* denotes required field

Your Name: *



Gender: *

Personal Email: *

This will be your username

Password: *

Display Name: *

This will be what others see in social areas of the site.

Address: *










Phone Number:

School/University: *

Graduation Date: *

Date of Birth: *

ASDA Membership No:





Hi returning User! please login with Facebook credentials where Facebook Username is same as THENEXTDDS Username.




Comments (0)

Direct Resin Restorations: Treatment Planning and Protecting the Dentin-Pulp Complex

Over the last decade, the use of composite resins for the direct restoration of posterior teeth has significantly increased due to aesthetic demands and the desire to preserve sound tooth structure during cavity preparation.1-4 With the development of adhesive systems5,6 and improved restorative resins,2,7,8 composite restorations are predictably successful (Figures 1-2-3).9 In order to restore posterior teeth with direct composite resin, however, the clinician must alter basic treatment concepts that apply to nonadhesive restorative techniques, which include diagnosis, cavity design, pulp protection, and restoration maintenance.10-12

Composite resin restorations are technique sensitive,10,13 particularly in the posterior region where access, visibility, and moisture are difficult to control.3,14 Despite these challenges, it is evident that composite resins are gaining popularity as the restorative material of choice.1,5,15 The objective of this article is to present updated information related to the use of composite resins for the restoration of the posterior dentition.

Advantages and Limitations

A primary advantage of adhesive composite resins to restore posterior teeth is the possibility of preserving sound tooth structure during cavity preparation (Figures 4-5-6-7-8-9).16,17 The prepara­tion for a composite resin restoration is generally limited to access to the lesion/defect, removal of the diseased tissue, and development of a cavity form to facilitate matricing and application of the restorative material. It is not necessary to reduce sound tooth structure to provide “bulk for strength,” nor is it necessary to remove unsupported enamel or to provide mechanical retention.18,19

Secondly, composite resin restorations represent a significant aesthetic treatment option,20 enabling the fabri­cation of restorations with a natural appearance. The use of composite resins also provides strength to weakened tooth structure and postoperative comfort due to their low thermal conductivity.1,3,4,21

A precise restorative technique is essential in order to properly use this modality.12 Sensitivity to the moisture in the mouth, limited adhesion to dentin, and polymerization stresses generated during lightcuring6,22 represent the primary limitations associated with this technique. These factors are particularly relevant in the posterior quadrant, since it is more difficult to obtain appropriate iso­lation in these regions as compared to the anterior sector.3

The following factors can also be considered restrictions to the utilization of composite resins on the posterior dentition:3,4,13,23,24

           High coefficient of thermal expansion.

           Low elastic modulus.

           Questionable wear resistance in situations of heavy occlusal stress.

           Possibility of undercuring.


When the proper treatment protocol is maintained, direct composite resins are indicated for the following posterior applications1,3,4,15,25-27:

           Carious lesions where restorative treatment is required.

           Cervical noncarious lesions.

           Restoration replacement.

           Foundations for indirect restorations.

           Provisional restoration of periodontally, endodontically, and prosthetically treated teeth.

           Pit and fissure sealants without utilizing cavity preparation.


In the authors’ experience, the clinician should in each clinical circumstance consider that 1) adequate isolation is mandatory; 2) sound tooth structure must be preserved whenever possible; and 3) treatment should commence only after information on the prevention and treatment of etiologic factors (eg, dental caries and periodontal disease) has been delivered. While this article provides emphasis to the use of direct posterior composite resins on incipient and moderate sized carious lesions, the majority of these principles are applicable to other indications as well.

