d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 1–10

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.intl.elsevierhealth.com/journals/dema

Polymerization stress – Is it clinically meaningful?

Jack L. Ferracane ∗ , Thomas J. Hilton

Department of Restorative Dentistry, Oregon Health & Science University, Portland, OR 97201, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objectives. The objective of this article is to discuss the evidence for polymerization shrinkage
Received 17 June 2015 and shrinkage stress of dental composite restoratives in terms of its potential relevance to
Accepted 30 June 2015 the clinical situation
Methods. Articles relating to the issue of polymerization contraction stress generation in
dental composite materials, and the factors that influence it, were reviewed and included.
Keywords: Particular attention was paid to evidence derived from clinical studies. Articles were iden-
Dental composite tified through PubMed and through the bibliographies of other articles.
Polymerization shrinkage Results. There is extensive evidence for the presence of polymerization contraction stress in
Contraction stress dental composites, as well as evidence for its deleterious effects, which include marginal
Clinical leakage, gap formation, cuspal deflection, tooth cracking, reduced bond strength and low-
Properties ered mechanical properties of the restorative. There is little, if any, direct evidence for the
clinical effect of these contraction stresses. No study has directly established a link between
these stresses and enhanced postoperative sensitivity or recurrent caries, for example. How-
ever, the concern over these stresses and the manner in which they influence the placement
of current composite materials demonstrates that they are considered to be very important.
Conclusion. Though no direct evidence exists to prove that the generation of contraction
stress in dental composite restorations causes reduced clinical longevity, the indirect evi-
dence from numerous in vitro studies and the concern over controlling their effects proves
that they are clinically relevant.
© 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

to provide restoration resistance and retention form allows

1. Introduction for a minimal intervention approach, providing another sig-
nificant advantage by conserving tooth structure [2]. However,
Dental composites are the most frequently used direct restor- the longevity of composite restorations, as well as the durabil-
ative materials and have become the first choice of a majority ity of the composite material itself as a tooth replacement, is
of practitioners world-wide for the restoration of posterior often questioned. Many believe that the most serious issue
teeth [1]. The primary reason for this ascent from its introduc- with dental composites is the fact that the polymerization
tion to dentistry approximately 50 years ago is mostly related reaction is accompanied by a volumetric shrinkage that gen-
to esthetics. The importance of the ability to replace lost or erates stress within the material and leads to compromised
damaged tooth structure in a convenient and cost effective adhesion to the tooth and a poor seal of the restoration.
manner, and with an excellent esthetic outcome, cannot be Clinical studies vary widely in terms of the success rate
overstated. In addition, the ability to use adhesive dentistry for composite restorations, and proponents and detractors

∗
Corresponding author. Tel.: +1 503 494 4327.
E-mail addresses: [email protected] (J.L. Ferracane), [email protected] (T.J. Hilton).
http://dx.doi.org/10.1016/j.dental.2015.06.020
0109-5641/© 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
2 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 1–10

alike often use essentially the same data to support their

difference
Statistical
opinions. Recent efforts by the National Institute for Den-

Yes
Yes

Yes

Yes
Yes
Yes

Yes

Yes

Yes
tal and Craniofacial Research of the National Institutes of

No

No

No

No
Health in the U.S. have targeted the development of new dental
composite restoratives with enhanced service life, specifi-

Comp: 7.8 years, am 12.8 years,

cally requesting that new materials double the longevity of

Comp 16.4% risk vs. am/year

Comp 64% risk vs. am/3 year

current materials. To justify these initiatives, NIDCR docu-

AFR: am: 2.1%, comp: 1.8%

AFR: am: 2.4%, comp: 1.7%
AFR: am: 2.2%, comp: 2.9%
AFR: am: 0.8%, comp: 2.7%

AFR: am: 2.4%, comp: 1.7%

ments point to an average lifetime of 6–7 years for dental

am: 0.35%, comp: 3.6%

am: 1.6%, comp: 2.9%

composite restorations [3]. While it is important to note that

Outcome

crowns: 14.6 years

reviews show that many clinical studies report much greater

Overall AFR: 3.1%

Comp: 5 years,
longevity for these materials [4], there is significant evidence

Comp: 6 years

am 8.7 years
am 16 years
for this relatively short lifespan for composites [5,6]. Fur-
ther, even with evidence that composites may have similar
service life as dental amalgam, composite failure due to caries
is typically higher than for amalgam [7]. The longevity of
both composite and amalgam is reduced in patients with
high caries risk status [4,5], but the effect is more signifi-

1 (early failures)
cant for composites [8]. An extensive review of clinical studies

Avg 2.8 years

Duration
in which dental composite and amalgam have been directly
compared shows that while one retrospective, single-practice
study reported improved longevity for composite vs. amal-

N/A

N/A

N/A
4.6
18

10
12
7

5
7
3

2
gam, the preponderance of clinical evidence demonstrates the
overall enhanced longevity of amalgam restorations (Table 1).
This conclusion is supported by a recent Cochrane review in

912 am, 1955 comp

1202 am, 747 comp
772 am, 115 comp,
# Restorations

which the odds ratio for failure of composite over amalgam

was nearly 2:1, with the increased risk for composite being

2318 comp

3286 comp
due to secondary caries; admittedly the evidence was consid- 89 crowns

138 comp

485 comp
1619 am,
300, 753

184 am,

131 am,

565 am,
ered weak due to the limited number of acceptable studies [18].
Table 1 – Clinical studies comparing the longevity of posterior composites and amalgams.

1262
1748
2780
3140

6218
Thus, the general consensus is that dental composite restora-
tions do not last as long as the profession desires, or perhaps
even consider acceptable. The latter statement accounts for
the fact that some dentists still hesitate to embrace this mate-
Teens (Portugal)
Dental school

Dental school

Dental school
rial for routine direct restoration of posterior teeth in their
Public health

Public health
Teens (USA)
Setting

practice.
Military

Military
Private

Private
Private

The question that then becomes of critical importance is

PBRN
why do dental composite restorations not demonstrate greater
longevity? To address this question, it is important to clarify
the reasons for replacement and failure of these materials.
There is a distinction between these two terms, and this has
Prospective-observational,
been clarified for dentistry many years ago. It is likely that non-random, volunteer
many restorations that may still be serviceable are replaced,
Study type

and for a variety of reasons, perhaps even because it is difficult

to determine their true quality [19]. For example, decay around
Retrospective

Retrospective
Retrospective

Retrospective

Retrospective

Retrospective
Prospective

Prospective
X-sectional

X-sectional

restorations is often difficult to confirm without removal of

the existing restoration to visualize the actual state of the
RCT
RCT

tooth. Stained margins, gaps at margins, fractured margins,

and other obvious deficiencies, possibly with or without the
presence of symptoms, may leave the dentist with a dilemma
about the need for immediate treatment to prevent greater
Year

