Thecontinuum of restorativematerialsin pediatric

dentistry-areviewfor the clinician

JoelH.Berg,
DDS,
MS

Abstract someof the newermaterials, misinformationhas been

Manychoicesare availableto the practitionerof restor- promulgatedregarding what these materials are, mak-
ing it difficult at timesto appreciatethe valueof having
ative dentistry for children. Withthe introductionof sev-
so manychoices. Clarification of these matters will al-
eral newclassesof restorativematerialsin recentyears,some
low the practitioner to performthe right restorative
confusionhas beencreatedaboutwhatthese materialsare, treatment for each situation.
making it difficult to identij~their appropriate clinical use.
This paperreviewsglass-ionomer materials, resin-modified Definitions and descriptionsofproductcategories
(reinforced)glass ionomers,compomers, andcompositeres-
ins for the practitioner.Definitionsof these materials,a gen- ionomersare fluoride-releasing materials used in a va-
eral descriptionof their contents,andusage-selection crite- riety of forms in restorative dentistry and they serve
ria are provided.Althoughmorechoicesfor tooth restora- manypurposes. Resin-modifiedglass ionomers, light-
tion canmakethe selectionof the right materialmorediffi- polymerizableversions of traditional glass ionomers,
cult, a better understandingof the componentsand the offer facilitated use and easier handling. Compomers,
strengthsandweaknesses of eachcategoryof materialsoffers the newest memberof the restorative family, will be
the opportunity to select the right materialfor the right situ- reviewed as modifications of resin composites, the
ation. (Pediatr Dent 20:2 93-100, 1998) fourth type of material, whichare the mostesthetically
desirable of the groups. Thesefour different materials
offer the clinician numerouschoices in determiningthe
ver the past 50 years, many changes have
O occurred in the developmentand availability
of restorative materials for children. Thedaily
lright material for each individual situation,

Glass ionomers
practice of pediatric dentistry at the time of the Glass-ionomercement(GIC) is a salt, by chemical
formation of the American Academyof Pediatric
definition, whichis formedby the reaction betweena
Dentistry didnt enjoy the numerouschoices available 2polyalkenoic acid and an aluminum-containingglass.
in todays practice. For posterior teeth, the
Aluminum, as a constituent elementin the glass, is criti-
practitioner was limited to amalgam,stainless-steel
cal for the glass-ionomer reaction to occur. Most
crowns, or possibly steel orthodontic bands retained
commonly,glass-ionomerglass, the "base" part of the
with a luting cement, which were also used as a reaction, is an aluminum-fluorosilicate glass. Wateris a
restoration. The anterior teeth were restored with
necessaryingredient of GIC,as an acid/basereaction can
silicate cement,acrylic, or other esthetically less-than- only occur in an aqueousmedium.The fluoride in the
desirable restorations.
glass materialis releasedovertime,3 with a very highfluo-
Today, the pediatric dental practitioner is con-
ride release occurring for a period of several weeks,
fronted with manymaterials from whichto select for
dissipating to a level of around10%of the original level
each restorative situation. Thenumberof choices, while in 3-4 weeks,andremainsat this level for 1 year or more.
allowing morecontrol of the final result, also creates
Someresearch has shownthat these materials, often
confusion in terms of howto distinguish the uses of
called "traditional glass ionomers"as distinguishedfrom
these various materials.
modifiedmaterials to be discussed later, can be "re-
This paper will provide a brief review of the
charged"in the presenceof ambientfluoride (suchas that
intracoronal restorative materials used for the modern
given during a professional fluoride treatment), which
pediatric dental practice. It will define the variouscat- 4can replenish the fluoride in the material.
egories of restorative materials described, and discuss Glassionomerscan be usedas a liner, a luting cement,
the distinctions in their clinical selection anduse. Be- or a base/corematerial. Asa restorative material, glass
cause of the relatively rapid and suddenappearanceof ionomeroffers the advantageof being the only material