Restorative Technique

Treatment Planning

In order to evaluate the preoperative condition and the necessity of the composite resin restoration, bitewing and periapical radiographs must be recorded to assess the extent of the lesion and to establish the restorative strategy. Vitality tests, prophylaxis, occlusal analysis, shade selection, and, when appropriate, tooth separation, are important steps prior to the initiation of cavity preparation.27,28

While the shade of the composite is not as important in the posterior area as it is in the anterior dentition, several shade options are available in the contemporary composite resin systems, which enable the selection of the composite that best matches the adjacent natural dentition. Since maxillary premolars are often visible from the facial aspect, the shade of the composite resin contributes significantly to the successful restoration of these teeth. Resin tints and pigments are also available to create a lifelike composition when the occlusal area is to be restored. When a rubber dam is used, shade selection should be accomplished prior to its application, due to possible color shifts associated with dehydration.

The occlusal analysis may be an important process when the restoration involves the occlusal aspect, and should be completed prior to the isolation of the operatory field.4 The analysis of the interocclusal relationship between the tooth to be restored and the adjacent teeth can significantly simplify the occlusal adjustment phase of the procedure. The centric and eccentric stops should be registered with articulating paper prior to initiating preparation, and maintained in sound tooth structure or reproduced on the restoration.

Elastic rubber rings can be important diagnostic tools for proximal incipient lesions, facilitating separation that enables the visualization and assessment of the suspect area.27 This evaluation, when performed in conjunction with the anamnesis and the radiographic information, can determine the necessity of tooth restoration.28  


Preparation Design

Once anesthesia has been administered to the patient, the treatment site is isolated with a rubber dam, which can be applied once preparation has been initiated or even prior to the adhesive protocol. The cavity design for posterior composite resin restorations depends primarily on the size and shape of the existing defect. The preparation of cavities in moderatesized or incipient caries lesions is generally restricted to three steps: access to the lesion, removal of infected carious tissues, and establishment of a cavity convenience form (Figure 10). Proximal incipient lesions may require extensive sound tissue removal as compared to decayed tissue, and the need for restoration must be positively verified,29,30 since these lesions are not always indicated for restorative procedures. For interproximal incipient lesions, it can be useful to temporarily separate the involved teeth to simplify the instrumentation of the lesion. Occlusal and facial access can be performed to prevent the breakage of the marginal ridge.18

Although controversies regarding the use of caries detecting solutions have been raised,31 the authors believe that this is the optimal manner to identify the irreversible infected carious tissue and to guide caries removal. Unsupported enamel can be preserved if it does not compromise the application of matrices and the insertion and polymerization of the restorative material. Bevels are often unnecessary in posterior composite restorations, except in those areas where aesthetics is of paramount importance.32 The cavosurface angle should be clear and well defined, which sometimes can be achieved with reciprocating devices.

The preparation can be performed with high speed burs and diamonds under water irrigation. Carious dentin may be more effectively removed with slow speed carbide burs and dentin spoon excavators. When the restoration involves proximal lesions or defects, or when it is intended to replace defective restorations (either amalgam or composite resin), prewedging may be useful. This step protects the interproximal rubber dam and the papillae, prevents bleeding that could jeopardize the bonding procedures, and promotes a slight separation between the teeth that favor the achievement of adequate proximal contacts. Once the preparation has been completed, the wedge is removed, the matrix is applied, and the wedge is repositioned.

Matricing and Wedging

The selection and placement of matrices to restore proximal boxes with composite resin are very important for obtaining an adequate restoration. Individual thin precontoured metallic matrices are the most suitable to obtain adequate contour and proper interproximal contacts without overhangs (Figures 12 and 13). The technique for applying the matrices varies depending on the facio­lingual extension of the proximal box. Alternative systems require the use of thin precontoured metallic matrices and a ring to maintain the position of the matrix and promote a slight separation between the tooth to be restored and the adjacent tooth. The placement and stabilization of the matrix with anatomic wooden wedges should, ideally, be performed prior to the application and polymerization of the adhesive system, which simplifies the application process (Figure 4). The clinician must not allow the fluid resin to accumulate adjacent to the matrix and the internal angles of the cavity. This “pooling” could result in failure and in the misdiagnosis of recurrent decay on the radiograph, since the majority of the fluid resins are not radiopaque.