2002
2003

2007
2010
2007
2007
2009
2009

2012

2012

2013

2013

2014

problems at a later date [20]. In any case, these conditions are

most likely related to a deterioration of the restoration with
time. But the existence of a deficiency at the time of placement
Sunnegårdh-Grönberg [5]
Van Nieuwenhuysen [10]

cannot be ruled out either. What is known is that the pri-

mary reason for replacement of dental composite restorations,
even in recent studies, is caries associated with the restoration
McCracken [16]

[5,11,12]. Whether this is a recurrence of the original caries or

Laccabue [17]
Bernardo [12]

Kopperud [6]
Simecek [13]

Overton [14]
Soncini [11]
Bogacki [9]

Opdam [7]
Opdam [8]

a new caries lesion formed specifically due to the presence of

Rho [15]

the restoration (i.e. secondary caries) may be a matter of dis-

Study

cussion and debate. Composites also fail due to chipping or

fracture of the material, fracture of the tooth, discoloration,
 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 1–10 3

and excessive wear. All point in full or in part to deficiencies

in the material or the placement technique.
While an initial deficiency is most likely a problem of
technique [21], the fact remains that in many cases it is the
characteristics of the material that influence the manifesta-
tion of this deficiency. This problem pertains to the “technique
sensitivity” of dental composites, a phenomenon that has
been related to their handling characteristics, shrinkage dur-
ing polymerization, limited depth of cure, and requirement to
be bonded to the tooth with a separate adhesive while incor-
porating meticulous isolation. Another potential problem is
that amalgam, a material with a long history of use and famil-
iarity, and admittedly a more forgiving placement procedure,
preceded composite as the most common direct placement
Fig. 1 – Schematic showing crack formation within enamel
restorative material. This, and initial hesitance on the part of
and delamination at margin of dental composite
dental schools to embrace the materials and provide adequate
restoration and enamel.
training, prolonged the time it has taken for many clinicians
to become comfortable with composites as a direct poste-
rior material [20]. The two main problems focused on by the
profession are the polymerization shrinkage occurring during fact is that this reaction produces internal stress that can-
curing and the need for bonding. The two are directly related in not adequately be relaxed, either by changes in the molecular
that high initial bond strengths would likely not be required structure within the composite or by deformation at its free
to produce a sealed interface if the materials did not shrink surfaces. Thus, these stresses are transferred to the bonded
during curing. This article will focus on this issue of polymer- interfaces with the tooth structure creating delamination or
ization shrinkage and its accompanying stress, in terms of its tooth fracture whenever and wherever the localized stress
potential relevance to the clinical situation. exceeds the adhesion strength or the strength of the adjacent
residual tooth structure [32–34]. Furthermore, these stresses
may increase with time, causing delayed damage to cavity
2. Polymerization shrinkage stress – the margins [35].
phenomenon It may be stated that it took many years of work by dental
researchers highlighting the potential significance of polymer-
In recent years, dental manufacturers have tried to address ization shrinkage stress to influence manufacturers to develop
the deficiencies in dental composite restoratives through the composites with lower polymerization stress. Consider that
development of enhanced dental bonding agents and com- what may have been the first article highlighting this phe-
posites with reduced shrinkage, or reduced shrinkage stress. nomenon of curing stress was published by Bowen in 1967
The ideal dental composite would undergo zero, or at least [36]. But it was not until the series of studies conducted by
low, shrinkage during setting. Zero shrinkage would ensure Davidson and Feilzer in Amsterdam during the mid-1980s
that the material remained physically adjacent to the tooth [37,38] that refocused attention on this issue. These studies
surface if originally placed there, with no subsequent dimen- set the stage for what may be described as a deluge of inves-
sional change if the material itself did not absorb water with tigations into this phenomenon that followed for more than
time. However, the typical dimethacrylate monomers used in two decades. However, possibly the first composites marketed
commercial composites do take up water [22], and therefore, as having low shrinkage (Aelite LS, Bisco; Filtek LS, 3M ESPE;
it may be beneficial overall for there to be some contraction InTen-S, Ivoclar Vivadent), were not introduced to the market
of the composite, at least those based on current monomers, until approximately the mid-2000s, despite the fact that sig-
that will be subsequently compensated by a delayed expan- nificant research was being conducted on the development of
sion during service. In any case, the production of composites alternative monomer systems throughout the 1990s [39–42].
with low shrinkage, often stated as being less than 1.0% by What is considered to be high shrinkage stress for dental
volume, has been a goal of manufacturers for many years. composite? The answer is likely any stress that approaches
But the true concern regarding curing shrinkage, which is or exceeds the local adhesive force or residual tooth struc-
inevitable due to the nature of the vinyl polymerization involv- ture strength, resulting in gap formation. However, residual
ing reductions in intermolecular dimensions and free volume, stresses that remain within the restoration apply continual
is the internal stress created within the material [23–25]. This force on the adhesive interface with the tooth, and may further
stress is a product of the constraint of the free shrinkage of the degrade that interface during function leading to debonding or
polymer, and is dependent upon a number of factors, includ- damage at a later date. The end result of all of these stresses is
ing the size and nature of the monomers, the acquisition of localized or generalized delamination, either at the interface
stiffness of the material during polymerization, the rate of the or at some point distant to the interface if the stress results
reaction, and the external constraints imposed by the bond- in tooth fracture (Fig. 1), which has been implicated as a pri-
ing to the tooth. The many factors involved in the evolution mary factor leading to the formation of caries around dental
of these stresses have been the subject of many comprehen- composite restorations. The question is, “Does the evidence,
sive reviews and will not be readdressed here [26–31]. The either in vitro or in vivo, support this hypothesis?”
4 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 1–10

