brännström & Nordenvall 1978, Luscher et al 1978, Forsten 1978, van Dijken 1980, Martin & Bryant 1984) while others showed that it has no effect (Ortiz et al 1979, Retief & Wood 1981, Retief et al 1982). Microleakage was significantly margins greater for both at the cervical margins than at the occlusal conventional and microfilled resins (Retief et al 1982). Buonocore et fillings al to (1956) dentin. intermediary layer considerable effort bonding during for agent. for idea between of using dentin a and bonding agent restoration led as to an a over many years to develop an effective dentinal products have become commercially available In many cavities where there is no enamel available on one or more cavity walls, dentin bonding is essential retention irritation. His Several the 1980s. bonding also did pioneering work on the adhesion of purposes Gap and formation to and prevent microleakage and pulpal marginal leakage is not prevented by most commercial dentin bonding agents (Forsten 1984, Welsh and Hembree 1985, Gordon et al 1986, van Dijken and Hörstedt 1986, 1987a). At the present time, glass ionomer cements and polycarboxylate cements seem to serve adaptation to best both as dentin adhesive restorative material. A good enamel and dentin without gap formation has been shown in vivo (van Dijken 1986, 1987a). In vitro caries Attempts have microleakage caries and made to study the relationship 1975). lesions In for filling between caries at the tooth-filling interface. The in vitro technique of Silverstone (1967) was used to produce caries-like ions been around restorations in extracted secondary teeth (Kidd this technique an acidified gelatine gel provides hydrogen the and carious attack on sound enamel. The microspace between cavity walls allows diffusion of hydrogen ions to occur 19 along the appeared cavity along walls. whereas only lesion. On leakage associated technique Kidd (1975, 1976b) showed that lesions the cavity walls in 77 % of the amalgam restorations, 13% of composite restorations showed evidence of a wall the and other hand, Grieve & Jones (1980) examined marginal with composite demonstrated Approximately 50% of caries fillings in vitro using the same in 95% of the unetched cavities. the restorations in etched unbevelled cavities showed lesions, caries occurred. These observations seem incompatible and Kidd (1985) claims that vivo while the studies. development in the bevelled and etched group virtually no in vitro models should be abandoned in favour of in The effect of the acid-etch technique on caries around composite fillings was observed earlier by Eriksen & Pears (1978). They studied the histology of caries lesions generated from bacterial lesions plaque penetrated growing along in unetched an in vitro system. The carious class V restorations, which also showed bacterial leakage. However in the composites made with an acidetch technique no bacterial leakage was seen and the carious lesion was limited to the free enamel surface. The size of many caries-inducing microorganisms is in the order of 1 pm. Bauer necessary form. and Henson for penetration of the bacteria and for a bacterial film to Jörgensen marginal (1984) stated that a space from 2-20 pm is and Wakumoto (1968) stated that the magnitude of the defect must be approximately 50 pm in order to produce recurrent caries. The penetration of a small ion like the hydrogen ion (about 1-2 indicator Å) of in the size of the to lesions produced in vitro as a consequence of microleakage of hydrogen has development. marginal gap and cannot be directly related ions caries the acidified gel experiments is therefore a poor The clinical relevance of the wall been questioned (Kidd 1985). The in vitro studies are based on the simple diffusion of hydrogen ions along the cavity wall whereas caries formed environment longevity that in vivo is a function of several conditions. therefore of on the success and any restoration (Goldberg et al 1981). It seems obvious microleakage of has a bacteria profound bearing The oral and substrate will play an important role in the formation of recurrent caries in vivo. 20 Biocompatibility The aim of biological testing is to prevent the introduction of materials with local or general biological side effects. justified need for (ADA 1979, (1985) FDI 1980, BSI suggested under three profile testing main so far only guidelines have been set up 1982, that the Despite the DIN 1986). In a review Mjör et al biological testing should be carried out headings: preliminary tests to obtain a toxicity of the material, usage tests to investigate the effect of the material in a manner identical or similar to their use in patients and antibacterial property and plaque formation tests. Mjör et al (1977) and Wennberg et al (1983) stated that many of the preliminary tests do not produce the same results as the usage tests and questionned the validity of in vitro methods for biological testing. Development of in vitro methods been advocated materials (1983) which is (Brown the concluded restoratives However, more closely simulate in vivo circumstances has Tyas that the still has the & 1979). The pulp test for restorative most widely accepted usage test and Wennberg et al degree final biological to be carried out in the of pulp reaction in evaluation of dental form of pulp studies. relation to clinical acceptability has not yet been established. Polymerized composites contain a large amount of remaining unreacted methacrylate groups (Ruyter & Svendsen 1978, Vankerckhoven et al 1982) and many of the (Björkner allergic during components in the composites are potential 1984, Hensten-Pettersen & Holland 1985). However, reactions their Tinkelman & 20 specific to sensitizors only a few composite resins have been reported years of use (Katz 1977, Nathanson & Lockhart 1979, Tinkelman 1979, Malmgren & Medin 1981, Niinimäki et al 1983, Björkner 1984). Composite tooth filling materials contain biologically reactive chemicals which are not bound when the material is introduced into the cavity. during et In cell culture tests chemically cured resins were more toxic and immediately after polymerization than 24 h later (Wennberg al 1983). A light-cured composite was less toxic than a chemically cured one. Composite materials caused less cell damage than silicates, 21 cold-curing plastics cement (Mjör et resin material (Spångberg al et al 1973) and zinc oxide eugenol 1977, Wennberg et al 1983). The toxicity of the is caused by substances leaking from the resin during the first 24 hours. The cytotoxic effect of composite materials have mostly been evaluated in pulp studies. moderate 1977, & in Pulp reactions different reports ranged from (Brännström none 1971, to slight and 1972, Bloch et al Mjör et al 1977, Heys et al 1985, Leidal and Eriksen 1985, Mjör Wennberg materials 1985). None of the individual components of composite held on the pulpal walls of cavity preparations for 21 days caused significant pulp reactions. The average response levels did not exceed 1 on a 0-4 scale (Stanley et al 1979). The tissue gingiva. most The often in contact with composite fillings is the toxicity per se may not be a serious factor in inducing reactions but the plaque importance. The few studies evaluating this kind of response are based on conventional composites. observed the et adhesive properties may be of more Larato (1972) and Dunkin & Chambers (1983) gingivitis adjacent to subgingival Class V composites, while gingiva adjacent to non-restored surfaces was not inflamed. Blank al (1979) adversely Sönju and plaque on affect the other hand found, that such composites did not the health of the gingiva. Skjörland (1976) accumulation on Skjörland (1973, 1976), and Dummer & Harrison (1983) found more conventional composites than on polished amalgam, silicate cement or tooth enamel. It been recommended earlier that the antibacterial properties of has restorative for materials should biocompatibility microspace do properties may (Mjör be assessed as part of their screening et al 1985). If