Polishing of Anterior Composite Resin Restorations

Written by Howard E. Strassler, DMD, FADM, FAGD and Judith Porter, DDS, EdD
Tuesday, 01 April 2003 00:00

The aesthetic appearance of a composite resin restoration depends upon shape, color, and
gloss of the restoration achieved by finishing and polishing. When composite resins were first
introduced in the late 1950s and early 1960s, they were self-cured and macrofilled with
particles in the 25 to 50 µm range. In most cases, the filler particles were quartz. These
composite resins, once contoured, had little surface gloss, and the patient sensed roughness
when their tongue touched the restoration.

The introduction in the late 1970s of visible light-cured composite resins with smaller
diameter filler particles of synthetic, softer glasses made composites more polishable. These
materials allowed the clinician to provide patients with more natural and aesthetic tooth-like
restorations in the anterior region of the mouth. As a result of changes in the polymerization
chemistry, visible-light cured composite resins demonstrated improved color stability. Light
activation was generally initiated when a blue light with a wavelength of 460 to 470 nm was
absorbed by a photo-initiator, usually camphoroquinone (CQ). The use of CQ combined with
an organic amine resulted in a chemical reaction so the composite resin hardened. This light-
activated reaction eliminated the need for the tertiary amines that were present in the early
self-cured resins. The tertiary amines contributed to unaesthetic color changes that
characterized these restorative materials.

In the last 15 years, manufacturers have introduced a wide variety of composite resins with
varied applications in both the anterior and posterior regions (see Table 1). For anterior
restorations, microfilled composites and hybrid composite resins have become accepted
standards. Microfilled composites offer high polishability with tooth-like translucency, but
unfortunately are radiolucent. The microfilled composites are polishable and maintain their
luster as a result of the inclusion of 0.04-µm colloidal silica particles within the polymer
matrix (homogenous microfill) or mixed with the polymer matrix, light cured, and then
crushed to make a prepolymer filler that is an organic filler within the microfilled composite
(heterogenous microfill). The small fillers and resin-rich surface promote high polishability.
Microfilled composites are generally loaded 32% to 50% by volume and have greater
polymerization shrinkage, higher water sorption, and a higher coefficient of thermal
expansion and contraction than hybrid composites.1
Hybrid composite resins combine microfiller particles (0.04-µm fumed silica) with microfine
glass fillers with an average particle size diameter of less than 2 µm. Typically these
composites are loaded 58% to 75% by volume and are radiopaque. This mixture of fillers
accounts for the excellent physical properties, including high polishability, as compared to
macrofilled composites.2 An important problem associated with hybrid composite resins is
their inability to maintain a gloss when exposed to toothbrushing with toothpaste or
application of prophylaxis pastes.3-6

Although microfilled composites maintain their gloss, these composites are susceptible to
fracture in high-stress-bearing areas.7 Consequently, a highly polishable composite resin with
optimal physical properties was needed for anterior and posterior restorations.
NEW GENERATION COMPOSITE RESIN

Recently, a new generation of hybrid composite resin has been introduced. These materials
have been categorized as nanofilled, with filler particles with a diameter in the 0.005- to 0.1-
µm range (Table 2). The nanofilled composites have physical properties equivalent to the
original hybrid composite resins, good handling characteristics, and greater polishability.8,9
These nanofilled composites offer an excellent alternative to microfilled composites because
they can be polished to a toothlike translucency.10 For anterior restorations, both microfill and
nanofilled hybrid resins can be expected to provide good color stability, resistance to stain,
low wear, and good polishability.2,8

While the new nanofilled composites are supplied with basic shades, they also have incisal,
enamel, and dentin shades. With the introduction of these composites, manufacturers have
provided specialized shade guides that help the clinician select the mix of shades to be used
in specialized circumstances, such as building on class IV incisal edge fractures from the
inside out and stratified building of completed facial veneers for aesthetic bonded
restorations. Examples include Filtek Supreme (3M ESPE), which provides a comprehensive
shade selection wheel that is used once the basic shade has been selected from a Vitapan
(Vident) classical shade guide, and Esthet-X (DENTSPLY/Caulk), which provides a
comprehensive, expanded shade guide that matches bleached teeth and includes some darker
shades than the traditional Vitapan guide. These advanced composite resins have been
formulated to be more sculptable and easily placed, with minimal slump and very little
tackiness.
THE IMPORTANCE OF FINISHING AND POLISHING