3. Polymerization stress – in vitro evidence

Numerous laboratory studies have been conducted to eval-

uate the potential negative effects of contraction stress by
examining marginal leakage, gap formation, cuspal deflection,
bond strength, tooth cracking, and mechanical properties of
the restorative. Typically these studies have incorporated sit-
uations in which stress is expected to be a significant factor,
i.e. constraint of free resin shrinking by a confining 3-D cav-
ity preparation, rapid curing protocols, and bulk placement of
“non-bulk-fill” materials. While there are inconsistencies in
the outcomes of different studies, there is significant evidence Fig. 2 – Gap formation at the pulpal floor of a dental
that higher contraction stresses lead to a greater incidence of composite restoration as a result of polymerization
problems. Following is a review of some of these studies and contraction in the absence of adequate adhesion.
the extent to which they support the case for the deleterious
effects of stress.
Many studies were conducted throughout the past 30 years strength at this margin produces a more perfect seal. It is also
or more to establish that stress is produced during the poly- true that when stress builds up within the curing material, it
merization reaction of dental composite, and other dental will tend to be relieved at the more vulnerable dentin interface
materials. A quick search of PubMed with the terms “dental and remain sealed with the enamel interface. Thus it would
composite polymerization shrinkage stress” returns 362 arti- be surprising to find a situation where a restoration margin
cles spanning 1977 to the present. These studies show that demonstrated total debonding or leakage as a result of con-
the magnitude of the generated stress depends on a num- traction stress, and rather, such an occurrence would most
ber of factors, such as monomer composition and extent of likely be due to inadequate adhesion (Fig. 2).
cure [43], filler amount and stiffness [44], external and inter- It is possible that the interface may remain bonded, due to
nal constraint of polymer deformation [38,45], curing method adequate adhesion forces, but continue to exist in a state of
[46], etc. Others have attempted to explain the relative contri- stress from the polymerization contraction. This would likely
bution of the different factors when the materials are placed only be evident in situations where the curing composite is
within cavity preparations differing in compliance [47,48]. Cer- under significant constraint imposed by the adhesion to the
tain studies have been conducted to probe specific aspects that walls of a three-dimensional cavity, as described many years
relate to the effect, rather than the simple presence or causes, ago and characterized by the configuration factor (C-factor)
of these stresses. [38]. It has been shown that the C-factor alone cannot be used
The most obvious concern with respect to the polymeriza- to predict contraction stresses for a given material, and other
tion shrinkage stresses is the detrimental effect on marginal factors, such as the volume of the material also may have
integrity and seal of the composite restoration to the tooth. a significant effect [60,61]. But studies in which composite
Numerous studies show that even when attempting to bond has been placed within preparations and then either pushed
the material to a cavity preparation, the marginal seal is typ- out or sectioned to test adhesion have shown reduced bond
ically compromised, resulting in marginal gaps, stains, or strength under conditions of greater constraint, suggesting
leakage [49,50]. This deficiency remains true even with cur- that the higher stresses negatively affected the bonds [62–67].
rent “improved” adhesive systems [51–53]. In fact most in vitro This outcome is consistent with the evidence already noted
leakage studies have shown that dental composites do not for unsealed margins around composite restorations.
provide a perfect seal to either enamel or dentin, independent Studies have also been conducted to measure the stress
of bonding or placement method [54]. This leakage has been produced during composite contraction by actually measur-
described as occurring on the nano-, micro-, and macro-scale, ing the propagation of cracks in tooth structure and dental
but the most important observation may be the fact that it sim- ceramics. A popular, though somewhat controversial, method
ply happens at all, and the true clinical consequence of it is for measuring the fracture toughness of a ceramic is through
not entirely clear. In any case, there is evidence that materials microindentation. Cracks propagating from the tips of the
that demonstrate reduced contraction stress produce better indent can be used to relate the resistance of the material
marginal seal and less leakage [55]. to such propagation, i.e. a measure of its fracture tough-
Experiments have been conducted to show a direct cor- ness. Likewise, cracks propagating from existing cracks may
relation between enhanced leakage and higher contraction be used to demonstrate that stresses have been produced,
stress for different brands of composites [56,57]. These studies as well as their magnitude. This method has been used to
provided a physically observable outcome for the stress that show that stress generated by a curing composite in a 3-
had been proven to exist in dental composites, and made the dimensional cavity are greatest closest to the margin and
concept of stress generation more “clinically relevant” to the result in propagation of existing cracks [32]. This outcome
practitioner and researcher alike. In most studies involving the suggests that brittle enamel at margins may be subjected to
placement of composite in preparations with margins in both cracking under the influence of composite contraction stress.
enamel and dentin, sealing is typically better to acid-etched Studies using this method have shown more extensive crack-
enamel [58,59], suggesting that the presence of a higher bond ing for direct placement composites vs. cemented inlays [68]
 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 1–10 5

and for larger restorations, i.e. larger volumes of composite for a link between contraction stress and clinically relevant
[69], and less extensive cracking with some lower shrinkage outcomes, they do not confirm it.
composite formulations [70]. This cracking in the tooth struc-
ture has also been related to the formation of “white lines”
around just cured dental composite restorations in the clin- 4. Polymerization shrinkage stress –
ical setting, which are especially apparent when the tooth clinical evidence
surface is dried due to the highlighting of the discontinuity
within the enamel or at the interface caused by the crack The purpose of this section is to present the evidence for
[71,72]. the potential effects of polymerization shrinkage stress on
Further evidence for the effect of stress has been gener- the clinical performance of dental composite restorations. It
ated by studying the mechanical properties of composites should be stated from the start that there is no direct clin-
cured under conditions of high constraint. Flexure strength ical evidence for this association. No clinical study, either
and modulus has been shown to be reduced under these randomized prospective or retrospective, has been conducted
conditions in specimens that were cut from a construct that to directly evaluate whether high shrinkage stress produces
provided strong adhesion to the walls to ensure high con- reduced longevity of dental composite restorations. Based on
traction stress conditions [63,73,74]. It is not known whether this deficiency in information, one must rely on studies that
the reduced strength and stiffness of the material resulting provide indications of clinical outcomes that may be related
from the residual stresses remaining in the composite after to stress effects on restorations. These outcomes may be loss
curing produces clinically relevant outcomes. But as stated of retention, marginal caries, marginal gaps, marginal stain-
earlier, it is likely that the residual stresses would be reduced ing, fracture of the material (due to the presence of internal
as water sorption occurs, providing an enhanced environment stresses), fracture of the tooth (due to compromised bond-
for polymer molecular motions to relieve the stresses, thus ing and support), and post-operative sensitivity. Considering
negating concerns over time. Perhaps the negative effects on these outcomes and the data available at the time, Sarrett
bond strength are of greater concern. in 2007 [20] concluded that “It appears doubtful that elim-
Some investigators have studied the direct effect of inating polymerization shrinkage would have much effect
polymerization contraction on cuspal flexure of mesial- on decreasing secondary caries risk.” This conclusion was
occlusal-distal cavity preparations, showing greater flexure largely based on the fact that there little correlation could be
when composites are very well cured using bulk-cure vs. incre- found between marginal quality and clinical success of dental
mental placement techniques [75–77], and reduced flexure restorations, in large part due to the overriding effects of oral
when certain flexible liners are placed [78]. A criticism of some hygiene and the bacterial composition of plaque at restoration
of these studies is the amount of illumination time used to margins on secondary caries.
ensure complete cure of the composite, which would be con- There are numerous clinical studies that cite secondary
sidered to be excessive clinically, and leading to unrealistically caries as the main reason for replacement of dental composite
high extents of cure that produce greater contraction stress restorations, with fracture of the material being second [4]. In
and more deleterious effects. While this creates some uncer- a recent review by Demarco et al. [84], it was suggested that
tainty about the clinical relevance of the outcomes, the effect in shorter term studies, the primary reason cited for failures
of the contraction stress, independent of how it was achieved, was secondary caries, but that in long term studies, beyond
remains. Other studies have more recently shown that some 10 years, more failures occurred due to fracture. This would
commercial composites specifically designed to have reduced be an interesting result, but may not be supported by others.
polymerization contraction and/or stress produce less delete- For example, Brunthaler reviewed clinical studies published
rious outcomes on marginal adaptation or cuspal deflection between 1996 and 2002 and concluded that in the early evalu-
[77,79–81]. ation times, i.e. from 0 to 5 years, failures were primarily due
Some evidence against the effect of contraction stress to fracture of the composite, followed by caries, and between
has been generated when examining models of polymeriza- 6 and 17 years, the predominant reason for replacement was
tion of composites in preparations using the finite element caries [85]. In the most recent systematic review of studies at
model or other mathematical models. Certain studies do not least four years long, the authors concluded that follow-up of
show enhanced negative effects, such as cuspal deflection, restorations was critical because secondary caries continued
when placing composites with equivalent curing characteris- to occur after three years [86]. This view was essentially sup-
tics in bulk, where stresses would be expected to be greater ported in the study by Opdam [4], in which fracture seemed to
than when placed incrementally [82,83]. These results are be a constant reason for failure, but caries increased over at
explained by the incremental deformation of the cavity walls least the first six years of studies.
with the curing of each successive composite increment, Logically, one would expect that the effects of polymeriza-
thereby reducing the total volume of composite required to tion shrinkage and shrinkage stresses would be manifested
fill the cavity. The result is higher residual stress than if the earlier for a material that is incapable of sealing its own
composite was placed and cured in bulk. marginal defects, in contrast to a corroding amalgam or a
Taking all of this work into consideration, there is signifi- material with anti-microbial characteristics. In other words,
cant in vitro evidence that polymerization contraction stress the composite has no defense mechanism for mitigating the
in resin dental composite materials produces negative out- dangers of marginal discrepancies. Therefore, the early fail-
comes. There are sufficient controlled studies to demonstrate ures of composites that result from the formation of secondary
this directly. Though these studies provide further evidence caries provide circumstantial evidence for the effects of
6 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 1–10