bacteria found in the cause pulpal inflammation, the different antibacterial explain the varying degree of pulp response. mixed materials show some degree of antibacterial activity, effects (1978) varied showed properties system. All when fresh, between that amongst though the microorganisms. Örstavik & Hensten-Pettersen there was a wide variation in antibacterial chemically cured dental composites in an in vitro materials showed some degree of antibacterial activity but the activity was strongly diminished, ceased totally, Freshly after setting and storage. in several cases 22 Clinical evaluations All active been testing programs on dental materials have until recently based on evaluation of a wide variety of mechanical and chemical properties in the laboratory. These tests serve primarily as a guide for determining whether or not a dental restorative has the potential for clinical include that use. Until recently testing programs usually did not requirements for clinical testing. clinical final evaluation analysis standardization material, of of the dental It is now generally agreed materials is essential for the efficiency of of clinical procedures, the materials and is necessary. Clinical assessments can be made by direct or indirect techniques. direct the that including the handling of the technique time of involves assessement, The an evaluation with the patient present at i.e. mirror and probe type of approach. During the 1970s the International Dental Association (FDI) adapted a direct registration performance. graded In according system, this system (Cvar & evaluations of clinical Ryge 1971) restorations were The criteria for the clinical evaluation of tooth restorations marginal quality to criteria describing the degree of failure at the time of examination. colored for included: discoloration, color matching ability, surface roughness, cavo-surface loss of anatomical form or wear, marginal adaptation and recurrent caries. In the some indirect techniques the assessments are made from replicas or type of representation of the original filling such as clinical photographs, Earlier investigations cavities years. reported The amalgam form of no conventional composite resins in anterior or low recurrent caries frequency after 1 to 5 marginal adaptation of composites was superior to that of during the first year. The composites tended to lose anatomic sooner than amalgam and surface roughness and body discoloration occurred Smales casts or scanning electron micrographs (Mjör et al 1985). (Qvist 1975, et al Ulvestad 1980, Eames et al 1974, Osborne & Gale 1980, 1978, Liatakus 1972, Leinfelder et al 1975, 1980, Chandler et al 1973). Ameye et color stability al (1981) which reported was that microfilled resins showed a good comparable or sometimes superior to the 23 conventional resins after 18 months. Marginal adaptation was, however, not satisfactory concluded Class IV and V restorations. that after of success percentage high in degree of 30 months than microfilled Loeys et al (1982) resins had a higher the conventional composites. However, marginal disintegration chip fractures a of microfilled resins was (Lambrechts et 1982). Christensen & Christensen (1982) could not al reported and by the same group in another study demonstrate differences in marginal integrity, color match or marginal discoloration between a microfilled and a conventional composite resin after 3 years. Only a few studies with a duration up to 2 years have compared microfilled or hybrid composites with conventional composites (Heuer et al 1982, Kullmann 1985). No study has compared the three resin types over longer periods of time. Mjör (1981) reported anatomical form resins private in intrinsic within (1985) reported reason for 39% the was a study based on questionnaires, the 7 that poor major reason (41%) for replacing composite practice, discoloration replaced that in followed by recurrent caries (20%) and (13%). years. More than half the restorations were In a later study of the same type, Mjör that recurrent caries was by far the most frequent replacing composite resins (43%). Crabb (1981) reported of the investigated anterior composite fillings and 68% of silicate fillings were replaced after 5 years. No distinction between the different composite resin types was made in these studies. The interest in posterior composite resins has grown rapidly initiated by a demand toxicity. for esthetic Several studied aspects clinically resistance to wear. but dentistry and by a concern over mercury of the properties of the resins have been the main interest has been focused on Inadequate resistance to wear was the major reason for the relative short life spans of conventional composites (Phillips et al 1973, resistance amounts of Lambrechts 1985, Eames to et wear al was 1974, improved Leinfelder et al 1975). Later, by using materials with increased smaller and softer filler particles (Vrijhoef et al 1985, 1983, Hendriks van Groeningen 1984, Wilder et al 1984, Dogon et al 1985, Lambrechts et al 1985, Lutz et al 1985, Boksman et al 1986, Leinfelder et al 1986, Council on Dentai Materials 1986). Marginal adaptation fillings. Because of becomes larger a major movements problem for the posterior during polymerization it is 24 particularly necessary gingivo-proximal incremental to improve the marginal adaptation along the margin. placement Attempts technique have been (Jörgensen made and by using Hisamitsu an 1984), indirect curing with light reflecting wedges (Lutz et al 1986) and the use of size glass ionomer cement as a build-up base material reducing the of the composite restoration (Me Lean et al 1985). The results from these studies cannot yet be evaluated. Many clinical evaluations of posterior composite fillings do not show that recurrent done on caries is a problem. Most studies, however, have been university faculty members, dental students or dental hygienists none of whom are representative populations with respect to caries activity. Potential caries risk Caries development properties of the that a filling is a individuals susceptibility to caries. the role of if potential caries made. a On the the filling in caries It is therefore obvious development can only be role of the patient is known. An evaluation of the risk for the individual member of the study must be group basis, determination of the number of lactobacilli Streptococcus positive function partly of the of the material and the handling technique used and partly evaluated and around mutans correlation caries activity 1983). When between (Klock one in & saliva the or number dental plaque, has shown a of microorganisms and the Krasse 1978, Crossner 1981, Zickert et al variable at a time - e.g. buffer capacity, sugar intake, amount of lactobacilli or S. mutans in saliva and oral hygiene is tested for correlations Grahnén et its relationship to dental caries, no or only weak with al caries 1977, activity were found (Bagramian et al 1974, Ainamo 1980, Bellini et al 1981, Eriksen et al 1986). When a concerted evaluation of several caries related variables is made the possibility of evaluating the potential caries risk for an individual is increased (Rundegren & Ericson 1978, van Dijken et al 1986, Bergman & Ericson 1986, VII, The multifactorial disqualifies the use nature of any of Stecksén-Blicks 1986). the single caries disease inevitably test as the sole basis for an 25 evaluation of the caries is improved caries risk of an individual. The prediction of when several test parameters are combined. Summary Despite the improved resins, the conventional disadvantages which qualities of the composites over the unfilled composites still revealed a number of led to clinical problems. Polishing difficulties and problems in obtaining lasting smooth surfaces led to rough filling surfaces with large Discoloration led Porosities within absorption and shrinkage led internal plaque formed, and to gingivitis. need for rapid revisions of the fillings. resin material roughness. led to increased wear, water