Pediatric Dentistry-20:2, 1998 AmericanAcademyof Pediatric Dentistry 93

 with a true chemicalbondto tooth structure) 6 Even
though the measuredin vitro bond strength of glass
ionomerto tooth structure is significantly lower than
the bondstrengths for the other materials, clinical ex-
perience showsglass ionomersto be well retained. This
maybe due to the fact that the chemical bond has a
different character than the purely mechanicalbondof
the other materials.
Thephysical properties of traditional glass ionomers
have improveddramatically quite recently with the
introduction of high powder-to-liquid ratio glass
ionomer materials. These denser materials provide a
"condensable" feel, fadlitating its use in posterior teeth.
These stronger materials have improved compressive
and flexural strengths, from 190 to 250 MPaand 30
to 45 MPa,respectively, allowing their use in larger
occlusal restorations than previously possible. These
stronger GICswere originally developedto be used in
areas of the world whereatraumatic restorative treat-
ment (ART)was used. This technique employsthe use
of hand instruments for caries excavation, without the
use of rotary instruments, with subsequentrestoration
using traditional glass-ionomermaterial. It is impor-
tant to use only traditional glass-ionomermaterials with
ART,as light-cured materials are not feasible in parts
of the worldwhereelectricity, and thus light curing, is
unavailable. Thetechniqueis quite useful for high-car-
ies populations of children; 7 it could therefore be
similarly useful in developed countries where caries
control for a transitional period is desired.
The coefficient of thermal expansion (COTE)
glass-ionomer materials is the most similar to tooth
structure, particularly to dentin, amongall dental ma-
terials. The COTEis a measure of the amount of
expansionor contraction a material will undergoin the
presenceof temperaturechanges.If there is a large dis-
parity in the COTEof the material and the tooth
structure, then temperature-related expansion/contrac-
tion could eventually lead to fracture or other failure
8of the restoration.
Thestrength of traditional glass ionomersresides in
the fact that they are cured withoutlight, althoughthis
could be seen as a weaknessfor someclinical indica-
tions. Glass ionomers also chemically bond to tooth
structure, are brittle, andwill crackor breakif subjected
to strong opposingforces such as dysfunctional occlu-
sion during excursive movementswith a hard food
substance. Glass-ionomer restorative materials have
9been combinedwith silver to provide reinforcement.
Success of at least one of these combinationsis well
documentedover manyyears of clinical use. J J~ The
currently described, high powder-to-liquid ratio ma-
terials offer superior physical properties to the silver-
reinforced variety without reinforcement, and should
proveat least as successful as the silver-reinforced ma-
terials. Theyoffer the distinct advantagesof the original
94 AmericanAcademyof Pediatric Dentistry
glass ionomers--high fluoride release, ~2 compatible
COTE,virtually no shrinkage (polymerization) upon
curing, and a chemicalbondto tooth structure. As will
be subsequently discussed, glass ionomerscontinue to
provide distinct usage indications, and particularly
benefit the practitioner of pediatric dentistry.~3
Resin-modified
glassionomers
Resin-modified glass ionomers (RMGI),sometimes
called resin-reinforced glass ionomers(RRGI), were
developed to overcome some of the perceived inad-
equacies of traditional GICs. They contain the same
componentsas traditional GICs, but have resin mate-
rials added to provide strengthening, as well as the
capability of "command-cure"with a light-initiated
curing of the resin composite component.
In addition to the acid (polyalkenoicacids) and base
(aluminum-fluorosilicateglass) constituents contained
for the GICreaction, RMGIcontains a hydrophilic
resin and a light-initiating compound (photoinitiator).
Theglass can be silanized to allow an adherenceof the
glass within the resin matrix. Thereare also the neces-
sary initiators for the self-cured resin reaction, so that
even in the dark most varieties of RMGI can obtain a
cure of the resin.
Given the additional constituent ingredients,
RMGIs offer several advantages over traditional GIC.
First, they are stronger in their physical and mechani-
cal properties by virtue of containing resin--a stronger
material. Therelative amountof resin to glass ionomer
in the mixture of RMGIwill therefore determine, to
someextent, the physical and clinical behavior of the
material, i.e., being more glass ionomer-like or more
resin-like.
As with traditional GICs, RMGIsmust be mixed
from a two-component system. The GIC and self-
cured resin elements must be separated to prohibit
reaction until it is neededin the chair. RMGI is there-
fore offered in both a hand-mixed as well as a
capsulated version to provide facilitated and morepre-
cisely measured mixing of the components. The
hydrophilic resin contained within RMGI is necessary
for miscibility in the water-basedGICmaterial.
RMGIsallow the practitioner to place a GIC-con-
taining material into cavity preparations where an
immediatecure is desired in the interest of time. The
GICcomponentoffers fluoride release while the resin
componentoffers strength and better esthetics than
with traditional GICs. The physical and mechanical
properties of RMGI are better than those of GICalone,
providingmoreresistance to fracture andpotential fail-
ure when large occlusal forces are present. The
disadvantage of these materials remains in their han-
dling properties, although improved compared with
