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Objective: To investigate the relation between handling characteristics and application time
of four composite materials with subjectively different viscosities.
Methods: Eight experienced faculty members placed one Class II and one Class IV restoration
in a random sequence into pre-prepared plastic teeth mounted on a typodont model, each using
4 types of composites (Herculite Précis (M1), Kerr; Tertic N-Ceram (M2), Ivoclar Vivadent;
Filtek Z350 (M3), 3M-ESPE; Charisma Opal (M4), HareausKulzer), resulting in a total of 64
restorations placed. The application process was filmed with a high definition video camera.
Two evaluators watched the recordings in a random sequence as well, timed the composite
application and wrote down their observations, which were dichotomized into positive and
negative ones. Application times were analysed with two-way Kruskal Wallis test (time x den-
tist) and the observation data were analysed with chi square test (P < 0.05).
Results: Materials did not differ in their application time (P > 0.05). The mean application
time was 12 ¼ minutes for the Class II and 9 ¾ minutes for Class IV restorations. However,
there were statistically significant differences between the dentists in terms of application
time. The observation data showed no significant difference between Class II and Class IV
restorations but there were significant material differences (P < 0.05). M2 yielded 6% negative
observations, while the other materials were between 35% and 38%.
Conclusion: There was no association between the handling characteristics of the tested com-
posite resins and the speed of application. However, one of the tested materials (M2) showed
significantly less problems in the application process.
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with the option for clinicians to determine the timing It is believed that a good initial quality of n
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of polymerisation, it was realised that the rheologi- tions will be mirrored in their longevity. Since
e ss ethen z
cal properties of these materials were influencing their good quality is the least sum of errors, it is worth it to
handling characteristics. Yet, there were no tests for look at the ease of application of composite materials
determining the handling characteristics. One way to that can be influenced by handling characteristics of
do this is the laboratory approach. Al-Sharaa & Watts8 the materials.
and Kaleem et al9 used the stickiness as the measurable The objective of this study therefore was to inves-
property to determine clinical handling by contacting tigate the application behaviour of four composite
the surface with a flat rod, then separating it from that materials with subjectively different viscosities. It was
surface and measuring either the height to that point hypothesised that the more difficult the application
or the force needed for separation. Other researchers technique or the material property, the longer it would
measured the slumping of the composite after being take to place a restoration. Therefore, timing of the
shaped into a specific form with laser scans by com- application could reveal some differences between the
paring the initial shape with the resulting shape as a composite materials. Furthermore, the sum of positive/
function of time10,11. negative observations is a measure of the handling
Another way to look at handling of materials is properties. Analysing anonymous observation proto-
to have the materials being used by dentists and ask cols of restoration placements in a free format could
their opinion with questionnaires. This is easy, but reveal some differences between composite materials
due to the large variation in subjective opinions of tested. The null hypothesis tested was that handling
dentists, it is difficult to get reliable data. It is better characteristics and application duration of four resin
to have measurable parameters, as done by Degrange composite materials would not show significant dif-
M (Battle of the Bonds, unpublished data) where ference.
dentists had to bond composites to bovine dentin and
subsequently the immediate shear bond strength was
Materials and methods
determined. However, they found that the variation
between dentists was much larger than the variation Materials used in this study are listed in Table 1. Eight
between the different adhesives. Therefore, one can experienced faculty members from the Department of
conclude that the dentist’s knowledge and skills are Restorative Dental Sciences at the University of Florida
very important, and will translate in a better quality of placed one Class II and one Class IV restoration, each
the restorations. using 4 types of composites into a pre-prepared typo-
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Material Composition (manufacturer data Batch # Manufacturer
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Charisma Opal A2 same 010023 (5x) Haraeus Kulzer
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370%
273%
Fig 1 Setup with
the Video camera
in the Simulation Fig 2 Affixed mounted typodont, aligned materials, and
Lab. markers.
dont tooth mounted on a typodont model. This resulted In the third step, each protocol of the 8 dentists was
in 2×4×8 = 64 restorations placed. The entire applica- regrouped according to cavity class and material, and
tion process was filmed with a video camera mounted coloured with the electronic highlighter: no colour =
in a fixed position in relation to the typodont model. descriptive facts, green: positive observations, red =
Two stations were set up in the Simulation Laboratory, negative observations.
where electric hand pieces were available for the pol- Finally, the positive and negative observations per
ishing process (Fig 1). For every dentist, a randomised dentist and material were counted and analysed with the
sequence for the materials used was prescribed using a Chi square test (SAS 9.2, SAS Institute).
random number table12. The dentists were instructed to
use the centripetal technique for Class II restorations.
Results
They were given metal circular matrix bands, wooden
wedges and Toffelmeier matrix band holders. For the The results of the composite application times for Class
Class IV restorations, silicon stents were provided. They II and IV restorations are shown in Table 2 and 3 and
were informed on the objective of the study and given in Figs 3 and 4. There were no significant differences
an instruction sheet. between the materials (P > 0.05), but the application
The materials were aligned according to the ran- duration varied significantly between the operators (den-
domisation and the typodont marked with numbers, vis- tists) (P > 0.05). Since the dentists’ behaviour was not a
ible in the film, identifying the materials used (Fig 2). topic of the study, this was not further investigated with
In the first step, the application time of the compos- post hoc tests.
ite, from the appearance of the first increment on the The pooled data (Class II and IV) of the evaluation
screen to the end of the last polymerisation step was of the observation protocols are presented in Table 4. A
timed using the time code of the video film. The results significant difference was observed between Material 2
were analysed with the Kruskal Wallis Test (SAS 9.2, and those of others (P > 0.001). This is obvious looking
SAS Institute). at the % of negative comments from the total sum of
In the second step, two dentists watched the appli- comments per material. Material 2 yielded 6% negative
cation and protocolled the observations for every comments, while the others varied from 35% to 38%
increment applied in a free format. They were blinded negative comments.