A relatively high polymerization stress in the composite resin, enamel interface of the acid-etched cavity margins. controversy around the the of to gap formation in the unetched parts of the fillings material/enamel some to surface and to amounts composite about the reported or There is frequency of recurrent caries resin fillings. No consideration was taken in these studies to the potential caries risk of the individuals. No studies resins have with surface No study of the been published comparing the conventional composite the new microfilled- and hybrid composites regarding the characteristics and irritating effect on the gingival margin. has compared the marginal adaptation and clinical behaviour three individually. types of composites either longitudinally or intra- 26 AIMS The aims of the present investigations were to examine the effect of commonly used finishing techniques on the surface texture of different composite resins. porosities in different composite resins. the effect of different types of composite resins on the marginal gingiva. the effect of the use of an intermediate low-viscous resin on the marginal adaptation of microfilled and hybrid composite resin fillings. the clinical quality and durability of different types of composite resins in anterior cavities. 27 METHODS Preparation of test specimens. In Study I, the specimens were prepared by allowing pressure. the The resin to set in plastic molds for six minutes under specimens were then kept in were prepared moist chambers before further handling was carried out. In Study pressure II, test method essentially specimens and a in two ways: using a condensation method. The pressure method was the same as in Study I, but a higher pressure was exerted by means of a clamp. The clamp was left in place during polymerization of activated materials, while it was removed for the the chemically light-activated spots. for materials which were then activated in five different This method is recommended in the ISO standard ISO/4049 (1985) preparing solubility. glass with specimens The order condensated to evaluate water absorption and specimens were prepared in small quartz tubes. The chemically activated resins were placed in the tubes a spatula syringe. The circular and the materials (diameter pressure. The tubes specimens were cut with in light-activated were then condensed 2 mm) smoothfaced were filled transversely resins in with the delivery the tubes with a amalgam condensor, using light and cured stepwise. The 6 mm high in the middle. Five test specimens a height of 2.5 mm and a diameter of 4 mm thus obtained for each product were used. Scanning mounted electron on surface metal a stubs roughness photomicrographs on microscopy (SEM) descriptive quantitatively and taken. as was made of polished specimens and then coated with a porosity evaluations layer of gold. The were based on the Surface roughness was evaluated qualitatively base (I), while porosity evaluations were measured pore size and pore area using a semi-automated computer based picture analysis method (II). SEM replica was characteristics (III) composite fillings. cleaning (III) the used in two in vivo studies, to study the surface and marginal adaptation (III, VI) of different Replica samples filling surfaces with a for SEM were prepared by first surface active cavity cleanser or a 5 % sodium hypochlorite (NaOCl) solution (VI), followed by 28 spraying with water and drying with compressed air. cleaned surface material. (TEM were made with a Impressions of the low viscous silicone impression The replica was prepared by filling the impression with Epon bedding-in resin, Fluka AG, Buchs, Switzerland). The positive casting was mounted on metal stubs, covered with gold and then studied in the SEM. The final evaluations were based on photomicrographs. surface characteristics were evaluated The on a descriptive base using photomicrograph standards (III). The marginal adaptation was evaluated descriptively (III, VI) and quantitatively (VI). Selection of patients for the in vivo studies (III-VII). The patients had to fulfill certain criteria in terms of number and localization of fillings required anterior region. determined by different patient and non-filled enamel surfaces present in the The number of fillings required in each patient was the need composite received at materials/placement to resin make intraindividual comparisons of the fillings least one or placement techniques. Each filling of each of the investigated techniques. In this way each patient served as a statistical unit. The patients included in the longitudinal evaluation of the different types of composite resins (VII) had up to twelve caries lesions at the start of the study. Filling V, margins located subgingivally were required in Studies IV and while the and VII in order fillings in the individual patients in Studies III, VI were located either at the gingival margin or subgingivally to obtain similar conditions for the different materials/techniques in each patient. Restorative procedure. The cavity margins in the enamel were bevelled, whereas the removed with field was saliva finishing then active were obtained (III, at equipment then cavity enamel, mostly at the gingival margins, was burs subjected suction cavities at low speed (III-VII). The operative to moisture control with cotton rolls and (III, VII) or with rubberdam (IV-VI). The dried by an air blast and cleaned with a surface cleanser. When a dry operation field could not be subgingival margins these were exposed electrosurgically VII). A layer of calcium hydroxide base was applied before acid etching were unsupported of the etched spraying with bevelled enamel cavity margins. for 60 water s with 37 % The bevelled margins phosphoric acid. After thorough (20 s) and drying with compressed air, either a 29 low-viscous intermediate resin followed by a composite resin (IV-VI) or the composite resin alone (III, VI, VII) were inserted. Excess lowviscous resin was removed by a gentle blast of compressed air immediately after placement. During polymerization the composite resin was kept under pressure with a matrix. The fillings were finished after one week. Clinical recordings. Silness index 1963), (Silness and Löe 1964), gingival (Löe 1976) and flow of crevicular fluid were measured in a cross-sectional (IV) and Plaque index bleeding on probing (Ainamo and Bay and one experimental gingivitis study (V). The flow of crevicular fluid was recorded Holm-Pedersen with standardized filter paper strips (Löe and 1965) placed at the orifice of the gingival pockets for three minutes. The strips were then stained with an alcoholic solution of 2 % ninhydrin (Orban and Stallard 1969). The coloured area of each strip was measured under a microscope with an ocular grid (Egelberg and Attström 1973). A slight used to modification of the USPHS-criteria (Ryge and Cvar 1971) was describe microfilled were evaluated visually extrinsic discoloration, marginal of clinical behaviour of brands of conventional, and hybrid composites (VII). Using this rating system the restorations regards the adaptation, and with mirror and probe as color match, marginal discoloration, surface roughness and the presence and location recurrent caries. The rating system is based on the basic clinical qualities of qualities are made every a restoration: further six acceptable or not acceptable. These divided into subratings. The evaluations were months over a six year period after polishing of the fillings. Caries risk evaluation. A prediction of the caries risk, expressed as the potential caries activity, was made for the patients involved in a longitudinal evaluation of different types of composite fillings (VII). The prediction was compared to the actual caries development in each patient. The potential caries activity was defined by the caries risk estimated from the net effect of microbial counts, oral hygiene, intake of fermentable carbohydrates, The recorded caries parameters development when were salivary flow rate and