The final aesthetic appearance of any composite resin is dependent upon the artistic abilities
of the clinician in (1) choosing the correct shade or shades of composite resin to mimic the
color and appearance of the teeth, and (2) shaping and contouring of the restoration. The
restoration’s ability to imitate the appearance of the tooth and/or adjacent teeth also depends
upon the proper finish and polish of the restorative to its highest luster.11,12 Research has shown
that the technique for polishing composite resins to their optimal smoothness and gloss is
specific to the type of composite resin and the product.10-17

Barkmeier and Cooley18 evaluated the ease of polish and surface finish of 4 heterogenous
microfills and 1 homogenous microfill. They found all 5 microfills had no difference in ease
of finish, but the homogenous microfill produced the smoothest surface. Hoelscher and
coworkers19 compared 3 different finishing systems employed with 4 aesthetic materials
(including glass ionomers and a hybrid and a microfill composite resin). Their findings
indicate that a finishing bur left the roughest surface, while abrasive disks, when used from
coarse to fine, yielded the smoothest finish of all materials tested. Setcos, Traim and Suzuki20
compared several disk systems used to polish hybrid and microfilled composites. Regardless
of composite type, the sequential use of disks from coarsest to finest produced the smoothest
surfaces.

The principles governing the polishing of composite resins are similar to those used to polish
dental metals. Unlike metals that have a homogenous alloyed surface and a uniform hardness,
however, composite resins are composed of resin matrix and filler particles. In some cases,
the resin matrix and fillers have different hardnesses. While composite resin finishing
systems can be used on metals, metal finishing and polishing systems should not be used for
composites in order to avoid undesirable staining and discoloration. The abrasive particles
used to polish composites are material specific. Similar to metal polishing, the sequence of
polishing for composite resin progresses from coarsest abrasive to finest.

Finishing and polishing devices and instruments can be classified as...

(1) coated abrasives; eg, abrasive finishing disks and strips;

(2) rotary cutting devices, eg, carbide finishing burs;

(3) rotary submicron particle diamond finishing abrasives;

(4) reciprocating abrasive tips; eg, laminated abrasive flat paddles;

(5) rubberized embedded abrasives; eg, rubber or silicone rotary points;

(6) hand instruments, and;

(7) abrasives suspended in a polishing paste.

No matter which abrasives are selected, the rule of coarsest to finest must be followed. Table
3 has a partial listing of instruments, devices, and materials for polishing composite resins.
The goal when placing a composite resin is minimal finishing and polishing. While this is not
difficult with routine anterior restorations (class III and class V), for larger, more involved
restorations (class IV and complete facial veneering, especially for multiple teeth),
significantly more contouring and finishing is usually required. Typically, for these larger
restorations the sequence for finishing and polishing involves gross contouring, shaping with
finishing burs and submicron finishing diamonds with a high-speed handpiece, followed by
additional finishing with abrasive discs and/or rubber points. For long incisal-gingival
restorations, narrow, long finishing burs or diamonds with safe-tipped ends allow the
establishment of aesthetic curved surfaces. While finishing burs and diamonds can be used
either wet or dry, the authors prefer using them dry with light pressure, with the dental
assistant suctioning the composite “dust” during the procedure. Working with a dry field
provides better visualization of shape and contour of the composite resin surface.

Judicious use of coarse and medium grit finishing disks using only small sections of the disk
allows the same level of control. Today, most disks have a small metal hub to reduce the
chance of accidentally hitting the composite with the hub. Some manufacturers (Shofu and
Brasseler) have placed their disks on silicone sheaths that slip over the metal mandrel,
thereby eliminating the potential to mar the composite resin surface. Additional finishing of
facial and lingual surfaces can be accomplished with specialized rubberized polishers in
flame, disk, and cup shapes. These shapes provide access to the different tooth contours.
These are used on a latch-type contra-angle handpiece. It is important whenever using
abrasive systems that the surface of the composite resin be physically debrided of composite
and abrasive debris with a damp cotton roll or gauze. If only an air-water spray is used, some
of the debris will remain on the surface and interfere with polishing when sequentially using
the next finest abrasive grit.

Interproximal finishing and polishing are accomplished with gapped finishing and polishing
strips covered with aluminum oxide abrasive particles, or with metal strips covered with
submicron diamond particles. Occasionally, even with the use of a matrix strip, the
restoration may bond to the adjacent teeth, literally splinting the teeth together. In these cases,
there are specialized accessories that allow the clinician to separate the teeth without
damaging the restoration. Included here is an ultra-thin stainless steel saw blade mounted in a
handle (Cerisaw, Den-Mat). This mini-hacksaw and handle allows for total control of the
instrument while gently sawing through the interproximal resin. When using a saw, a gingival
wooden wedge should be placed between the teeth to protect the gingival papilla. Den-Mat
also places diamond strips in the CeriSaw handle to finish interproximal surfaces of resin
restorations and ceramic veneers. In addition, Axis Dental combines a gapped diamond-
containing metal finishing strip with saw teeth on the strip.