excessive stresses compromising the adhesion to the tooth, failure due to secondary caries does not negate the possibility
thus providing sites for bacteria to either invade a gap to form that stress is a contributor for composites.
wall lesions, or at least colonize the surface near the mar- Most of the potential clinical manifestations of stress can
gin and produce demineralization of adjacent tooth structure, be negated by the presence of excellent adhesion to the tooth
i.e. new caries associated with a defective restorative mate- structure, thus providing an impervious seal. Such a seal
rial seal. In general, restorations most at risk are class IIs with would not eliminate the formation of new lesions on the
deep gingival margins, extending into areas that are difficult to surface near the margins, but the presence of a smooth, unin-
clean, and possibly onto dentin, which is much more quickly terrupted cavosurface margin would likely reduce the ability
demineralized under a bacteria-acid challenge than enamel. of bacterial biofilms to form as they would be more easily
The problem with this interpretation of caries at the gingival cleansed. Thus, it becomes difficult to separate the effects
margin is determining whether the material formed an ade- of contraction stress and inadequate bonding. The two are
quate seal from the start, i.e. was placed in close adaptation directly related. As stated above, studies have shown that
to the tooth to facilitate bonding, or if the forces of contrac- composites generating high contraction stresses, either due to
tion produced an interfacial delamination. The latter would their formulation or to external cavity constraints, have poorer
not be surprising as it is typically more difficult to bond to this adhesion to the tooth. Because it is not possible to ensure per-
tissue near the gingiva due to difficulties with isolation and fect adhesion under all conditions, one must attribute these
access. failures to the contraction stress. In its absence, the gaps
It is true that a bonded margin may be subject to degrada- would likely never occur, unless there is contamination dur-
tion with time, and that this would enhance the probability of ing bonding or improper adhesive technique. There is clinical
experiencing marginal caries at some later date. It would not evidence for stained margins in dental composite restora-
be appropriate to conclude that recurring caries lesions can tions, even in the absence of caries [20], and it is tempting
only occur within the first months or years after placement. to attribute these “gaps” to the effects of contraction stress.
While the effects of contraction stress would not be expected In many cases these defects can be easily resolved by pol-
to be present after the first few months of tooth restoration, ishing or remarginating, and do not lead to caries. However,
when the composite has essentially become saturated with loss of retention of composites in class V lesions was the
water and has relieved any residual internal stresses, the long- de facto method for measuring success in clinical studies,
term effects of the initial debonding would be ever present, and the rate of loss was much higher before improved den-
and could be manifest at some later date. In this case, it is tal adhesives were introduced to the market [92]. Again, if the
likely that subsequent failure due to recurrent caries would material did not shrink and produce stresses on the interface,
likely be directly related to patient factors, as has been con- it is unlikely that the composite would be lost from the cavity
cluded by others [4]. preparation unless there was essentially no adhesion present.
The association of failure due to polymerization stress However, in the presence of a stress challenge, the magnitude
effects leading to recurring caries around composite restora- of the adhesive forces becomes more critical and inadequate
tions is also challenged by an important observation from adhesion is more readily apparent. Further evidence to sup-
clinical studies on other dental materials, such as amal- port this contention is the result obtained clinically with
gam and glass ionomer, in which the primary reason for glass ionomer materials, which have generally shown better
replacement of these alternative restorations is also sec- marginal seal and retention in class V restorations [93,94] than
ondary caries [21,87]. Composites, including compomer, glass adhesive-retained composites. While glass ionomers generate
ionomers, resin-modified glass ionomers, and amalgam all contraction stress, they also establish an immediate adhesion
undergo some level of shrinkage during setting. Only amal- to tooth structure during setting and undergo relatively rapid
gam is not typically bonded to the cavity preparation with an stress relief due to water sorption [95]. In addition, the creation
adhesive or through its own chemical interactions, as with of internal failures within glass ionomer, rather than exter-
the glass ionomers. Therefore, if not bonded, all materials nal delaminations, may lead to relief of contraction stress and
would be expected to form marginal gaps that could lead to overall enhanced marginal adaptation.
failure due to caries in susceptible patients. It is true that Studies showing reduced clinical longevity for composites
the setting of amalgam should not result in internal stresses, known to produce high stresses during curing would provide
especially in that it is not bonded to the cavity and is there- evidence for the association between the two. One long-term
fore free of external constraints. In addition, amalgam likely clinical study showed a higher failure rate due to secondary
possesses certain antimicrobial effects that might stall bacte- caries and loss of class II restorations for one commercial com-
rial invasion into gaps [88–90], at least until corrosion helps posite, Z100 (3M ESPE), as compared with three others (Tetric
to seal these margins. This may be the reason that amal- Ceram, Ivoclar Vivadent; Herculite XRV, Kerr; Filtek Z250, 3M
gams, while imperfect in initial marginal seal, demonstrate ESPE); and this tended to be associated with the use of a par-
superior longevity than dental composites in clinical stud- ticular adhesive material [6]. Of note is the fact that this same
ies, especially for patients with high caries risk. Based on a composite used with another adhesive, Scotchbond Multipur-
potential for antibacterial properties from fluoride release in pose (3M ESPE) showed an excellent performance after four
glass ionomers [91], one would expect these materials to be years in another study [96], providing further evidence that the
more resistant to secondary caries, but this is not the case, problems in the Kopperud study were due to a specific adhe-
likely because the amount of fluoride release is insufficient sive deficiency. In in vitro studies, Z100 composite has been
to totally inhibit bacterial colonization and biofilm formation. shown to produce relatively high polymerization contraction
In any case, the fact that all of these materials demonstrate stresses in comparison to other composites [44]. While the
 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 1–10 7