buffer pH. regarded as negative factors favoring certain values were exceeded (Rundegren and 30 Ericson 1978, van Dijken et al 1986). The parameters were recorded three times during the six year evaluation period. Oral hygiene was defined as a negative factor when a plaque score of more than or 2 gingival bleeding at more than 30 % of the tooth surfaces were recorded on more than one occasion. Samples tubes of stimulated whole saliva were collected into ice-chilled by chewing on a lump of paraffin. The numbers of colony forming units (CFU) per ml saliva of lactobacilli (Carlsson et al 1975), total streptococci and S. mutans (Jordan et al 1968) were determined as well as buffer pH (Ericsson 1959) and flow rate. The presence of more than 5x10^ CFU/ml saliva of S. mutans and 105 CFU/ml saliva of lactobacilli on two of three occasions, were regarded as negative factors as was a buffer pH of 5.3 or lower (Ericson 1972) and a flow rate of 0.75 ml/min or less. A mean intake of fermentable carbohydrates six times a day or more was regarded as a negative factor. The dietary record was based on a four day protocol (Carlgren and Rossander 1982). For each individual a maximum of six negative factors could thus be obtained. Statistical analysis. The surface characteristics of the composite materials were presented on a descriptive base (I, III). In the in and/or vivo filling studies, when different types of composite fillings techniques were compared, each patient received at least one of each of the types of fillings investigated and served in this way as a statistical unit. To eliminate the effect of an uneven representation of fillings each material with a given index score were normalized to from the materials in each patient (VII), the number of total number of fillings with that material in the particular patient. placed For example, out of four fillings made from one material in a patient, one (25 % of these fillings) may have a score of 0 for a particular factor, one (25 %) may have score 1, and two (50 %) may have score 3. When the relative frequencies in each patient are known the scores for a factor can be calculated for all patients. For observations index, frequencies were (%) compared, variance when on an ordinal scale - e.g. plaque index, gingival the classification in the USPHS-system (IV-VII) - the relative of ranked and tested using Friedmans two-way analysis of test (Siegel 1956). When the null hypothesis was rejected or all brands materials the scores for each material within each patient or were not techniques test (Siegel 1956). represented were in each patient (VII), the compared two at a time using the sign 31 The size of the marginal defects (VI) between independent samples in the various test groups, were tested using the Mann Whitney U-test (Siegel 1956), while the related samples - samples each of the test groups - were tested using the Wilcoxon in the one-week and one-year matched-pairs signed rank test (Siegel 1956). The differences between two materials or between one filling and the enamel surface regarding the amount of crevicular fluid secreted were tested using the increase Study in Students t-test for paired observations (IV, V). The the amount of exudate between day zero and day seven in V, was compared using a two-way analysis of variance (Steel and Torrie 1960). 32 RESULTS I. Effect of finishing procedures on surface textures of some resin restorations. A comparison between new and old types of composite resins. Acta Odontol Scand 1980; 38: 293-301. The effects of twelve finishing procedures on the surface textures of two anterior conventional composites, two anterior microfilled resins and a glass ionomer cement were investigated. The final evaluations based on the SEM photomicrographs, showed that the microfilled composite resins are superior in finishability to the resins loaded with larger filler particles. The use of fine grit devices resulted in smooth surfaces. In contrast the macrofilled composites showed rough surfaces with protruding filler particles. Only the Sof-lex polishing system produced smooth surfaces on all composite resins, whereas the use of a polishing paste led to very rough surfaces on the macrofilled resins. CONCLUSION: Microfilled materials are superior to macrofilled materials as regards the possibility of obtaining and retaining a smooth surface. II. Porosity in posterior composite resins. 471-8. Scand J Dent Res 1986; 94: The pore area (%) and the pore sizes were measured in 90 specimens made of eight brands of posterior composites and one anterior composite. Six materials were light-cured and three chemically cured. The specimens were prepared in two ways: condensed specimens, in order to simulate the clinical situation and pressure specimens according to the ISO standards for laboratory test specimens. Porosities occupied 0.01-4.5% of the surface depending on the material. Most of the materials, including all those chemically activated, showed more porosity in the condensed than in the pressure specimens. Reversed results emerged for two of the materials, and for another two, the specimens were similar in this respect. The mean pore sizes were smaller in the condensed than in the pressure specimens. CONCLUSION: Neither mean pore size nor total amount of porosities could be related to the curing method of the composite resins. III. SEM study of surface characteristics and marginal adaptation of anterior resin restorations after 3-4 years. Scand J Dent Res 1985; 93: 453-62. A SEM replica technique was used to study the surface roughness and marginal adaptation of 278 anterior resin fillings. The fillings were made of two conventional, three microfilled and two hybrid composite materials. After 3-4 years in v i v o , replicas were made. The surface roughness studied by SEM was graded by using photomicrograph standards. The degradation of the bonding between the acid etched enamel and the filling material was investigated in two specified areas, one located on the incisal part and one on the gingival part of the etched margin of each filling. The 3/4-year-old composite restorations showed degradation of surfaces and margins, with eroded areas and exposed filler particles. Cohesive failures were seen as chip fractures and marginal fractures parallel to 33 cavity margins. Rough surface characteristics increased in the following order: 1) light-cured microfilled, 2) chemically cured microfilled, 3) hybrid and conventional composites. A light cured microfilled resin showed the smoothest surface characteristics with less surface degradation and porosity. Marginal defects were seen in about 50% of the conventional and hybrid composite fillings. Defects occured in 66-88% of the chemically cured microfilled resins but in only 44% of the visible light-cured microfilled resin. Marginal defects were observed more frequently in stress bearing fillings than in non-stress bearing ones. CONCLUSION: The type of filler particle seems to determine the final surface characteristics. IV. The effect of different types of composite resin fillings on marginal gingiva. J Clin Period 1987; 14: In press. The effect of conventional, microfilled and hybrid composite resin fillings on the gingival health was evaluated in two groups of patients. The plaque and gingival indices were recorded in both groups. In addition, the flow of crevicular fluid was recorded in the first study and bleeding on probing in the second group. Group one consisted of 18 adults. A total of 108 fillings were made. Two conventional fillings were inserted in neighbouring surfaces in one proximal space, two hybrid composite fillings in a second proximal space and two microfilled resin fillings in a third proximal space in each patient. One proximal space in the region contained two non-filled enamel control surfaces. The observations were made one year after insertion of the fillings. Group two consisted of 24 adults with 228 subgingival, anterior Class III and IV composite fillings which were 3-4 years old at the time registration (c.f. III). Each patient had at least one filling of each the three composite types and at least one non-filled enamel surface to allow for an intraindividual comparison. The patients were not informed about the registrations in advance of the visit. In group one the figures for the amount of plaque on and degree of gingivitis around the composite fillings were not significantly higher than the figures for the enamel surfaces. Significant differences in the amount of crevicular fluid were found between both the conventional and the hybrid composites and the enamel. In group two the indices for each resin type were significantly higher than those for the enamel surfaces and the fillings showed greater amounts of plaque and a higher degree of gingivitis than the 1-year old fillings. CONCLUSION: The degree of gingivitis increased with time. As concerns the amount of plaque formed and the occurrence of gingivitis, there was no difference amongst the 3 types of composite resins. V. Development of initial gingivitis around different types of composite resin. J Clin Period 1987; 14: In press. The development of experimental gingivitis around one-year-old restorations made from the three types of composite resins and around enamel surfaces was studied. 18 patients (IV) started an oral hygiene regime aimed at eliminating all marginal gingival inflammation in the experimental area. When the gingival index scores approached zero, the experimental period of seven days started. The early signs of gingivitis were significantly fewer around the intact enamel surfaces than around the composite surfaces. Neither the clinical indices nor the exudate measurements showed any differences in this respect between the three composite resin types. 34 CONCLUSION: extent. All types of composites promote gingivitis to the same VI. Marginal adaptation of composite resin restorations placed with or without intermediate low-viscous resin. A SEM investigation. Acta Odontol Scand 1987; 45: In press. The marginal adaptation to acid-etched enamel of hybrid and microfilled resin fillings, placed with or without intermediate low-viscous resin was investigated in v i v o . Class III fillings were placed in either the upper or lower front teeth in 37 adults. Each patient received two hybrid and two raicrofilled composite resin fillings. One of each composite resin filling was placed using a low-viscous resin recommended by the manufacturer of the composite material. After one week no difference was seen between fillings of the same material placed with or without intermediate resin. After one year the hybrid resin fillings placed using intermediate resin showed better adaptation than the ones without, while no differences were seen between the microfilled resins. The microfilled resins showed a greater number and more severe defects than the hybrid resins. CONCLUSION: Hybrid resins placed using bonding agent had the best marginal adaptation. VII. A clinical evaluation of anterior conventional, microfilled and hybrid composite resin fillings. A six-year follow-up study. Acta Odontol Scand 1986; 44: 357-67 The clinical behaviour and durability of 303 anterior resin fillings of seven composite materials - 2 conventional, 3 microfilled and 2 hybrid were evaluated over a six year period. The restorations were placed in 27 patients including patients who experienced relatively high levels of caries. Each patient received at least one filling of each of the three composite resin types. Each restoration was evaluated with respect to extrinsic discoloration, color match, marginal discoloration, marginal adaptation, surface roughness and the presence and location of recurrent caries. A prediction of potential caries activity was made for all patients. The prediction, based on six caries risk factors, was compared to the actual caries development during the six year period in each patient. Unacceptable color match scores varied widely among the brands (3.5-79.7%) after six years. Unacceptable marginal discoloration was seen in 1.7% of the restorations, while unacceptable marginal adaptation varied among the resins (13.7-37.3%). Recurrent caries occurring at the margins of the composite fillings varied among the materials (9.3% 29.4%). During the experimental period between 14.8% and 55.1% of the fillings of each material were replaced per patient. Recurrent caries was the major reason for replacement. CONCLUSION: There was a wide variation in clinical behaviour and durability within each composite resin group. Recurrent caries was the major reason for replacement. Patients with a high number of caries risk factors showed a clearly higher increment of caries, especially of recurrent caries around composite fillings. 35 GENERAL DISCUSSION The In evaluation of a filling material can be made in vivo or in v i t r o . vivo the investigations probe and information and color on visual inspection (Smales and Creaven 1979). The obtained in this way about roughness, marginal adaptation matching systematic 1971) are generally based on an evaluation made by has evaluation the weakness of not being quantitized. suggested in The the USHPS-system (Cvar and Ryge helps to standardize the evaluations but as the system is based only small a few scores it is not sufficiently sensitive for testing a number of samples in an experimental series. It is more suited for use on larger populations in epidemiological evaluations. Attempts to increase the number of descriptive ratings have merely resulted in poorer evaluator agreements (Mjör & Haugen 1976). It is now performed majority not the consented that clinical investigations should be as a final evaluation of new restorative materials, of been often general the subjected to previous clinical investigations. obliged same of materials Several composites; product, Dentists are to base their judgements on the information applied by manufacturers. studies but the composites introduced to date on to the market have the problems arise in long-term clinical the uneven composition between batches of the change of composition, and the disappearance of from the market before substantial clinical tests have been performed (Lambrechts 1983, VII). It is difficult to predict clinical behaviour from laboratory tests, which determine only whether a material has the potential for clinical use. The shortcomings have led to making can replica be made evaluations make the a of the subjective clinical assessment methods development models of more objective ranking methods. of the surfaces (III, VI) direct measurements of defects in the surface. This provides more objective of the quality of the surface. Another possibility is to multipower enlargement of the replica sample or of a cross- section of it (van Dijken and Horstedt 1986, visual that inspection might probe. surface SEM By of indicate defects. biological observations roughness offer qualitatively 1987a) to make possible a Such defects although of a magnitude risk an would excellent (I, III, not be recognized by a means VI) and for evaluating the enlarged 36 structures can replicating be used for morphometric measurements (II). By using techniques it is also possible to monitor continuing in vivo changes in surface morphology for extended periods of time. The finishing problems. The materials is traditional conventional composite resins still raises serious difference such in that hardness of the two major parts of the a smooth finish cannot be obtained with the polishing procedures (I). Some microfilled materials were introduced could of in the seventies and the manufacturers claimed that they be polished to a smooth surface. At the same time new polishing devices were composites. various designed anterior profilometer confirmed to produce smooth surfaces on the various In vitro studies of the effect of polishing procedures on (I, that and posterior composites with the SEM and van Dijken et al 1983, van Dijken and Ruyter 1987), microfilled composites could be polished to a smooth surface. The macrofilled conventional and hybrid composites showed two different abrasion patterns (van Dijken and Ruyter 1987). One was seen after the resin matrix seen in polishing The polishing polymer system was used. The filler particles and resulting in low Ra values and Products, surface abrasion pattern was seen after brushing with pastes resulting in the preferential removal of the organic leading in Toothbrushing macrofilled turn in to a protrusion of the filler vitro of the smooth surfaces of various composite resins obtained initially by Sof-lex (3M Dental St Paul, roughness. MN. USA) polish also showed a marked increase in The SEM evaluation showed the disappearance of the smear layer obtained with the Sof-lex polish (van Dijken et al van structure Dijken and Ruyter 1987). between the various the influence of demonstrated filler other matrix particles. 