Another useful device to help separate interproximal contacts for placement of matrix strips
or gapped finishing strips is the Contact Disc (Centrix). This thin, rigid disk can be inserted
from the incisal, occlusal, or facial directions to force the teeth apart. If excess composite
resin is present, the disk will create space to allow a matrix strip to be placed without
bleeding, as may occur when using a gingival wooden wedge to accomplish the same task. In
the presence of excess interproximal composite resin, the disk will break away excess resin
without damaging the restoration. Premier Dental Products has developed a diamond-
impregnated thin disk (CompDisk) that not only creates space with rapid separation, but can
also be used for interproximal finishing or cleaning interproximal surfaces before bonding.
Occasionally, after placement of the composite restoration, finishing the margin is best
accomplished with a hand instrument or by using a specialized reciprocating handpiece with
a flat abrasive paddle. Carbide-tipped hand instruments (Brasseler; Den-Mat), restorative
knives (Hu-Friedy), or scalpel blades with shapes that allow access to the margin of the
restoration will allow the clinician to remove excess restorative material in a more controlled
manner than with rotary burs or diamonds.12,21 Carbide carvers are especially useful for
marginating composite resin restorations when only minimal excess is present. In
inaccessible areas such as the gingival margin of an interproximal surface, specialized
instruments and devices such as a reciprocating handpiece (Profin, Dentatus) with a flat
Lamineer abrasive tip can be used.21,22 Lamineer tips come in a variety of submicron abrasives
for finishing and polishing the cervical margin of the restoration. The flat tips can also be
used to finish and shape facial surfaces and incisal embrasures.

Final polish of the composite resin surface to its most lustrous finish can be accomplished
using disks with the finest aluminum oxide abrasive. Using a disk will not only smooth the
resin surface, but will also heat the surface, creating a high luster. This heating is sufficient to
allow the polymer matrix to reach its glass transition temperature. This phenomenon gives the
composite resin a glassy appearance. Also, a composite resin can be polished with specialized
composite resin polishing pastes that contain either very fine aluminum oxide abrasive
particles or diamond particles. This is best accomplished with foam cups, felt-mounted disks,
or fine goat-hair brushes. If the surface of the restoration is generally smooth, disks work
well. For surfaces that have anatomic variations such as lobular forms or striations, composite
polishing pastes work best.

Figure 1a. Facial view of the Figure 1b. Palatal view

maxillary anterior teeth. The showing the misalignment of
central incisors are lingually the incisors.
positioned and the lateral
incisors are rotated distally.
CASE REPORT

During the restorative treatment consultation, the patient was presented with 3 options—
ceramic crowns, porcelain veneers, or direct placement composite resin. Adhesive bonding
with composite resin and ceramic veneers are alternative treatments for aesthetic correction
of tooth malposition in the anterior area.23,24 Because of financial considerations, the patient
chose direct placement composite resin restorations.
 Figure 2a. Palatal view of cast Figure 2b. Stone has been
demonstrating malaligned removed from the cast to
incisors. simulate tooth preparation.

Figure 3a. Diagnostic buildup Figure 3b. Palatal view of the

with composite resin. buildup.

During the treatment planning phase, study casts were used to further evaluate tooth position.
The maxillary incisors were reduced on the casts to determine how much tooth preparation
would be needed to allow for adequate composite resin to align the incisors (Figures 2a and
2b). A diagnostic buildup with composite resin was performed to assess tooth shape,
proportions, and widths, and for patient acceptance (Figures 3a and 3b). When the patient
accepted the proposed treatment, he was scheduled for restoration with a direct placement,
nanofilled hybrid composite resin (Point 4, Kerr).

Before tooth isolation, a shade was selected with a Vitapan shade guide (Vident). This
selection was checked by placing an increment of composite resin most closely matching the
shade of the maxillary canine on the lateral incisor and light curing that increment. Like many
of the new generation of nanofilled composite resins, Point 4 offers regular shades, opaque
shades, translucent shades, and bleaching shades. Although Point 4 has very little color
change when light cured, some composite resins change shade when light cured because of
removal of the orange-yellow photoinitiator (camphoroquinone) during the polymerization
process. Accurate shade selection is a critical step when placing anterior composite
restorations.

