Our lecture today is about another filling material which can be used directly or indirectly and its called

dental composite. when we say direct placement of a restorative material, I drill a cavity in the clinic and I immediately fill it with permanent filling and the patient goes home , now there is an aesthetic material (composite) its a tooth colored filling material unlike amalgam so it cant be directly placed in the patients mouth therere modifications of these materials that have other things that can be used for indirect restorations, which means that you dig your cavity you take an impression you send it to the lab the lab makes the restoration for you then you cement it in the cavity in the patients mouth again this is indirect. So composite the regular composite is used directly some types are modified can be used for the indirect technique now a lot of people ask to replace there amalgam fillings with composite because they see the aesthetic difference , so they can be used as replacement of amalgam not in every case but in most cases , and can be used if you want to Re-contour the tooth and make it look like a normal one in tend of morphology that in this case we call

(pig shaped lateral incisor) the lateral incisor in this patient looks slightly pointed so i can use the composite and add it in layers and shape the lateral incisor so it will look more normal so this is another use of composite in addition to use as restorative material and it can be used to correct Diastema

means space between the two central incisors. Again composite was added to both teeth interproximly to make them contact each other and therefore to look more natural , but mostly for any filling material its used for necessity for restore function and of course for this case aesthetic , Before After

which

he have got cervical caries on the gingival third of anterior teeth incisors laterals canines so these cavities are gonna be drilled and then filled with composite because these teeth are in the interior part of the oral cavity so we need them to be aesthetic so this how they will look like after being restored . Okay another example of tooth colored material are Glass ionomer cements (GIC) which we will talk about next lecture there are modifications of glass ionomer cements its called Resin modified-GIC therere modification on composite it self and the resulting material is called Compomers well talk about it today . In terms of definition Composite means something that is compose of more than one thing , essentially its made of a matrix made of resin inside of this matrix therere are Fillers small particles that add properties such as strength, wear resistance, minimize shrinkage during setting we dont want our material to shrink because if it

shrinks there will be microleakge all around it right? so fillers contribute by minimizing shrinkage after the material sets now to attach these components together we need a material its called Coupling agent (silane) which will hold the resin matrix with an arm and hold the filler with another arm to make them all as one , and therere pigments to add different shapes so sometimes composite are yellow, deep yellow , grayish , more white to accommodate different shapes for different people . Now in terms of the resin matrix the major component is what we call BIS-GMA

(bisphenol A-glycidyl methacrylate) in addition to other types of monomers(UDMA (Urethane dimethacrylate) ) are add to minimize the viscosity of the material now if your material is too viscous you cannot manipulate easily it will not flow very well , that's why they add low molecular weight monomers to make the material less viscous but the major component is (Bis-Gma). Now fillers stand for many types like silica, quartz, glasses composed of barium,

strontium some of these are radio opaque some are radiolucent now we want to be able to distinguish the material on a radiograph because we want to know for example if it's filling the entire cavity or part of it is missing we want to be able to tell it apart from enamel and dentine so we should be able to see it on radiographs now fillers:
Add strength Increase wear resistance Reduce polymerization (setting ) shrinkage

different sizes of fillers are manufactured so there're different types of composites according to the size of the filler that is incorporated into it some types of composite have large fillers sizes some have smaller , the smaller the size of the filler the more polish-able and smoother the surface of the composite will be unlike large fillers but large fillers are stronger so for example that's why the type of composite that has small filler size can be used for anterior teeth because we only want aestatic but if we want more strentgh i can use composite with large filler sizes for exapmle in posertior teeth

Coupling agent (silane) binds filler to matrix and reduces wear and Pigments to produce different colors and shades

now the doctor is talking about this picture

This picture shows you the different sizes of the fillers in picture :This is types of composite that has large fillers now what happens is the surface of the filling is rough that's why it doesnt give me good polishability unlike a composite that has small fillers which is called Microfilled because it has microfillers . The first is called Macrofilled because it has large fillers the second one is Microfilled as we just mentioned and we can join them both together to get the best advantage of both types and its called Hybrid now this hybrid can be used for Ant. and Post. Teeth because it has strength and good aesthetics and nowadays we mostly use this type . Now the polymerization process is simply monomers joined together to form polymers like acrylic resin material that we talked about in the summer semester so we got initiators and activators we've got free radicals that join monomer chain
together to form one polymer then the material becomes rigid or hard so this process

goes on until all of the free radicals are used and there's no monomers to be joined together .

Now sometimes of these materials set by mixing some two components together like if you remember zinc oxide eugenol or rubber impression material you have a base and a catalyst the base contains the initiator and the catalyst has the activator once you mix them together the material becomes hard after 4 or 5 minutes after the reaction stops so this is a chemical cure material so the base here is made of composite and the initiator (benzoyl peroxide) just like normal acrylic resin and the catalyst again it contains the resin matrix and the activator (tertiary amine) so we need manual mixing which can't induce mistakes due to the incorporation of air bubbles this is one of the disadvantages of chemical cure material. Now other type which we use nowadays is the light cure it's only one component that contains everything but it has a component that is sensitive to light once you apply it in your cavity you subject it to a certain light with a certain wave length for 40 seconds or so the material will become hard so instead of waiting for 4 or 5 minutes 40 seconds the material is completely set so this is light cure material , now this wave length ranges from 400-500 Nm it depends on the type of composite and the color of this light is blue the unit itself is called light cure unit so we subject the material for this blue light for few seconds and the material becomes hard now how the setting occurs ? Now you place a specific amount of composite in your cavity and you're applying light, how deep you think this setting will occur? For example if you put 3 mm layer of composite how much should you apply inside the cavity? Can you place this composite in one pulp completely in the cavity all at once? No it should be double layer now that's how deep curing can occur? It depends on factors:1- how strong the light is (the intensity of the light). 2-how thick is your composite. 3-the shade of the composite itself ( if it's dark or light ) this can affect how easy the light can pass thru the layer of composite and cure it from top to bottom. 4- the distance between the light source and your filling so if i place my light source as close as possible to the composite this is much better than placing it too far away because if it's too far away the intensity of the light will decrease it wont be the same .