1983, disc flattened equally, the SEM as having the characteristics of a relatively smooth surface. smooth were particles on the The differences macrofilled in surface composites clearly the size, hardness and amount of the abrasion pattern. The traditional quartz particles show very little wear compared to the glass particles in the newer of hybrid composites (van Dijken and Ruyter 1987). The development composite particles produced toothbrushing composites. resins with a high content of smaller and softer glass materials resembled very with surface closely those profiles of the which after microfilled 37 The toothbrushing al 1983, van Dijken and Ruyter 1987) were also seen in vivo (III, VI). Aged composite with a SEM similar newly abrasion patterns observed in vitro (van Dijken et fillings replica to those roughness, formation and chip showed rough characteristics in vivo on in vitro samples (III). surfaces increased with large filler particles studied technique found finished microfilled loaded the in aged the form fractures. resins patches microfilled of It of eroded should In comparison to resins showed an surface areas, crack be observed that in aged roughness occured which gave them an overall smoother character than the aged macrofilled composites, which showed rough characteristics over the whole surface. It can be concluded that the final surface structure of a composite filling will use polishing of superficial softer be determined by toothbrushing procedures in vivo. The procedures layers abrasives lasting than effect. resulting in smooth but easily abraded or polishing devices with more finely grained and The those found in commercial dentifrices have no clinical degradation of the composite surfaces occurred not only because of the mechanical forces and abrasion of the toothpaste but also as a result of a combination of thermomechanical fatigue and chemical attack. Differences filler in surface content can roughness between materials with a similar be influenced by the number and size of pores in the surface of the composite. Pores, which are caused by entrapped air are common and handling exhibit in dental composites and are closely correlated to mixing in procedures. vitro both Light-activated fewer resins have been shown to and proportionally smaller voids than chemically activated resins (Reinhardt et al 1982). This was also seen in an in vivo study (III) where a light-cured microfilled resin showed considerably an in fewer vitro pores than two chemically cured ones. However, study of porosity in posterior composite resins, in two of five light-cured resins showed roughly the same number of pores as the chemically that resins, this investigated of cured light-cured resins cannot for light-cured syringe composites. instead This means that even if it is possible exhibit less porosity than chemically cured be treated as a generalization and should be each individual material. However, composites of a properly bulk fillings with minimal porosity. packing manufactured technique the introduction and may the use of a give composite 38 It has been stated that rough filling surfaces favour the accumulation and retention of debris and bacterial plaque and promote gingivitis (Larato 1972, Mörmann et al 1974, Gildenhuys et al 1975, Smales 1981). Skjörland (1973, and in vivo, quantity large on 1976) and Sönju and Skjörland (1976) showed, that the amount the amount of in vitro plaque accumulation differed in various hard surfaces of the mouth. A comparatively was formed on conventional composites, but its presence was scarcely demonstrable on silicate, amalgam or enamel. Many restorations are placed adjacent to or below the gingival margin. The surfaces factors of contributing inflammatory and to changes suggested the these restorations have been implicated as possible rough that gingival disease. Waerhaug (1956) noted around different types of restorative materials they were mainly caused by plaque accumulated on area. Löe (1968) reported that the roughness of restorations, probably more than chemical irritation from the material itself, produced inflammation. He concluded that restorations should be well polished to reduce plaque accumulation. Because of expected rough their to surface manufacturers has, when composites. the however, resins with Enamel is the microfilled resins were affect the health of the gingiva less adversely than the conventional study smoothness, respect probably This argument was also used by the first hybrid composites were introduced. No compared the properties of the three composite to plaque accumulation and gingival reaction. the smoothest and most acceptable surface in the mouth and all restored surfaces should be compared to it. There are a variety inflammation. These and bleeding shape, histological accurate but to beside gingival (Ainamo that indices available include those based on tendency, to assess gingival changes in gingival color quantity of sulcular fluid and The histological index probably provides the most of gingival inflammation (Appelgren et al 1979), other objectives the time and level of expertise required prepare method. developed to assessment obtain, this data. of for index and score the biopsies limit the application of Alternative clinical (Löe gingival use. Among indices the have therefore been most commonly used are the & Silness 1963) and the gingival bleeding index & Bay 1975), both of which assess the tendency of the gingiva bleed on light probing. The bleeding indices are based on the fact the degree of gingivitis is reflected by vascular changes in the 39 gingiva. The early inflammatory changes of the gingival index are detected by the subjective observation of surface changes in color and texture. This subjectivity involves simply scoring is overcome in the bleeding index, which bleeding or no bleeding and requires little calibration. To overcome differences in the amount of force applied to the probe pressure-sensitive (force-controlled) probes have been developed. Another the on the the fact that when the degree of gingival inflammation increases, amount of exudate in the gingival sulcus increases. Poulsen et al (1979) of method for evaluating gingival inflammation is measurement of gingival crevicular fluid (Brill and Krasse 1958), a method based showed studying Cimasoni (1983) procedure of that for and inflammation but gingivitis in clinical trials, it is the most reliable and sensitive quantifying gingival in different parts inflammation. and The of the gingiva and the Improved plaque control may reduce inflammation Multiple severity of the gingival exudate fluid may reflect different inflammation region. pocket. the stated index pocket development available gingival stages that measuring crevicular fluid is an efficient method the not measurements may reduce at superficial the base of the may be necessary to record adequately of the disease and to follow the effect of the patients oral hygiene procedures. As the as well than rate of plaque accumulation and the development of gingivitis as the level of oral hygiene differs more inter-individually intra-individually, respect to gingivitis the can same on index relatively