Figure 4. Preparation of
maxillary incisors.
The teeth were isolated using a split rubber dam. Split rubber dam involves punching holes
for rubber dam placement and then cutting through the septa between holes with a scissor. A
bite block was placed. Use of the rubber dam combined with a bite block improves patient
comfort and affords better access when preparing and restoring anterior teeth with direct
bonded composite resin. Here, the teeth were prepared with a thin, medium-grit flame-shaped
diamond (Revelation 653-016, SS White Burs) on a high-speed handpiece with water spray
(Figure 4).

Before acid etching, dead soft stainless steel metal matrix, 0.001-inch thick, was placed distal
to the maxillary central incisors. A piece of Tofflemire stainless steel rigid matrix (0.002-inch
thick) was cut into a small rectangular strip and was placed between the central incisors. This
more rigid strip holds the correct orientation of the midline.

Figure 5. Etched facial Figure 6. Application of

surfaces of maxillary incisors. adhesive to etched tooth
surfaces.

The tooth surfaces were etched for 15 seconds with a 32% phosphoric acid etchant and then
rinsed with an air-water spray for 15 seconds. The etched tooth surfaces were dried, leaving a
slightly frosty appearance to the enamel, and the dentin was moistened, leaving a glossy
appearance (Figure 5). An enamel/dentin adhesive (Optibond Solo Plus, Kerr) was applied to
the facial surface of the etched enamel (Figure 6), and then light cured for 20 seconds with an
Optilux 501 (Demetron/Kerr) curing light. The nanofilled composite resin hybrid (Point 4,
Kerr) was placed on the facial surfaces of both central incisors and sculpted with a thin, broad
plastic filling instrument (PFIAB1, HuFriedy). This instrument allows for smooth shaping of
the broad facial areas of incisors. The instrument was lightly wetted with a coating of
adhesive resin to prevent the composite resin from sticking to the instrument and pulling
away from the enamel surface. The composite resin was light cured for 20 seconds using a
wide-angle light probe tip so that the entire facial surface could be polymerized. After
placement of the composite resin on the central incisors, the lateral incisors were restored
using the same protocol.

FINISHING AND POLISHING

Many manufacturers provide kits containing finishing burs, diamond abrasives, rubberized
abrasives, and disks that give the clinician an orderly sequence of finishing and polishing
instruments. There is no one approach to the finishing and polishing of composite resins, but
a general rule is to proceed from coarse to fine grit size.
 Figure 7. Long, thin composite Figure 8. Shaping of the
resin finishing bur trimming gingival margin with a thin
the facial surface. needle shaped finishing bur.

Figure 9. Fine diamond

finishing bur for contouring the
gingival margin.

In this case, the facial surfaces were contoured using a long, narrow, safe-ended, multifluted
finishing bur (7204, SS White Burs) (Figure 7), but a submicron diamond abrasive with a
similar shape could also have been used. The gingival margin was contoured and marginated
with a shorter, thin-needle shaped finishing bur (CFT 2, SS White Burs) (Figure 8). Another
popular choice for shaping facial surfaces of veneers and class IV restorations is the ET series
of finishing burs and diamonds (Brasseler USA). The choice of finishing bur and diamond
abrasive is usually made by the practitioner based upon experience. Finishing burs can have
as few as 8 or 12 blades for gross reduction. For finer finishing, 16- or 30-bladed burs are
available. Diamond composite finishing abrasives usually have a diamond particle size of
approximately 30 µm for fine grit, 15 µm for extra-fine grit, and 8 µm for ultra-fine grit. Note
that a thin, new finishing bur can cut aggressively into a facial surface. A composite resin
finishing bur dulls to the ideal after 2 sequences of autoclaving. To further finish the gingival
margin, a flame-shaped fine finishing diamond (862-016, SS White Burs) (Figure 9) was
used as it allows better access to the gingival margin without nicking the root surface. After
the fine diamond was used, the composite surface was further finished with a flame-shaped
extra-fine bur and then a flame-shaped ultra-fine diamond.

Figure 10. Coarse disk Figure 11. Disk shaping the

shaping the incisal edge. facial and incisal embrasures.
The incisal edge was shaped and the length determined using a coarse disk (Soflex XT disk
No. 2381C, 3M ESPE) (Figure 10). The best technique for shaping the incisal edge is to have
the patient seated in an upright position that mimics how the incisal edges are visualized. The
disk should be oriented with a slight lingual inclination following the chisel shape of the
incisal edge of an intact incisor. The incisal embrasures and facial embrasures were
established using a thin, flexible diamond disk (Vision Flex Disc, Brasseler USA) (Figure
11). These areas can also be shaped with a reciprocating handpiece (Profin) and an “S” series
knife edge lamineer tip. Once shaped, the areas were finished using successively smoother
disks, from a medium to fine to finest grit.