regarding to the materials. Both evaluators had to agree
on the protocolled observations. In the instance of dis-
Discussion
puted results, the film was rewound and the scene was
observed repeatedly until an agreement was reached. The materials included in the study were selected based
The sequence of the observation was randomised in a on their perceived consistency, since the thixotropic
different way than the sequence of application of the behaviour of the composites interferes with viscos-
restorations. ity measurements. Material 1 was considered the least
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Table 2 Application times of 8 dentists in minutes placing Table 3 Application times of 8 dentists in minutes placing Class n
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Class II and IV composites. Grouped according to materials se nz
II and IV composites (Herculite Précis, Tetric N-Ceram, Filtek
Z350 XT, Charisma Opal). Grouped according to dentists.
20
18
16
14
12 1
10 2
Fig 3 Application time (min-
8 3
utes) by dentist (x-axis) and
composites for Class II com- 6 4
posite restorations. Kruskal
Wallis: Dentists P < 0.05, Mate- 4
rial NS. (Materials: 1 = Herculite 2
Précis, 2 = Tetric N-Ceram, 3 =
0
Filtec Z350 XT, 4 = Charisma 1 2 3 4 5 6 7 8
Opal).
25
20
1
15
2
Fig 4 Application time (min-
utes) by dentist (x-axis) and 3
10
material in Minutes for Class IV 4
composite restorations. Kruskal
Wallis: Dentists P < 0.05, Mate- 5
rial NS. (Materials: 1 = Herculite
Précis, 2 = Tetric N-Ceram, 3 = 0
Filtek Z350 XT, 4 = Charisma 1 2 3 4 5 6 7 8
Opal).
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Table 4 Sum of positive and negaitive comments after dichotomization for the different materials. n
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Composite Sum of positive comments Sum of negative comments Total % negative comments of total
comments
1 49 29 78 37%
2 98 6 104 6%
3 48 30 78 38%
4 60 33 93 35%
Materials: 1 = Herculite Précis, 2 = Tetric N-Ceram, 3 = Filtek Z350 XT, 4 = Charisma Opal
flowable and Material 4 the most flowable. The other two and OptraPol (Ivoclar) polishers, each operator used a
materials were positioned in between Material 1 and 4 in different approach. Therefore, this procedure was not
terms of ‘viscosity’. The composites tested have different comparable anymore and it was decided to disregard
filler loads and different monomer matrices (Table 1) that these parts of the videos when considering the duration
might have influenced their consistency4,7. Observing required for each restoration.
with a video camera was thought to be more objective The null hypothesis could only partially be rejected,
than asking the practitioners their opinion on the han- since, against the expectation, we could not find any
dling properties of the composites. By using standardised application time effect between the composites that
tooth preparations, offering standard instruments, giving had definitely different consistencies as seen in the
them a ‘new’ material (the standard material in the clinic application videos. The dentists very obviously quickly
is Filtek Z 250) and requiring them to use the centripetal changed their application modes when they encountered
technique, all practitioners who participated faced the difficulties like slumping or stickiness. Despite using
same conditions, thus decreasing variability. We did not dentists from the same institution, their individual
standardise the number of increments, since we wanted to application techniques varied substantially, which is
be as close as possible to normal conditions in the dental documented by the significant time differences for the
office. We assumed that the dentists would know that same task. This was even more pronounced for the
the maximal thickness of an increment for a light curing polishing process, which was the reason not to evaluate
composite would be 2 mm. Random assignments for the this part of the composite application.
placement of the restorations, as well as the sequence of Looking at the most often observed negative events
the evaluation, possibly eliminated the learning curves. (Fig 5), stickiness of the composite was the largest
One drawback of this in vitro study is that typodont teeth problem by far, being expressed by the observation
were used instead of human teeth. However, they were ‘sticks to instrument/detaches from tooth’. This is by far
wetted with the corresponding adhesive system of the the most difficult task for a composite manufacturer to
composites applied, thus mimicking the situation in real be solved. In principle, the material should be sticky in
teeth. Another drawback is the ambient temperature in order to wet the primed tooth surface well since extend-
the simulation laboratory, which is less than the tooth ed manipulation creates bad margin quality13, on the
temperature in the mouth. Since the temperature influ- other hand, it should not stick to the instrument. Since
ences the rheological properties of composites9, this the stickiness is temperature dependant8, being more
aspect could have affected the outcome. pronounced at higher temperatures, one should expect
Since the placement of the adhesive resin was not even more problems in vivo, since teeth are known to
within the scope of the study and no visible differ- have a temperature slightly below 37°C in contrast to
ences were observed, this step was neither evaluated the room temperature used in this experiment (approxi-
for timing, nor for handling aspects. The polishing of mately 20°C). In the clinical situation, the longer the
the restorations, which should be a standard procedure, composite is manipulated, the more problems are to be
was not seen as such by the dentists. Although the expected due to viscosity changes in the material as a
operators were provided with Soflex discs (3M ESPE) function of time and temperature.
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Material 1 Material 2
Sticksto instrument/
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Sticks to instrument/
detach from tooth detach from tooth
Finger prints
Reaches gelphase
Not flow to cavity wall
To stiff
Material 2
Material 3
Stick to instrument/ Sticksto instrument/
detach from tooth detach from tooth
Finger prints Pillow effect
(lots, constantly) Pulls away
Pillow effect Slumos (a lot)
Slumps
Fig 5 Frequency distribution
Gets whitish, dry
for the most common negative Reached gel phase
observations.