observed a comparison removal, plaque of different materials with accumulation and appearance of be made only if the various materials are compared in mouth. registered plaque plaque In two fillings (Silness good oral supragingival cross-sectional of & studies (IV), plaque was the three composite resin types with the Löe 1964). hygiene were It was shown that patients with able to clean plaque from the parts of the composite fillings regardless of the type of composite. There were more filled surfaces than there were control enamel surfaces with observable plaque on them. The amount of subgingival To is not registered with the Silness and Löe index. be able to evaluate the condition of the pocket the more sensitive method of plaque the of gingival fluid registration was used to observe the effect subgingivally located fillings on gingival health (IV, V). No differences were seen in crevicular fluid exudation around the 40 fillings made from conventional, microfilled or hybrid composites, the but amount of fluid around the filled surfaces was always higher than around the unfilled enamel surfaces. The stronger reaction around the composite surfaces may be due to the toxicity of the materials and/or irritation from remains of bacterial plaque. Differences among in the gingivitis produced plaque different model retention and properties evoking gingivitis composites were also studied in an experimental according to Löe et al (1965) (V). All composites a strong gingival response and the materials were comparable despite the great differences in their surface characteristics. The results gingivitis found that cross-sectional on in (IV) and the experimental surface characteristics per se had only gingival responses. However, observations anterior are based on it must be observed different composite resins in fillings. The differences in plaque accumulation may be even pronounced cavities. while two differences effects the more the study (V) support the observations of Waerhaug (1956), who that minimal of when These the areas resins are used in posterior proximal are more difficult for the patients to clean, at the same time the plaque accumulation ratio in the posterior region of the mouth is faster than in the anterior part (Lang et al 1973). Differences in gingival responses for the composite resins in posterior fillings should be studied. The SEM investigation of the adaptation to acid-etched enamel of composite resins placed with or without the use of low-viscous bonding agents (VI), showed defects such as marginal fractures, of the that resin with and fractures in the enamel. chip fractures It should be pointed out the SEM method used, adaptation could be evaluated only at the surface of the fillings. The deeper parts can only be investigated in cross sections of teeth extracted e.g. Dijken and Hörstedt 1986, for orthodontic reasons (van 1987a). The most common defects observed were fractures in the resin material often close to the filling/enamel border. One marginal week polymerization there was no difference in defects between fillings of the same material placed with or without a bonding agent the after bonding agent. The hybrid resins both with and without a showed a significantly better marginal adaptation than microfilled resins (III, VI, van Dijken and Hörstedt 1987b). contraction stresses microfilled than for The during polymerization, which are larger for the the resins loaded with larger filler particles 41 are likely severity one to be the main cause of fractures in the resin. The of the defects for both composite materials increased at the year registration which indicates a decreased resistance to thermo-mechanical stress in the mouth. The marginal important retention, the defects when of their microleakage fillings to composite severity is fillings will become clinically sufficient to cause loss of or increased plaque retention and predispose recurrent caries. Retention of composite resin fillings is not improved by the use of intermediate resin (VI, Low and Majid 1979, Ulvestad evaluation of composites, placed at the etched cervical margins. with the observed in will long the that application resin freshly are In a longitudinal and hybrid most prone to caries were the technique could not be used. occur easily along those margins and in acid-etched times for bacterial acids a higher It can be concluded that the failures margins the do studied not necessarily lead to anterior composite fillings, low viscous resin was not used. In larger fillings it may be assumed the 1985). microfilled margins clearance complications in even if a al acid-etch frequency of caries could occur. clinical et conventional, The when penetration combination Smith of without a bonding agent (VII), no caries occurred margins, Bacterial 1978, fillings bonding will mixed most not are penetrate material essential adaptation agents more necessary. During longer times the viscosity of the composite resin increases, of the etched and enamel as easily as the (Jacobsen et al 1977). Further investigations so that ways of improving the cervical marginal composite resin fillings can be discovered possibly by finding resins with low polymerization shrinkage. The clinical quality that implications problem and of recurrent caries is both a restoration a caries problem. Eriksen et al (1986) reported an increase in the prevalence of recurrent caries around amalgam fillings could be registered only for the fillings reaching a marginal breakdown ranking surfaces pattern scale. a Goldberg correlation moderate/severe the resulting marginal occlusal surfaces. primarily a et in quality scores of 5 and 6 on an 1-6 al (1981) existed showed between that for the smooth recurrent caries and quality. No such relationship was found for Eriksen indicated that recurrent caries is not restoration problem, but is intimately related to the 42 caries-challenge of the patients. Unfortunately no such studies have been performed previously for composite resin fillings. In a far recent the study Mjör (1985) reported that recurrent caries was by most common private practice. 5 years with (Chandler (41%) for replacement of composites in In other studies a et reason very low al 1973, thefillings had lasted up to 4 and rate of caries or no recurrent caries Leinfelder et al 1980, Qvist et al 1980, Ström and Qvist 1986). The higher compared prevalence to (1986), amalgam was composite also of recurrent caries around composite fillings and gold restorations as shown by Eriksen et al shown restorations Variations in considered in caries before Study VII. In this study 18.6% of the exhibited caries at the end of the six years. susceptibility any comparisons among individuals must be between materials can be made as regards evaluation of the frequency of recurrent caries. Use of dental students or other underestimation 1980), of the with a chances low of caries risk results in an recurrent caries (Leidal & Dahl a circumstance that underlines the importance of the selection patients evaluation Ericson in caries clinical system (1978). accurately for studies. caries In on calculation We factors thesis we have used an risk first suggested by Rundegren and predicting caries risk in a patient increases when several a factors. this It is based on the assumption that the possibility of related factors are evaluated. based also groups of find develop used that of the patients more caries. In this study the evaluation is sum with of negative evaluations of 6 a higher number of negative The system of Rundegren and Ericson was in studies by Bergman and Ericson (1986) and van Dijken et al (1986). In Study VII we found that patients with a high potential caries risk clearly showed recurrent 46% of the registered for contiguous to the composite fillings. recurrent caries lesions as root surface caries, on especially of The fact that the buccal surfaces were can be seen as a contra-indication composite resins as the material of choice in these cavities. choice of depend very patients use a greater actual development of caries, caries, of tooth-colored with much on the material patients in The the individual patient should caries susceptibility. In older three or more negative factors one must reconsider the composites, especially in teeth with gingival recessions. 