traditional GIC.The material must still be mixed, and
beginsto set thereafter. Becauseresin exists in the mix,
PediatricDentistry - 20:2, 1998
the potential of polymerization shrinkage begins with acceptable. This could be a result of the slightly lower
this material. AlthoughRMGIs have a higher measured mineralization level of primary comparedwith perma-
bond strength in vitro than traditional GICs, the ex- nent tooth enamel. This difference might allow an
istence of polymerization shrinkage warrants a higher effective etch from somecompomerprimers. Experi-
bond strength to prevent the material from pulling mentsare currently being carried out to scientifically
awayfrom the margins and walls of the cavity during evaluate this issue. For the permanentdentition, one
polymerization. mustevaluate each case and determinethe quality level
of enamelbondneededfor the situation and the clini-
Compomers cal scenario. If the patient is cooperative and the
Compomersare the newest memberof the family opportunityexists to take the time to etch, rinse, and
of restorative materialsavailablefor pediatric restorative dry, then the option to etch must be considered.
dentistry. Compomers are defined as polyacid-modi- Compomers have been received with great popular-
fled resins. Compomers are essentially resin composites, ity, and particularly in dentistry for children.15 Their
with the difference that the componentresin mono- composite-like esthetics, minimalsteps in placement,
mers are modifiedto contain acidic functional groups no mixing, light polymerization (command-cure),and
capable of participating in an acid/base glass-ionomer other features combinefor highly rated ease-of-use. In
reaction after the polymerizationof the resin molecule addition, the actual handling characteristics of
has taken place. compomersare reported to be amongthe best of any
Significant confusion has been created concerning available materials. Their physical properties approach
what compomersactually are. Compomers(the name those of resin composites, the strongest material de-
is a hybridization of COMPositeand Glass IonOMER) scribed heretofore.
are not glass-ionomer materials. As mentioned As a single-component material, compomersare
previously, a true glass-ionomer material must be a availablein a variety of delivery formsincludingsyringe
two-component system, otherwise the acid/base reaction (screw) tubes, Compules, and most recently in
would take place immediately. The only way to use a Aplitips.It is likely that the successof compomers will
real GICis to mix its componentsprior to use. In continue for the foreseeable future, mainly becauseof
the single-component compomer system, there their ease-of-use. Further developmentof these mate-
must be no water or moisture to prevent a premature rials will result in an eveneasier-to-handleproductand
GICreaction. will likely offer other enhancedfeatures.
With compomers, a resin polymerization takes A common question that arises concerning
place, after whichthe materialis completelyset. Aglass- compomers is howthey can effect the marginal inter-
ionomerreaction then occurs in the presence of water face with their fluoride release if the GICreaction
(the necessary mediumfor an acid/base reaction) only doesnt occur until after the material is set. Theanswer
after the restoration is placed and water is absorbed is that these materials release fluoride fromtheir sur-
from saliva into the surface. In the presence of water face and can imparta fluoride effect to the surrounding
from the ambient environment, the acid functional environmentas the fluoride is incorporated into sur-
groups which are attached to the monomerunits and roundingtooth structure.
are nowpart of the polymerizedmaterial, can react with Compomersare thus much more like resins than
the glass (base) to initiate a glass-ionomer reaction. As glass ionomers. Their great acceptance is due prima-
result of this reaction, fluoride can be released. Although rily to the easy handling of these materials. When
somecompomers mayhave fluoride salts in addition to placed into a cavity preparation, compomer materials
the fluoride released fromthe latter GICreaction, the handle exceptionally well, and are described as "stay-
amountof total fluoride released is significantly lower ing in place" better than any other unset material. With
than that of traditional GICor RMGI materials. amalgamas the standard for clinical ease-of-handling,
Becausecompomers are essentially resin composites, compomers are accepted as having the greatest level of
they generally require the use of primers (and possibly user-friendliness amongthe nonamalgam materials.
adhesives) prior to their placement,la These interme-
diary fluids allow the compomer resin to adhere to the Composite resin
tooth structure in the preparation. Compositeresin, also knownas resin composite, is
Acid etching has been described as an optional step the mostesthetically desirable materialdescribedin this
with some compomers.The primers and/or adhesives paper. Composite resin contains a monomeric or
used prior to placement of the compomer can contain prepolymericresin that is filled to various levels with
acidic constituents whichcould provide etching of the glass or quartz. Thefiller particles are silanized (also
dentin and possibly the enamel. Within the primary referred to as silanated) to allow the hydrophilicfiller
dentition, it is possible that the use of compomers in to bond to the hydrophobic resin matrix. Good
their currently available form without etching maybe silanization is essential for obtaininga stable material