failures in the Kopperud study, which were predominantly Practitioners often relate empirical accounts of the small
due to caries, were likely related to inadequate bonding, it occlusal lesion filled with composite that caused significant
is difficult to dissociate this from the fact that virtually all post-op pain for the patient. Upon removal from the tooth,
of the failures that occurred when this adhesive was used and often with the placement of a glass ionomer liner on the
were in association with this composite. However, it should pulpal floor, the pain is resolved. Perhaps the lack of perfect
be noted that there are studies of varying duration in which bonding to the entire pulpal floor leaves a gap under the com-
this particular composite was compared with others and did posite when polymerization stress caused the material to be
not show a higher failure rate [97–99], as well as one in lifted from the floor (Fig. 2). This gap fills with pulpal fluids,
which the performance of Z100 was superior, largely because and when occlusal forces are applied, the composite, hav-
two other composites failed more frequently due to fracture ing relatively low modulus compared to the original enamel
[100]. Another interesting piece of circumstantial evidence or a dental amalgam, deforms, forcing the fluids back down
regarding the performance of Z100 is the higher incidence the tubules, stimulating the tooth. The presence of a liner of
of marginal chipping/fracture that has been reported some- glass ionomer seals the pulpal floor to avoid this phenomenon.
what anecdotally, and in some cases corroborated by a slightly Again, in the presence of adequate adhesion throughout the
greater discoloration seen in clinical studies for this material cavity preparation, the problem is ameliorated. A recent meta-
as compared to others [101]. A similar marginal deterioration analysis reported that composite restorations placed with
of Z100 during wear testing has been shown in an in vitro study rubber dam and with acid-etching, two conditions expected to
designed to assess this phenomenon for six dental compos- enhance adhesion to the entire tooth structure, demonstrated
ites bonded to enamel [102]. Again, is it possible that stresses the best results [1]. Perhaps it is mainly in the cases with less
at the cavosurface margin led to a compromised bond that than ideal bonding where specific problems arise that can be
degraded over time? attributed to the phenomenon of contraction stress.
The rapid formation of a polymer network with high stiff-
ness due to the rapid kinetics of light activated resin curing has
been associated with negative effects of contraction stresses 5. Conclusion
[103], leading to the development of methods for reducing the
curing rate. Such “soft-start” curing methods, such as step- The relationship between polymerization contraction stress in
cure [104], ramp-cure [105,106], and pulse delay cure [107,108], dental composite restoratives and clinical outcomes seems so
have been shown to reduce contraction stress under certain obvious that many have taken it as a matter of fact, despite the
conditions. There is little clinical evidence to support these reality that very little clinical proof for it exists. There appears
methods as offering an improvement over more conventional to be reasonable in vitro evidence for the negative effects
continuous light curing protocols. In one study in which den- of contraction stress on marginal discrepancies, leakage, and
tal composite was placed with a modified “soft-start” curing staining, reduced bond strengths, reduced mechanical proper-
method, with and without a potentially stress relieving liner ties, and tooth deformation. In a court of law, perhaps the best
in high C-factor, class I cavities, the success rate was very good term for what currently exists to establish this link would be
and post-operative sensitivity and secondary caries incidence “circumstantial evidence”, the value of which may lay in the
was very low up to 12 years [109]. The author suggested that mind of the juror, or in this case, the researcher or clinician.
the excellent outcomes obtained cast doubt on the influence It would seem to go without saying that the ideal situation
of the C-factor, and therefore stress, in the clinical situation. for dental composite restorations would involve an absence
However, one might also conclude that the excellent outcomes of significant stress generation during curing. As this is as
resulted from the efforts to reduce or minimize stress by the yet an unattained goal, it would seem to be prudent dur-
curing methods used. ing application to continue to accommodate the material’s
It has been hypothesized that a polymer with reduced con- inadequacies by striving to achieve optimal bonding involving
traction rate, such as a self-cure composite, would generate appropriate isolation of the preparation, logical incremen-
less stress due to a slower curing rate that provides more tal placement techniques as indicated for specific materials,
time for molecules to relax stresses during cross-linking [108]. appropriate curing protocols that minimize stress produc-
In fact, dual-cure resin composite cements have been shown tion, and perhaps the prudent use of bulk-fill materials as
to have reduced contraction stress in vitro when allowed to more supportive data is generated. Considering the extent to
self-cure as opposed to being light-activated first, the latter which this phenomenon has influenced the manner in which
producing a faster cure [110]. Again, there is no evidence for these materials are manipulated in the oral environment, it
an improved clinical outcome, perhaps in part due to the fact seems logical to conclude that polymerization contraction
that most controlled studies with dental composites and resin stress of dental composite restoratives is absolutely clinically
cements show fairly good outcomes. In addition, it appears meaningful.
that the final contraction stress is more a function of overall
extent of cure than curing rate [111].
Another manifestation of contraction stress in dental com- references
posite restorations is postoperative sensitivity. It is interesting
that the incidence of postoperative sensitivity in controlled
clinical trials is typically very low, as is the overall failure rate. [1] Heintze S, Rousson V. Clinical effectiveness of direct class II
However, anecdotally, and as evidenced by studies [112], post- restorations – a meta-analysis. J Adhes Dent
operative sensitivity may play a role in restoration longevity. 2012;14:407–31.
8 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 1–10