43 Materials which leak fluor like the glass ionomer cements should be used (van Dijken 1986). Body discoloration as a fillings was fillings in practice (Mjör 1981). Ulvestad old reported reason the replacement of anterior reach 13% of the total number of replaced a cross-sectional conventional Dogon to for chemically study of fillings made in private (1978) reported that 83% of five year cured fillings were cosmetically poor. et al (1985) replaced 43.7% fillings made of a chemically cured microfilled years resin and only 1.5% of the light-cured variation after 3 of use. On the other hand, only 2% of fillings of the Ström and Qvist (1986) reported that same chemically cured resin showed unsatisfactory color match after a four-year assessment. A yellowish/brownish reported with (Eriksen mismatch increasing 1974, Ulvestad 1980). The color resins has been tertiary amines due to body discoloration has been age in several longitudinal investigations 1978, Qvist et al 1980, Leinfelder et al shift in connection with aging of chemically cured ascribed to the oxidation of residuals of certain present in the catalytic system and to the amount of inhibitor (Asmussen 1983). Discoloration by oxidation of the unreacted methacrylate groups has also been considered to be important (Ruyter & Svendsson 1978). they polymerized by a mechanism in which aromatic amines are not are required the Light-cured materials were more color stable since (Asmussen 1983). However, the color stability will depend on particular brand or batch, because some products contain amines or inhibitors that may break down and liberate colored agents. The do number of fillings replaced because of discoloration in Study VII not necessarily acceptable attitude wanted color and to represent match. sometimes color adjust the number Patients accepted (Ulvestad tended a of to fillings with a nonhave a more lenient discoloration which the dentist 1978, VII). From Study VII it is clear that the color change is time dependant and varies greatly among the materials. years are composites. The results clearly show that periods longer than three required to evaluate the clinical color stability of 44 GENERAL SUMMARY AND CONCLUSIONS Microfilled larger composite filler retaining factors a with smooth which varied to surface. the possibility among the investigated to the curing method employed. composite resins aged in of obtaining and Porosities in the resins was one of the determined surface roughness. greatly related resins were superior to composites loaded with regard vivo The number of porosities composites and could not be The surface characteristics of showed degradation of surfaces and margins. The chemically cured microfilled resins showed more marginal defects than a visible light-cured microfilled resin and the conventional and hybrid resins. The difference conventional, clinically in surface microfilled measurable of gingivitis of normal of hybrid and composition of the composites did not result in differences in the amount of plaque and degree around the resin types measured either during a period oral development characteristics and home care in the investigated patients or during the plaque and gingivitis in an experimental gingivitis study. The use of a low-viscous intermediate resin produced no effect on the marginal hybrid adaptation resin of fillings microfilled resins to the etched enamel. placed with a bonding The agent showed better adaptation than the ones without after one year. Despite their smoother surface characteristics, showed their of with on the microfilled resins no advantage over the conventional and hybrid resins regarding effect on the gingival health, marginal adaptation or frequency recurrent caries. the the component Since the materials are classified in accordance content and size of the filler it may be suggested large per variations within the resin groups - based that the filler se is not the determining factor for the durability of the composite filling. In Table I a comparison is made of rankings for different composites with respect to some of the selected variables in Papers III and VII. 45 Table I. Ranking of the criteria evaluated in studies III and VII. The material judged "best" for each individual criterion was ranked lowest Cod* turfac* marginal m a rg1 n a l recurrent l o s e of color roughness defects degradatIon carles retention match III VI I VII III VII Conv. Microf. Hybri d It is A 7 2.5 2 2.5 1.5 3 18.5 P 4 2.5 4 5 1.5 4 21 S 2 6 5 4 6 5 28 I 3 7 7 6 7 6 36 Du 1 1 1 2.5 5 1 11.5 M 5 4 3 1 3 2 18 D 6 5 6 7 4 7 35 quite within III-VII VI I VII I ranking clear each type. testperiods that there are wide variations among materials It should also be observed that judgements based on shorter than 3 years long are unreliable. Each new composite resin must be evaluated on its own merits and not because it belongs to a certain group. ranking this than it techniques and a any of the other materials tested. However, was adaptation. not superior Great careful in should is be exercised for the delicate making a composite filling. A good technique evaluation there in spite of in terms of recurrent caries or marginal respect involved essentialif One of the microfilled resins has a better to of the caries be a good result. risk of a patient are Because recurrent caries will certainly become the major reason for replacement it is important to include caries risk patients in a clinical evaluation. The introduction of the newer composite types has not yet completely satisfied the demand for a durable anterior restorative. resins have replaced susceptibility of the the silicate cements regardless of the caries patients. It is suggested that the composites should not be used as the only tooth colored restorative, indication patients should with a be high based The composite on the but that its patients caries risk level. In caries risk level a fluoride-leaking material such as the glass ionomer cements should be preferred. 46 ACKNOWLEDGEMENTS I wish to express my sincere gratitude to those who have contributed to this investigation with special thanks to Professor Thorild Ericson, criticism given to me at all my tutor, for all his support, help stages of the work. and constructive Associate Professor Jukka Meurman and Jaana Stadigh for valuable cooperation in the first part of the investigation. Dr Per Hörstedt for fruitful discussions and help with the scanning electron microscope. Dr Eystein Ruyter, NIOM, and Dr Roy Holland, NIOM, for their constructive criticism and encouragement and Professor Ivar Mjör, Director of the Scandinavian Institute of Dental Materials, Oslo and all my friends at NIOM for their support, help and care during my visit to NIOM and Mr Sten Stölen for teaching me how to use the scanning electron microscope. Associate Professor Kenneth Wing and Dr Staffan Sjöström for fruitful discussions and valuable cooperation during the investigation. Margareta Widman, Christina Bonnedahl, Gun Dahlgren and Inga Hamberg for excellent chairside assistance. Engineer Rolf Sjöström for his never failing interest and valuable statistical advice. Professor Maud Bergman, Professor Axel Bergenholtz, Associate Professor Lars Matsson, Associate Professor Lennart Hänström and Dr Mats Ryberg for valuable advice. John Erik Dahlgren, Bengt Forsell, Christer Abraharasson and Bengt Carfors for skilful assistance with the production of the photographs. Mrs Britt-Marie Kvarnbrink for secreterial aid, Patricia Shrimpton for revising the English and to all my collagues and friends for their encouraging interest. Last but not least I would like to extend my thanks to all my patients who contributed to the performance of this investigation. 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