Figure 12. Safe-sided

Lamineer tip on reciprocating
handpiece shaping the gingival
interproximal embrasure.

One of the most difficult areas to access when finishing any aesthetic restoration is the
gingival margin of an interproximal surface. Finishing strips do not work well because of
difficulty in accessing this area. In this case, the Profin with a Lamineer tip was used in the
gingival interproximal areas because the reciprocating handpiece, with its back and forth
motion, provides the control needed to safely finish and polish the root surfaces without
notching (Figure 12). Finishing burs on a high-speed handpiece, if not used correctly, can
easily notch the root surface. Even the thinnest finishing burs or submicron diamond
abrasives are rounded and can notch a root surface. The Lamineer tips are safe-sided and are
available in decreasing diamond abrasive grits to allow finishing and then polishing of the
gingivoproximal area.

There are times when a rotary instrument or even a reciprocating instrument does not have
complete access to the interproximal surface. For these special situations, a hand instrument
allows for fine control, precision placement, and effective removal of excess composite resin.
Hand instruments for this purpose include carbide-tipped composite instruments (with
specialized shapes to access different tooth surfaces), composite carving knives, and a No. 12
scalpel blade.21

The finishing and polishing of the interproximal surfaces of composite resin restorations
require the same attention given to accessible surfaces. Care should be taken not to remove
excessive composite resin, resulting in an open proximal contact. Interproximal strips can be
used to shape and contour the interproximal contact area, thus maintaining the contact. When
using finishing strips, always proceed from medium abrasive grit, to fine grit, to the finest
grit. Gapped finishing strips work best as they allow ease of placement between the teeth. If
difficulty is encountered introducing the strip through the contact, a plastic filling instrument
can be used to rapidly separate the teeth, and then the finishing strip is slid below the
interproximal contact area. If a diamond abrasive-gapped strip (eg, Gateway Strip, Brasseler)
is used, additional care must be taken to not remove tooth structure when finishing the
interproximal areas. These diamond-impregnated strips also work well for removing stain on
interproximal tooth surfaces before the bonding procedure.

Figure 13. Finishing cup Figure 14. Egg-shaped 12-

smoothing the facial surface of bladed finishing bur
the composite resin. completing the margin and
shaping the lingual surface of
the composite restoration.

Figure 15. Flame-shaped

finishing point polishing the
lingual surface of the
composite restoration.

Intermediate finishing of the facial surface was accomplished with a cup-shaped rubber
finisher (Astropol, Ivoclar Vivadent) (Fig 13). The cup shape allows access to the gingival
facial margin and also contours the facial surface. If lobular facial form is desired in the
restoration, this can be accomplished once the facial surface has been smoothed by using a
disk-shaped rubberized abrasive. The lingual surface was finished with an egg-shaped
finishing bur (7406, SS White Burs) (Figure 14). The surface was then smoothed with a
flame-shaped point (Astropol, Ivoclar Vivadent) (Figure 15). The occlusion was then checked
just prior to final polishing.

Figure 16a. Completed Figure 16b. Aesthetic

restoration, facial view. alignment has been achieved
 with direct composite resin
bonding.

The final polish was accomplished with a composite resin polishing paste (Extra Smooth
Composite Polishing Paste, Den-Mat) on a foam cup attached to a screw-in metal mandrel
(Luminescence, Premier Dental Products). Either a foam cup polisher or felt-covered disk
will bring the polishing paste in contact with the anatomic areas created on the facial and
lingual surfaces. Another technique for attaining a smooth, high luster is using the finest grit
aluminum oxide disk available or the finest grit of rubber polishing point. Using the finest
abrasive disk or rubber point at greater than 18,000 rpm creates a highly lustrous surface.
This is because of both the polishing effect of the disk and heating of the resin surface; a
glassy appearance is the result. Interproxmal areas can be further polished with small-width
gapped fine abrasive finishing strips or composite resin polishing paste on a Lamineer plastic
polishing tip on a reciprocating handpiece. The final result is seen in Figures 16a and 16b.

DISCUSSION

The clinical success of finishing and polishing techniques can best be observed over time.
While the current generation of composite resins are highly polishable, highly polished
surfaces of resin-rich microfills are still prone to staining.25 The staining of composite resin
surfaces is directly related to patient variables, including diet (coffee, tea, wine, etc), as well
as other habits (smoking, spit tobacco, and the use of alcohol-containing mouthrinses). The
stain