[2] Lynch C, Opdam N, Hickel R, Brunton P, Gurgan S, [19] Mjor IA. Clinical diagnosis of recurrent caries. J Am Dent
Kakaboura A, et al. Guidance on posterior resin Assoc 2005;136:1426–33.
composites: academy of operative dentistry – European [20] Sarrett DC. Prediction of clinical outcomes of a restoration
section. J Dent 2014;42:377–83. based on in vivo marginal quality evaluation. J Adhes Dent
[3] NIDCR. http://www.nidcr.nih.gov/grantsandfunding/See 2007;9(Suppl 1):117–20.
Funding Opportunities Sorted By/ConceptClearance/ [21] Manhart J, Chen H, Hamm G, Hickel R. Buonocore Memorial
CurrentCC/DentalResinComposites.htm; 2009 [url accessed Lecture. Review of the clinical survival of direct and
05.30.15]. indirect restorations in posterior teeth of the permanent
[4] Opdam NJ, van de Sande FH, Bronkhorst E, Cenci MS, dentition. Oper Dent 2004;29:481–508.
Bottenberg P, Pallesen U, et al. Longevity of posterior [22] Venz S, Dickens B. NIR-spectroscopic investigation of water
composite restorations: a systematic review and sorption characteristics of dental resins and composites. J
meta-analysis. J Dent Res 2014;93:943–9. Biomed Mater Res 1991;25:1231–48.
[5] Sunnegårdh-Grönberg K, van Dijken JW, Funegård U, [23] Kinomoto Y, Torii M, Takeshige F, Ebisu S. Comparison of
Lindberg A, Nilsson M. Selection of dental materials and polymerization contraction stresses between self- and
longevity of replaced restorations in Public Dental Health light-curing composites. J Dent 1999;27:383–9.
clinics in northern Sweden. J Dent 2009;37: [24] Park JW, Ferracane JL. Measuring the residual stress in
673–8. dental composites using a ring slitting method. Dent Mater
[6] Kopperud SE, Tveit AB, Gaarden T, Sandvik L, Espelid I. 2005;21:882–9.
Longevity of posterior dental restorations and reasons for [25] Park JW, Ferracane JL. Residual stress in composites with
failure. Eur J Oral Sci 2012;120:539–48. the thin-ring-slitting approach. J Dent Res 2006;85:945–9.
[7] Opdam NJ, Bronkhorst EM, Roeters JM, Loomans BA. A [26] Carvalho RM, Pereira JC, Yoshiyama M, Pashley DH. A
retrospective clinical study on longevity of posterior review of polymerization contraction: the influence of
composite and amalgam restorations. Dent Mater stress development versus stress relief. Oper Dent
2007;23:2–8. 1996;21:17–24.
[8] Opdam NJ, Bronkhorst EM, Loomans BA, Huysmans MC. [27] Braga RR, Ferracane JL. Alternatives in polymerization
The 12-year survival of composite vs. amalgam contraction stress management. Crit Rev Oral Biol Med
restorations. J Dent Res 2010;89:1063–7. 2004;15:176–84.
[9] Bogacki RE, Hunt RJ, del Aguila M, Smith WR. Survival [28] Lu H, Stansbury JW, Bowman CN. Towards the elucidation
analysis of posterior restorations using an insurance of shrinkage stress development and relaxation in dental
claims database. Oper Dent 2002;27:488–92. composites. Dent Mater 2004;20:979–86.
[10] Van Nieuwenhuysen JP, D’Hoore W, Carvalho J, Qvist V. [29] Stansbury JW, Trujillo-Lemon M, Lu H, Ding X, Lin Y, Ge J.
Long-term evaluation of extensive restorations in Conversion-dependent shrinkage stress and strain in
permanent teeth. J Dent 2003;31:395–405. dental resins and composites. Dent Mater 2005;21:56–67.
[11] Soncini JA, Maserejian NN, Trachtenberg F, Tavares M, [30] Ferracane JL. Buonocore Lecture. Placing dental composites
Hayes C. The longevity of amalgam versus – a stressful experience. Oper Dent 2008;33:247–57.
compomer/composite restorations in posterior primary [31] Mantri SP, Mantri SS. Management of shrinkage stresses in
and permanent teeth: findings from the New England direct restorative light-cured composites: a review. J Esthet
Children’s Amalgam Trial. J Am Dent Assoc Restor Dent 2013;25:305–13.
2007;138:763–72. [32] Yamamoto T, Ferracane JL, Sakaguchi RL, Swain MV.
[12] Bernardo M, Luis H, Martin MD, Leroux BG, Rue T, Leitão J, Calculation of contraction stresses in dental composites by
et al. Survival and reasons for failure of amalgam versus analysis of crack propagation in the matrix surrounding a
composite posterior restorations placed in a randomized cavity. Dent Mater 2009;25:543–50.
clinical trial. J Am Dent Assoc 2007;138:775–83. [33] Kahler B, Swain MV, Kotousov A. Comparison of an
[13] Simecek JW, Diefenderfer KE, Cohen ME. An evaluation of analytical expression of resin composite curing stresses
replacement rates for posterior resin-based composite and with in vitro observations of marginal cracking. Am J Dent
amalgam restorations in U.S. Navy and marine corps 2010;23:357–64.
recruits. J Am Dent Assoc 2009;140:200–9. [34] Yamamoto T, Nishide A, Swain MV, Ferracane JL, Sakaguchi
[14] Overton JD, Sullivan DJ. Early failure of Class II resin RL, Momoi Y. Contraction stresses in dental composites
composite versus Class II amalgam restorations placed by adjacent to and at the bonded interface as measured by
dental students. J Dent Educ 2012;76:338–40. crack analysis. Acta Biomater 2011;7:417–23.
[15] Rho YJ, Namgung C, Jin BH, Lim BS, Cho BH. Longevity of [35] Yamamoto T, Hanabusa M, Momoi Y, Sakaguchi RL.
direct restorations in stress-bearing posterior cavities: a Polymerization stress of dental resin composite continues
retrospective study. Oper Dent 2013;38:572–82. to develop 12 hours after irradiation. J Esthet Restor Dent
[16] McCracken MS, Gordan VV, Litaker MS, Funkhouser E, 2015;27:44–54.
Fellows JL, Shamp DG, et al., National Dental [36] Bowen RL. Adhesive bonding of various materials to hard
Practice-Based Research Network Collaborative Group. A tissues. VI. Forces developing in direct-filling materials
24-month evaluation of amalgam and resin-based during hardening. J Am Dent Assoc 1967;74:439–45.
composite restorations: findings from The National Dental [37] Davidson CL, de Gee AJ. Relaxation of polymerization
Practice-Based Research Network. J Am Dent Assoc contraction stresses by flow in dental composites. J Dent
2013;144:583–93. Res 1984;63:146–8.
[17] Laccabue M, Ahlf RL, Simecek JW. Frequency of restoration [38] Feilzer AJ, de Gee AJ, Davidson CL. Setting stress in
replacement in posterior teeth for U.S. Navy and Marine composite resin in relation to configuration of the
Corps personnel. Oper Dent 2014;39:43–9. restoration. J Dent Res 1987;66:1636–9.
[18] Rasines Alcaraz MG, Veitz-Keenan A, Sahrmann P, [39] Eick JD, Robinson SJ, Byerley TJ, Chappelow CC. Adhesives
Schmidlin PR, Davis D, Iheozor-Ejiofor Z. Direct composite and nonshrinking dental resins of the future. Quintessence
resin fillings versus amalgam fillings for permanent or Int 1993;24:632–40.
adult posterior teeth. Cochrane Database Syst Rev [40] Peutzfeldt A. Resin composites in dentistry: the monomer
2014;3:CD005620. systems. Eur J Oral Sci 1997;105:97–116.
 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 1–10 9