Pediatric Dent#try-20:2, 1998 AmericanAcademyof Pediatric Dentistry 95

which is resistant to wear and homogenousin its merization shrinkage. This shrinkage, ranging from 2
composition. Also contained in resin composites to 3.5%(volumetrically), causes the composite, which
are pigments, stabilizers, and a photoinitiator.
has bondedcircumferentiallyto the cavity walls, to pull
Radiopaquingagents such as yttrium trifluoride may towards the center of its mass. This force can create
tension that can be relieved by placement technique.
also be addedif the filler itself is not radiopaque,as is
the case with quartz and someglass compositions. Incremental placement has been proposed as a method
The physical and mechanicalproperties of compos-to minimize polymerization shrinkage. The numberof
ite resin are excellent. These properties, such as steps and the care required to effectively place a com-
compressive,flexural, and tensile strengths, meet orposite-resin restoration is the greatest in this category
exceed the respective strengths of amalgam.Compos- of materials. In spite of this, their excellentesthetics,
ite resin, however, has not completely replaced clinical durability, and other continuously improving
amalgamas a restorative material only because of itscharacteristics are winningthe support of moreprac-
titioners, and their use in both anterior and posterior
relative handlingdifficulty. Several clinical steps must
be taken to allow compositeresin to adhereto the tooth
pediatric restorative dentistry is growing.
structure. One must obtain an excellent interfacial Composite resins are available in a variety of shades
bonding of the compositeto the tooth, whichis gen- and opacities. The clinician can easily duplicate the
erally accomplishedthrough the use of an intermediary
appropriate tooth shades by using a shade guide before
bonding agent. Most modern bonding systems (not cavity preparation. Thecolor stability of compositeshas
specifically discussed in this paper)16use an interme-
also improvedconsiderably in recent years.
diary priming agent which allows a hydrophobic It is importantto be able to distinguish filler con-
bonding agent to bond to the wet surface of the den-tent (quantity) fromfiller size (particle size) within
tin below.This is necessaryto create a superficial bond
composite resins.17 With manyrecently introduced
to the hydrophobiccomposite resin. A mechanical in- products described as "flowable" composites or "hy-
terlocking is achieved by flowing the water-tolerantbrids" or other designations,it is critical to distinguish
primer into the surface of the dentin whereit perme-betweenthese different compositeresins and to under-
ates the spaces in the networked structure of the stand the clinical use implications.
collagen that was created by the acid etch. The bond- Filler content is merely a description of the quan-
tity of filler in a composite.It is generallymeasured
ing agent bonds to the primer and the compositeresin. as
In so-called fifth-generation systems(see Swift in this
the weight:weight quantity of filler placedinto the resin
issue), the chemically active agents makingup the matrix, and is expressedas a percent (Table1). If there
primer and bondingagents are delivered from the sameis nofiller in the resin matrix, the materialmaybe called
bottle. Evenin these cases, a priming procedurefol- an "unfilled" resin. Thesematerials are used as unfilled
lowed by a bonding procedure must be accomplished sealants, and sometimes as components of bonding
prior to placementof compositeresin. agents. If the resin matrix is filled approximately30%
One must be aware that polymerization shrinkage by weight, the material maybe designatedas a "filled"
does occur with currently available composites, and sealant. Manysealants are filled to this extent today.
Somebonding agents are also filled as muchor even
careful bondingand placementare therefore essential.
As it is polymerized,compositeresin undergoespoly- slightly more, and are therefore called filled bonding
agents. The introduction of "flow-
able" compositeshas created the need
to define filler content. Flowable
compositesare composite-resinmate-
rials that are 50- to 70%-filled by
weight.Whatone calls flowableis the
definitionof the user.
Highly filled, modern, compos-
~-~-"~v4 ite-resin materials are 75- to
85%-filled by weight. At this level
of filler content,a stiff, easily pack-
able material is achieved, whichcan
be used for both anterior and pos-
terior placements.
t] 1 2 ~, 4 5
The mathematics of adding
more filler to resin and measuring
the weight:weight filler content
Fig.Relationship
offiller:monomer
ratiotopercentage
fillercontent
ofcomposils. percentage shows that the more