Protection of the Dentin-Pulp Complex

The clinical need for a protective agent (base or liner) is one of the most controversial issues in restorative dentistry.33 In order to prevent injury to the pulp, it was once believed that it was necessary to apply bases or liners on the exposed vital dentin.34 Recently, however, the failure of restorations has been attributed to the inappro­priate sealing of the tooth/restorative interface,35 and a modification of the concepts of “pulpal protection” has occurred.33,36-40

Studies have demonstrated that the pulp possesses an inherent ability to heal, repair, and form mineralized tissue bridges under several restorative materials.41,42 Bacterial leakage has been attributed as a key factor for triggering pulp inflammation and necrosis, regardless of the material used to cover dentin and pulp.43 Additional histological studies have indicated that restorative materials in direct contact with the pulp do not elicit inflammation, maintaining the pulpal metabolism with or without the hard tissue bridge formation, as long as a biological marginal seal is secured.43-45 These data support the concept that the repair of the pulpal tissue does not depend on the type of lining, base, or restorative material, but rather upon the capacity of the restorative material to effectively seal the tooth/restoration interface.

Adverse pulp responses associated with composite resin restorations have been attributed to a variety of factors (eg, nonconverted monomers, contraction stresses, bacterial leakage).4,46,47 As a result of these reports, composite resins and the adhesive systems have not always been regarded as biocompatible materials and, consequently, have been suggested by some not to be used directly on vital dentin. A base or liner has often been utilized to chemically and mechanically isolate the composite resin from the vital tissues. Calcium hydroxide was widely advocated for this purpose prior to 1990, but complications have been reported following its use.39,48 Lining the dentin with calcium hydroxide cement prevents the lined area from being etched and bonded, compromising the effectiveness of the adhesive techniques. The lack of adhesion between calcium hydroxide and tooth structure may also generate a gap at this interface40; this space can be colonized by bacteria and/or act as a “hydraulic pump,” stimulating the flow of the tubular fluid inward. This hydraulic pressure might be responsible for post­operative sensitivity, particularly to masticatory forces.49 Calcium hydroxide based cements may also be visible beneath composite resin restorations. Glass ionomer cements have been recommended as base materials for these restorations to act as dentin adhesive materials,50 mediating the adhesion between the natural tooth and the composite resin. Although glass ionomer cements have several positive properties (eg, fluoride release and effective thermal insulation), the weak bond strength and difficult handling properties of these materials have restricted their broad acceptance.

It is now generally accepted that the hybridization of the exposed dentin with an adhesive system is one of the most effective means of protecting the pulp-dentin complex under composite resin restorations, regardless of the depth of the preparation.6,39,44,45,51 While concepts such as adhesion, material placement, and finishing/polishing are also important considerations, they are beyond the scope of this presentation and will be discussed hereafter.

*Department of Operative Dentistry, School of Dentistry, Universidade Federal de Santa Catarina, Florianopolis, SC, Brazil