[41] Guggenberger R, Weinmann W. Exploring beyond polymerization stress of bonded restorations as a function
methacrylates. Am J Dent 2000;13:82D–4D. of the C-Factor, volume and substrate stiffness. J Dent
[42] Palin WM, Fleming GJ. Low-shrink monomers for dental 2014;42:140–8.
restorations. Dent Update 2003;30:118–22. [62] Yoshikawa T, Sano H, Burrow MF, Tagami J, Pashley DH.
[43] Gonçalves F, Pfeifer CS, Ferracane JL, Braga RR. Contraction Effects of dentin depth and cavity configuration on bond
stress determinants in dimethacrylate composites. J Dent strength. J Dent Res 1999;78:898–905.
Res 2008;87:367–71. [63] Choi KK, Ryu GJ, Choi SM, Lee MJ, Park SJ, Ferracane JL.
[44] Condon JR, Ferracane JL. Assessing the e-ect of composite Effects of cavity configuration on composite restoration.
formulation on polymerization stress. J Am Dent Assoc Oper Dent 2004;29:462–9.
2000;131:497–503. [64] Cunha LG, Alonso RC, Pfeifer CS, Correr-Sobrinho L,
[45] Condon JR, Ferracane JL. Reduction of composite Ferracane JL, Sinhoreti MA. Modulated photoactivation
contraction stress through non-bonded microfiller methods: influence on contraction stress, degree of
particles. Dent Mater 1998;14:256–60. conversion and push-out bond strength of composite
[46] Feilzer AJ, de Gee AJ, Davidson CL. Setting stresses in restoratives. J Dent 2007;35:318–24.
composites for two different curing modes. Dent Mater [65] He Z, Shimada Y, Tagami J. The effects of cavity size and
1993;9:2–5. incremental technique on micro-tensile bond strength of
[47] Min SH, Ferracane J, Lee IB. Effect of shrinkage strain, resin composite in Class I cavities. Dent Mater
modulus, and instrument compliance on polymerization 2007;23:533–8.
shrinkage stress of light-cured composites during the [66] Van Ende A, De Munck J, Mine A, Lambrechts P, Van
initial curing stage. Dent Mater 2010;26:1024–33. Meerbeek B. Does a low-shrinking composite induce less
[48] Meira JB, Braga RR, Ballester RY, Tanaka CB, Versluis A. stress at the adhesive interface? Dent Mater 2010;26:215–22.
Understanding contradictory data in contraction stress [67] Kim RJ, Kim YJ, Choi NS, Lee IB. Polymerization shrinkage,
tests. J Dent Res 2011;90:365–70. modulus, and shrinkage stress related to tooth-restoration
[49] Hilton TJ. Can modern restorative procedures and interfacial debonding in bulk-fill composites. J Dent
materials reliably seal cavities? In vitro investigations. Part 2015;43:430–9.
2. Am J Dent 2002;15:279–89. [68] Yamamoto T, Nakamura Y, Nishide A, Kubota Y, Momoi Y.
[50] Hilton TJ. Can modern restorative procedures and Contraction stresses in direct and indirect composite
materials reliably seal cavities? In vitro investigations. Part restorations compared by crack analysis. J Adhes Dent
1. Am J Dent 2002;15:198–210. 2013;15:47–54.
[51] Atoui JA, Chinelatti MA, Palma-Dibb RG, Corona SA. [69] Braga RR, Koplin C, Yamamoto T, Tyler K, Ferracane JL,
Microleakage in conservative cavities varying the Swain MV. Composite polymerization stress as a function
preparation method and surface treatment. J Appl Oral Sci of specimen configuration assessed by crack analysis and
2010;18:421–5. finite element method. Dent Mater 2013;29:1026–33.
[52] Souza-Junior EJ, de Souza-Régis MR, Alonso RC, de Freitas [70] Yamamoto T, Kubota Y, Momoi Y, Ferracane JL.
AP, Sinhoreti MA, Cunha LG. Effect of the curing method Polymerization stresses in low-shrinkage dental resin
and composite volume on marginal and internal composites measured by crack analysis. Dent Mater
adaptation of composite restoratives. Oper Dent 2012;28:e143–9.
2011;36:231–8. [71] Christensen RP, Palmer TM, Ploeger BJ, Yost MP. Resin
[53] Krifka S, Federlin M, Hiller KA, Schmalz G. Microleakage of polymerization problems – are they caused by resin curing
silorane- and methacrylate-based class V composite lights, resin formulations, or both? Compend Contin Educ
restorations. Clin Oral Investig 2012;16:1117–24. Dent Suppl 1999;25:S42–54.
[54] Hilton TJ, Schwartz RS, Ferracane JL. Microleakage of four [72] Heintze SD, Cavalleri A, Peschke A, Schüpbach P.
Class II resin composite insertion techniques at intraoral Fluorescence microscopy for the evaluation of the margins
temperature. Quintessence Int 1997;28:135–44. of Class V restorations in vitro. J Adhes Dent 2005;7:19–28.
[55] Griffiths BM, Naasan M, Sherriff M, Watson TF. Variable [73] Nayif MM, Nakajima M, Aksornmuang J, Ikeda M, Tagami J.
polymerisation shrinkage and the interfacial Effect of adhesion to cavity walls on the mechanical
micropermeability of a dentin bonding system. J Adhes properties of resin composites. Dent Mater 2008;24:83–9.
Dent 1999;1:119–31. [74] Nayif MM, Nakajima M, Foxton RM, Tagami J. Bond strength
[56] Ferracane JL, Mitchem JC. Relationship between composite and ultimate tensile strength of resin composite filled into
contraction stress and leakage in Class V cavities. Am J dentine cavity; effect of bulk and incremental filling
Dent 2003;16:239–43. technique. J Dent 2008;36:228–34.
[57] Calheiros FC, Sadek FT, Braga RR, Cardoso PE. [75] Park J, Chang J, Ferracane J, Lee IB. How should composite
Polymerization contraction stress of low-shrinkage be layered to reduce shrinkage stress: incremental or bulk
composites and its correlation with microleakage in class V filling? Dent Mater 2008;24:1501–5.
restorations. J Dent 2004;32:407–12. [76] Kim ME, Park SH. Comparison of premolar cuspal
[58] Hilton TJ, Ferracane JL. Cavity preparation factors and deflection in bulk or in incremental composite restoration
microleakage of class II composite restorations filled at methods. Oper Dent 2011;36:326–34.
intraoral temperatures. Am J Dent 1998;11:123–30. [77] Kwon Y, Ferracane J, Lee IB. Effect of layering methods,
[59] Samimi P, Barekatain M, Alaei S. Comparison of composite type, and flowable liner on the polymerization
microleakage of composite restorations using fifth and shrinkage stress of light cured composites. Dent Mater
sixth generation dentin bonding agent: an in vivo study. J 2012;28:801–9.
Contemp Dent Pract 2012;13:632–6. [78] Alomari QD, Reinhardt JW, Boyer DB. Effect of liners on
[60] Witzel MF, Ballester RY, Meira JB, Lima RG, Braga RR. cusp deflection and gap formation in composite
Composite shrinkage stress as a function of specimen restorations. Oper Dent 2001;26:406–11.
dimensions and compliance of the testing system. Dent [79] Palin WM, Fleming GJ, Nathwani H, Burke FJ, Randall RC.
Mater 2007;23:204–10. In vitro cuspal deflection and microleakage of maxillary
[61] Boaro LC, Brandt WC, Meira JB, Rodrigues FP, Palin WM, premolars restored with novel low-shrink dental
Braga RR. Experimental and FE displacement and composites. Dent Mater 2005;21:324–35.
10 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 1–10