96 American Academy of Pediatric Dentistry Pediatric Dentistry - 20.2, 1998

 Therefore, a composite-resin material can be both
flowable and a hybrid. It could also be a flowable,
microfilled material. It is importantto be awareof both
Filler Content(w/w), the filler content and size to appreciate the appropri-
Category ApproximateRanges ate clinical indications for the material. Many clinicians
Unfilled resin 0 % choose to purchase only one material, commonlya
Unfilled bondingagent 0 % hybrid that can be universally used. However, to
Unftlledsealant 0 % achievethe best esthetic results for anterior restorations,
Filled sealant 15-50% microfilled materials are sometimespreferred.
Filled bondingagent 15-50 % Continuum
Flowable composite 50-70 %
Compositeresin 70-85 % Basedon the definitions anddescriptions of the vari-
ous categories of restorative materials, one could
imagine a continuumover which these four materials
could be viewedwith respect to their characteristics,
with glass ionomerson the left through compositeres-
ins on the right (Table 3). Construction of such
TypicalParticle continuumis logical whenone considers the overlap
Category Size Range(gtrn) in clinical-use indications.~8 Thebehaviorsand physi-
cal properties of these materials warrant an
Microfilled .01 -. 1 ~9
understandingof their relationship to each other.
Hybrid(contains various 0.5 - 5.0 Traditional GICsrelease high levels of fluoride,
mixturesof microfillers bondto tooth structure, 2 and dont shrink.2. However,
andmacrofillers) GICs are somewhatopaque in color, must be mixed,
Macrofilled >5.0 - 50 and lack strength for someposterior indications. The
RMGIswere developed to overcome some of the in-
adequacies perceived with the GICs. They are light
polymerizable because of their resin componentand
filler added,the less the filler content percentagenum- have better esthetic properties than GICs.It is inter-
ber will rise (Figure). Whatthis meansis that, for esting to note, however,that in order to improveupon
example,ifa compositeis 50%filled (i.e., a low-filled, GICs, technology was borrowedfrom the right side of
flowable composite) then the filler-to-resin weight continuum,the composite resins.
ratio is 1:1. If twice the amountof filler exists in a Similarly, becauseof perceived inadequaciesin the
different composite resin, then the filler-to-resin ease-of-use of composite-resinmaterials despite their
weight ratio is 2:1. However,the filler content rises excellent physical properties, compomers were devel-
only 17 percentage points to 67%.If three times the oped. Compomers are essentially composite resins, as
amountof filler is added in a third exampleof com- mentioned,which borrowedthe glass-ionomer reaction
posite resin, the resulting weight percent is 75%. from the left side of the continuum,the GICs. This
Thus, one can see that a low-filled flowable compos- GICreaction takes places only after the material is po-
ite has only one-third the amount of filler of a lymerizedvia a typical resin-polymerizationprocess.
minimallyfilled hybrid composite. Someare filled to Onecan visualize the interrelationships of the four
as much as 85%. materials of this continuum.Cognizanceof the specific
Aseparate issue to be consideredis the filler size of strengths, weakness,and features of each material will
the particles in the material. Thefiller size is generally enhancethe clinicians ability to makethe best choices
expressedas the mediansize (usually the modeas well) 22
for eachindividual situation.
of the filler particles withinthe resin matrix(Table2).
Fillers ground to 5-50 ~tm are referred to as Clinical
distinctions
and
situations
"macrofillers". Fillers that arent groundbut produced Whenevaluating materials for a given clinical situ-
by other procedures and range from 0.01 to 0.1 ~lm ation, one mustfirst accept the fact that such evaluation
are called "microfillers". Whenvarious mixesof macro- is needed.In other words, if it is predeterminedin the
and microfillers are created, with a resultant typical practice that a certain material is alwaysused for cer-
particle size rangingfrom0.5 to 5.0 I.lrn, the material tain clinical situations, then it is pointless to offer
is referred to as a hybrid. Thesehybrid materials offer several options. However,if one is open to selecting a
the advantageof being suitable for anterior (polishablity material basedon its appropriatenessfor the givenclini-
due to microfill) and posterior indications (durability cal scenario, then all available options should be
as a result of larger particle size). included in the selection procedure.