  1. DeGrange M (ed). Minimally invasive restorations with bonding. Carol Stream, IL: Quintessence Publishing; 1997:283.
  2. Jordan RE, Suzuki M. Posterior composite restorations: Where and how they work best. J Am Dent Assoc 1991;122(12):30-37.
  3. Dietschi D, Spreafico R. Adhesive metal-free restorations: Current concepts for the esthetic treatment of posterior teeth. Carol Stream, IL: Quintessence Publishing; 1997:215.
  4. Heymann HO, Sturdevant JR, Roberson TM, Sockwell CL. Tooth-colored restorations for Classes I, II and IV cavity preparations. In: Sturdevant CM, Roberson TM, Heymann HO, Sturdevant JR. The Art and Science of Operative Dentistry. 3rd ed. St Louis, MO: Mosby; 1993:586-625.
  5. Jendrensen MD. Clinical behavior of 21st-century adhesives and composites. Quint Int 1993;24(9):659-662.
  6. Van Meerbeek B, Perdigão J, Lambrechts P, Vanherle G. The clinical performance of adhesives. J Dent 1998;26(1):1-20.
  7. Ferracane JL. Current trends in dental composites. Crit Rev Oral Biol Med 1995;6(4):302-318.
  8. Leinfelder KF. New developments in resin restorative systems. J Am Dent Assoc 1997;128(5):573-581.
  9. Rasmusson CG, Lundin SA. Class II restorations in six different posterior composite resins: Five-year results. Swed Dent J 1995; 19(5):173-182.
  10. Ferracane JL. Using posterior composites appropriately. J Am Dent Assoc 1992;123(7):53-58.
  11. Leinfelder KF. Using composite resin as a posterior restorative material. J Am Dent Assoc 1991;122(4):65-70.
  12. Liebenberg WH. Posterior composite resin restorations: Operative innovations. Pract Periodont Aesthet Dent 1996;8(8):769-778.
  13. Rykke M. Dental materials for posterior restorations. Endodont Dent Traumatol 1992;8(4):139-148.
  14. Mitchem JC. The use and abuse of aesthetic materials in posterior teeth. Int Dent J 1988;38(2):119-125.
  15. Lyons K. Alternatives to amalgam. NZ Dent J 1997;93:47-50.
  16. Leinfelder KF. A conservative approach to placing posterior composite resin restorations. J Am Dent Assoc 1996;127(6):743-748.
  17. Summit JB, Della BA, Burgess JO. The strength of Class II composite restorations as affected by preparation design. Quint Int 1994;25(4):251-257.
  18. Albers HF. Tooth-Colored Restorations. 8th ed. Santa Rosa, CA: Alta Books; 1997.
  19. Hilton TJ. Direct posterior composite restorations. In: Schwartz RS, Summit JB, Robbins JW. Fundamentals of Operative Dentistry. Contemporary Concepts. Carol Stream, IL: Quintessence Pub­lishing; 1996:207-228.
  20. Magne P, Holz J. Stratification of composite restorations: Systematic and durable replication of natural aesthetics. Pract Periodont Aesthet Dent 1996;8(1):61-68.
  21. Ferracane JL. Materials in Dentistry. Principles and Applications. Philadelphia, PA: Lippincott; 1995:88-102.
  22. Carvalho RM, Pereira JC, Yoshiyama M, Pashley DH. A review of polymerization contraction: The influence of stress development versus stress relief. Oper Dent 1996;21(1):17-24.
  23. Bryant RW, Mahler DB. Modulus of elasticity in bending of composites and amalgams. J Prosthet Dent 1986;56(2):243-248.
  24. Talib R. Dental composites: A review. J Nihon Univ Sch Dent 1993;35(3):161-170.
  25. Cvitko E, Denehy GE. Utilization of composite resins and direct bonding following periodontal treatment. Pract Periodont Aesthet Dent 1993;5(4):33-38.
  26. Willems G, Lambrechts P, Braem M, Vanherle G. Composite resins in the 21st century. Quint Int 1993;24(9):641-658.
  27. Baratieri NM, Ritter AV, Baratieri LN. Interproximal caries lesion diagnosis in posterior permanent teeth: A comparison of radiographic and clinical examination with and without tooth separation. São Paulo, SP: Anais do V World Congress on Preventive Dentistry; Julho/1994, #20:50.