[80] Papadogiannis D, Kakaboura A, Palaghias G, Eliades G. [95] Feilzer AJ, Kakaboura AI, de Gee AJ, Davidson CL. The
Setting characteristics and cavity adaptation of influence of water sorption on the development of setting
low-shrinking resin composites. Dent Mater shrinkage stress in traditional and resin-modified glass
2009;25:1509–16. ionomer cements. Dent Mater 1995;11:186–90.
[81] Tantbirojn D, Pfeifer CS, Braga RR, Versluis A. Do low-shrink [96] Baratieri LN, Ritter AV. Four-year clinical evaluation of
composites reduce polymerization shrinkage effects? J posterior resin-based composite restorations placed using
Dent Res 2011;90:596–601. the total-etch technique. J Esthet Restor Dent 2001;13:50–7.
[82] Versluis A, Douglas W, Cross M, Sakaguchi R. Does an [97] Hondrum SA. The longevity of resin-based composite
incremental filling technique reduce polymerization restorations in posterior teeth. Gen Dent 2000;48:398–404.
shrinkage stresses? J Dent Res 1996;75:871–8. [98] Ernst C-P, Martin M, Stuff S, Willershausen B. Clinical
[83] Campodonico CE, Tantbirojn D, Olin PS, Versluis A. Cuspal performance of a packable resin composite for posterior
deflection and depth of cure in resin-based composite teeth after 3 years. Clin Oral Invest 2001;5:148–55.
restorations filled by using bulk, incremental and [99] Palaniappan S, Bharadwaj D, Mattar DL, Peumans M, Van
transtooth-illumination techniques. J Am Dent Assoc Meerbeek B, Lambrechts P. Three-year randomized clinical
2011;142:1176–82. trial to evaluate the clinical performance and wear of a
[84] Demarco FF, Corrêa MB, Cenci MS, Moraes RR, Opdam NJ. nanocomposite versus a hybrid composite. Dent Mater
Longevity of posterior composite restorations: not only a 2009;25:1302–14.
matter of materials. Dent Mater 2012;28:87–101. [100] Mair LH. Ten-year clinical assessment of three posterior
[85] Brunthaler A, König F, Lucas T, Sperr W, Schedle A. resin composites and two amalgams. Quintessence Int
Longevity of direct resin composite restorations in 1998;29:483–90.
posterior teeth. Clin Oral Investig 2003;7:63–70. [101] Türkün LS, Aktener BO, Ateş M. Clinical evaluation of
[86] Ástvaldsdóttir Á, Dagerhamn J, van Dijken JW, Naimi-Akbar different posterior resin composite materials: a 7-year
A, Sandborgh-Englund G, Tranæus S, et al. Longevity of report. Quintessence Int 2003;34:418–26.
posterior resin composite restorations in adults – a [102] Ferracane JL, Condon JR. In vitro evaluation of the marginal
systematic review. J Dent 2015;43:934–54. degradation of dental composites under simulated occlusal
[87] Goldstein GR. The longevity of direct and indirect posterior loading. Dent Mater 1999;15:262–7.
restorations is uncertain and may be affected by a number [103] Braga RR, Ferracane JL. Contraction stress related to degree
of dentist-, patient-, and material-related factors. J Evid of conversion and reaction kinetics. J Dent Res
Based Dent Pract 2010;10:30–1. 2002;81:114–8.
[88] Morrier JJ, Barsotti O, Blanc-Benon J, Rocca JP, Dumont J. [104] Silikas N, Eliades G, Watts DC. Light intensity effects on
Antibacterial properties of five dental amalgams: an resin-composite degree of conversion and shrinkage strain.
in vitro study. Dent Mater 1989;5:310–3. Dent Mater 2000;16:292–6.
[89] Beyth N, Domb AJ, Weiss EI. An in vitro quantitative [105] Bouschlicher MR, Rueggeberg FA. Effect of ramped light
antibacterial analysis of amalgam and composite resins. J intensity on polymerization force and conversion in a
Dent 2007;35:201–6. photoactivated composite. J Esthet Dent 2000;12:328–39.
[90] Al Ghadban A, Al Shaarani F. Antibacterial properties of [106] Ernst CP, Brand N, Frommator U, Rippin G, Willershausen B.
amalgam and composite resin materials used as cores Reduction of polymerization shrinkage stress and marginal
under crowns. Eur J Prosthodont Restor Dent 2012;20: microleakage using soft-start polymerization. J Esthet
71–6. Restor Dent 2003;15:93–103.
[91] Farrugia C, Camilleri J. Antimicrobial properties of [107] Lim BS, Ferracane JL, Sakaguchi RL, Condon JR. Reduction
conventional restorative filling materials and advances in of polymerization contraction stress for dental composites
antimicrobial properties of composite resins and glass by two-step light-activation. Dent Mater 2002;18:436–44.
ionomer cements – a literature review. Dent Mater [108] Sakaguchi RL, Wiltbank BD, Murchison CF. Contraction
2015;31:e89–99. force rate of polymer composites is linearly correlated with
[92] Peumans M, De Munck J, Mine A, Van Meerbeek B. Clinical irradiance. Dent Mater 2004;20:402–7.
effectiveness of contemporary adhesives for the [109] van Dijken JW. Durability of resin composite restorations in
restoration of non-carious cervical lesions. A systematic high C-factor cavities: a 12-year follow-up. J Dent
review. Dent Mater 2014;30:1089–103. 2010;38:469–74.
[93] Peumans M, Kanumilli P, De Munck J, Van Landuyt K, [110] Braga RR, Ferracane JL, Condon JR. Polymerization
Lambrechts P, Van Meerbeek B. Clinical effectiveness of contraction stress in dual-cure cements and its effect on
contemporary adhesives: a systematic review of current interfacial integrity of bonded inlays. J Dent 2002;30:333–40.
clinical trials. Dent Mater 2005;21:864–81. [111] Pfeifer CS, Ferracane JL, Sakaguchi RL, Braga RR. Factors
[94] Francisconi LF, Scaffa PM, de Barros VR, Coutinho M, affecting photopolymerization stress in dental composites.
Francisconi PA. Glass ionomer cements and their role in J Dent Res 2008;87:1043–7.
the restoration of non-carious cervical lesions. J Appl Oral [112] Hayashi M, Wilson NH. Failure risk of posterior composites
Sci 2009;17:364–9. with post-operative sensitivity. Oper Dent 2003;28:681–8.