Pediatric Dentistry -20:2, 1998 AmericanAcademyof Pediatric Dentistry 97

 Resin-mwodified
Glass Ionomers Glass Ionomers Compomers CompositeResins
Setting Self-cure Self-cure(acid/base Light-cure Light-cure
(acid/basereaction) reaction)
Resincure
Light-cure
Mixing Two-component Two-component One-component One-component
system system system Nomixing required
Mixingrequired Mixingrequired Nomixingrequired (dual- or self-
cured composites,
require mixing)
DeliverySystem Capsule or hand mix Capsuleor hand mix Compules, screw Compules, screw

tubes, or Aplitips
tubes, or Aplitips
Fluoride-release High Moderate- High Moderate Minimal - None
Adhesion Chemicallybonds to Chemicallybonds Mechanicallybonds Mechanicallybonds
tooth (self-adhesive) to tooth (self-adhesive, to tooth, bonding to tooth, bonding
somerequire primer) agentsrequired agentsrequired (not
(not self-adhesive) self-adhesive)
Esthetics Opaque Good Very Good Excellent
PhysicalProperties Good Good- Very Good Very Good Excellent
HandlingPropertiesFair Good Excellent Very Good
Ease-ofluse Initially moisture- Less moisture Tolerates more Techniquesensitive-
sensitive,relativelyfew sensitive,relatively moisture,requires rubber damand acid-
steps, slowercuring fewsteps bondingagent etching/priming/
bondingrequired
Solubility Low Moderate- Low Moderate Low
Dimensional Thermalexpansion/ Higher thermal Higher thermal Highest thermal
Changes contractionsimiliar expansion/contraction expansion/contraction expansion/contraction
to tooth structure and polymerization and polymerization and polymerization
shrinkage shrinkage shrinkage
Examples ~
Fuji IX Fuji II~LC Dyract
TM TPHSpectrum
TM

Ketac-Molar Vitremer
TM CompoglassF
TM
Prodigy
Fuji II
TM Photac-Fil Quick
HytacAplirip Z100
F2000
TM
Charisma
Renamel
TM

Tetric Ceram
PertacII

Selection of the appropriate material should be
madeprior to beginning treatment, where possible,
and preferably at the time of diagnosis and treatment
planning. In somecases, however,selection of the mate-
rial cannot be accurately performeduntil the cavity
preparationis completedand a dearer assesessmentof the
remainingtooth structure, etc., can be made(Table 4).
For the primarydentition, in Class I, II, III, or V
situations, all four materials can be used. 23-25 In such
cases, you only need to determine the relative impor-

98 AmericanAcademyof Pediatric Dentiswy Pediatric Dentistry- 20:2, 1998

 Resin-modified
Glass Ionomer Glass [onomer
ClassI or Primaryteeth Primaryteeth Primaryteeth All situations
Preventive Permanentteeth Permanentteeth Permanentteeth whereexcellent
Restoration (small) (small) (small) estheticsare
needed
ClassII Primaryteeth (small) Primaryteeth Primaryteeth All situations where
Goodfor high fluoride- Goodfor high fluoride- Permanentteeth excellentisolation
release scenarios release scenarios (smallor transitional)is possible
ClassIII Primaryteeth Primaryteeth (small) Primaryteeth All situations where
(~sitional) wherehigh Permanentteeth Permanentteeth excellentisolation
fluoriderelease is needed (transitional) (selectsituations) is possibleand ultimate
esthetics are needed
Class IV Primaryteeth Primaryteeth Primaryteeth (small) Requiredfor best
(temporary) (transitional) Permanentteeth esthetics--good for
(transitional) incisal stress areas
Class V Primary and Prim~ and All situations where All situations where
permanent teeth where permanentteeth goodisolation is excellentisolation
fluoride release is more possible and good is possible andultimate
importantthan esthetics esthetics are needed esthetics are needed