  28. Pitts NB. Regression of approximal carious lesions diagnosed from serial standardized bitewing radiographs. Caries Res 1986;20(1):85-90.
  29. Craig RG, ed. Dental Restorative Materials. 8th ed. St. Louis, MO: Mosby; 1989:262.
  30. Pitts NB. Diagnostic tools and measurements. Impact on appropriate care. Community Dent Oral Epidemiol 1997;25(1):24-35.
  31. Kidd EA, Joyston BS, Beighton D. The use of a caries detector dye during cavity preparation: A microbiological assessment. Br Dent J 1993;174(7):245-248.
  32. Moore DH, Vann WF. The effect of a cavosurface bevel on microleakage on posterior composite restorations. J Prosthet Dent 1988;59(1):21-24.
  33. Leinfelder KF. Changing restorative traditions: The use of bases and liners. J Am Dent Assoc 1994;125(1):65-67.
  34. Stanley H, Swerdlow H, Stanwich L. A comparison of the biological effects of filling materials with recommendations for pulp protection. Am Acad Gold Foil Ops 1967;12:56-62.
  35. Bayne SC, Heymann HO, Swift EJ. Update on dental composite restorations. J Am Dent Assoc 1994;125(6):687-701.
  36. Pashley DH. Dynamics of the pulpo-dentin complex. Crit Rev Oral Biol Med 1996;7(2):104-133.
  37. Sockwell CL, Heymann HO. Tooth-colored restorations. In: Sturdevant CM, Barton RE, Sockwell CL, Strickland WD, eds. The Art and Science of Operative Dentistry. St Louis, MO: Mosby; 1985:295.
  38. Sübay RK, Asci S. Human pulpar response to hydroxyapatite and a calcium hydroxide material as direct capping agents. Oral Surg Oral Med Oral Pathol 1993;76:485-492.
  39. Cox CF, Suzuki S. Re-evaluating pulp protection: Calcium hydroxide liners vs. cohesive hybridization. J Am Dent Assoc 1994;125(7):823-831.
  40. Goracci G, Mori G. Scanning electron microscopic evaluation of resin-dentin and calcium hydroxide-dentin interface with resin composite restorations. Quint Int 1996;27(2):129-135.
  41. Cox CF, Bergenholtz G, Heys DR, et al. Pulp capping of dental pulp mechanically exposed to oral microflora: A 1- to 2-year observation of wound healing in the monkey. J Oral Pathol 1985;14:156-168.
  42. Snuggs H, Cox C, Powel C, White K. Pulpal healing and dentinal bridge formation in an acidic environment. Quint Int 1993;24(7):501-510.
  43. Bergenholtz G, Cox CF, Loesche WJ, Syed SA. Bacterial leakage around dental restorations: Its effect on the dental pulp. J Oral Pathol 1982;11(6):439-450.
  44. Cox CF, Keall C, Keall H, et al. Biocompatibility of surface-sealed dental materials against exposed pulps. J Prosthet Dent 1987;57(1):1-8.
  45. Cox CF, Sübay RK, Suzuki S, et al. Biocompatibility of various dental materials: Pulp healing with a surface seal. Int J Periodont Rest Dent 1996;16(3):240-251.
  46. Johnson GH, Gordon GE, Bales DJ. Postoperative sensitivity associated with posterior composite and amalgam restorations. Oper Dent 1988;13(2):66-73.
  47. Suzuki M, Jordan RE, Boksman L. Posterior composite resin restorations: Clinical considerations in posterior composite resin dental restorative materials. Vanherle G, Smith, eds. St. Paul, MN: 3M Co.;455-464.
  48. Pereira JC, Manfio AP, Franco EB, Lopes ES. Clinical evaluation of Dycal under amalgam restorations. Am J Dent 1990;3:67-70.
  49. Brännström M. Sensitivity of dentine. Oral Surg Oral Med Oral Pathol 1966;21(4):517-526.
  50. Mount GJ. An Atlas of Glass-Ionomer Cement, Martin Dunitz, 1994:150.
  51. Baratieri LN, Monteiro JS, Andrada MAC, et al. Esthetic-Direct Adhesive Restorations on Fractured Anterior Teeth. Carol Stream, IL: Quintessence Publishing; 1998:397.
Sorry, your current access level does not permit you to view this page.