tance of the inherent strengths and weaknessesof the
different material options. For example,if the patient
has a high caries risk, a high fluoride-releasing mate-
rial maybe the best choice. If esthetics is the main
concern, a composite resin or a compomershould be
used. If there is concernabout occlusal stress, the ma-
terials with better resistance to wearshouldbe chosen.
Similarly, if ease of placementis the important con-
sideration, a RMGIor a compomer should be
considered. For Class IV restorations of the permanent
dentition, only compositeresin can provide the appro-
priate strength, wear resistance, and translucency/
esthetics neededfor this situation. However,even in
Class IV preparations, compomersor even RMGIscan
be used as long-termtransitional restorations.
In the permanentdentition, where tooth and res-
toration wear, esthetics, and longevity have different
importance, care should be given to the longer term
aspects of the restoration, with particular attention
to wear resistance. Therefore, for Class II restora-
tions in permanent teeth, only composite resin
should be used for long-term durability. Other ma-
terials can be used as transitional restorative
materials. Modernhybrid composites, when placed
according to the manufacturers directions, can pro-
vide excellent esthetic results with long-termsuccess.
For Class I restorations, including preventive resin
restorations (PRRs),26-28one can chooseany of the de-
scribed materials dependingon needs and the size of
the preparation. Glass ionomerscan be used as the fill-
ing materialbeneaththe surfacesealant of a PlieR.,29 30
as can RMGIs,compomers,or composite resins. For
Class III restorations in permanentteeth, only com-
posite resin can providethe ideal esthetics of the natural
dentition. Compomers might also be used for Class III
restorations in permanentteeth, but they will not have
the sameesthetic quality as compositeresins, although
their handling is simpler. For Class Vrestorations in
the primary or permanentdentition, any of the listed
materials could be used, the selection being madebased
on the priority of needs for the individual situation.
It is difficult to say that one should use a certain
material in every case of a certain situation. Givenan
understandingof the properties of each of the materi-
als available, the clinician must choose the correct
material based on the needs of the individual.
Futuredevelopments
It is clear that evenwith todays manychoices, new
ones will emerge.It is likely that changesin composite
resins will makethemeasier to handle, with attendant
improvementsto other problems, including polymer-
ization shrinkage and strict isolation requirements.
Compomers,on the other hand, will become more

Pediatric Dentistry-20.2, 1998 AmericanAcademyof Pediatric Dentistry 99

composite-like, while retaining the handling features
andfluoride release they currentlypossess.It will there-
fore be likely that compomersand composites will
becomedifficult to distinguish, as future iterations of
these materials bring themcloser together, allowing a
superimpositionof their combinedfavorable qualities.
Glass ionomers and RMGIswill also undergo fur-
ther development, moving toward a stronger,
condensablematerial that offer more universal appli-
cation-and the likely emergenceof more esthetically
desirable materials. In addition, GICswill retain the
feature as the material of choice whenhigh fluoride
release is desired througha transitional period.
Conclusions
Manynew developments have occurred in restor-
ative dentistry for children in recent years. Onemust
develop a clear understanding of the unique features,
strengths, weaknesses, and requirements of each ma-
terial available to be able to apply the right materialto
the right situation.
Continued development of the existing materials
will make them more user-friendly with improved
properties. Development in new directions will
likely add materials to the selection portfolio in the
years ahead.
Dr. Berg is head of the scientific department,ESPEDental-Medizin
GmbH & Co. KG, Seefeld, Germany,clinical associate professor,
Departmentof Pediatric Dentistry, University of Texas at Hous-
ton Dental Branch, Houston,Texas, and adjunct clinical profes-
sor, Departmentof Pediatric Dentistry, University of Pennsylva-
nia School of Dental Medicine, Philadelphia, Pennsylvania.
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This paper is ~omthe ContinuingEducationCourse"Restorative Materials for Pediatric Dentistry Today~
What You Should KnowToday and WhereWe Are Going.C at the AAPD51st Annual Session, May22, 199Z
The course was sponsoredby the AAPDFoundation.
100American
Academy
of PediatricDentistry
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PediatricDentistry- 20:2,1998