* Darker shade composite: - you might need to place it in thinner sheets (smaller amounts) so you can get assured that the light will pass thru from the top till the bottom . so these four factors are from the most important factors that can affect how deep your light can reach and cause the material to properly sett if your material not properly sett it will be weak , it might fracture , it might cause microlekage , it might cause recurrent caries and staining , part of its components might leak out and this is can cause toxicity all of these components once they are set involve in the reaction they're not harmful but , if we allow them to leak out they might cause damage to pulp or dentine so we need our filling to be set and hard . the third type of materials (This classification is according to setting mechanism ) is Dual cure material so two pastes system like chemical cure materials but the difference is botfly reactions occur so you mix it you put it in your cavity you apply light once the light is been applied for 40 seconds for example you turn it off the material will continue to set chemically , when do we use this type of material ? when we have deep cavities that are interproximal, when we have deep cavities we are not sure that the light is going to go all the way down for example if the cavity is sub-gingival so im not sure that the light can go thru and cure the lower layer we can use this type of composite because it will also chemically set with time so even if light don't reach the bottom layer for example it will chemically set on its own after few minutes so this type of material is indicated if you have deep cavities if you're not sure that the light can reach the lower layer of the composite .

Classification of composites
Now another way of classifying composite is according to the size of the filler:-Macrofilled: - large size fillers . -Microfilled: - small size fillers . -Small-Particles composite. -Hybrid: - mixture of Macro and Micro. -Flowable :- Very low viscosity . -Pit and fissure sealants: - Used to see pits and fissures on Post. teeth and they're based on Resin.

-Packable composite: - which means that you can actually condense them in cavities (they have high viscosity). -Smart Composite: - they're manufacture claims that they can produce fluoride. -Core build up composite:- they can be used if you have a badly destroyed tooth that you want to place a crown on you can build up the tooth with a filling then prepare it and place a crown on top of it , again this type of composite is viscous and stronger than the other types of composites ( it has large fillers ) usually used in Post. teeth. * The doctor said that we don't have to memorize the size of the fillers in each type of composite and she started reading the slides without extra details .

Macrofilled composites
*First generation *Difficult to polish (Because the fillers are large) *Stronger than composites with smaller particles (So theyre strong but difficult to polish thats why theyre not used in Ant. Teeth)

Microfilled composites
*Volume of filler is 35-50%(smaller compared to other composites due to the larger volume of several small particles as opposed to one large particle of the same weight) *Lower physical properties ( Not Very Strong ). You cannot keep adding fillers over and over again to the resin matrix because you want to keep space for the resin itself thats why instead of adding small fillers that will occupy a lot of space they suggested adding both large and small fillers ( Large fillers and in between small fillers ) so in total youll have a larger filler volume which will add good properties .

Small particle composite

*Used to be used for posterior restorations but have been replaced by hybrid composite

Hybrid composite

*Mixture of macro and microfillers (75-80% by weight) *Microhybrid composite: contains 2 particle sizes, small 0.5-3 m and microfine fillers 0.04 m *Hybrids have high polishability and strength so they can be used for anterior and posterior restorations

Flowable composites

*Low-viscosity, light cured *Can be lightly filled (40%), or more heavily filled (70%) *Delivered into cavity using a syringe *Weaker and wear more compared to hybrids (Because it doesnt have the same argument of fillers as hybrid composites ) *Used for PRR :- Preventive Resin Restoration in this restoration they just drill or open up the fissures on the occlusal surface of Post. teeth with a shallow cavity maybe 0.5 or 1.0 mm and they fill it with this type of composite so if you have a shallow caries just 1 mm deep on pits and fissures you can use this material to fill it . *Pit and fissure sealing *Liners (cushion stress caused by polymerization shrinkage of overlying composite) *Class V

- to make the material flow very well we need to have smaller filler amount . - can be used for cavities not subjected to stress

Pit and fissure sealants

*Range from no filler to more heavily filled composites similar to flowable composites *Low viscosity *Preventive material

Packable composites

*Highly viscous *Heavily filled *Stiff and strong *Posterior restorations (as a substitute for amalgam) *Shrink less due to higher filler content

Smart composites

*Combat caries by having the ability to release fluoride, calcium, hydroxyl ions when acidity increases *Effectiveness has not yet been proven

Core buildup composites

*Heavily filled *Replace lost tooth structure in teeth needing crowns *Colored to distinguish them from natural tooth structure - The first choice for core buildup material is amalgam, if you cant use amalgam you can use composite.

Provisional restorative composites

*Replace acrylic resin in constructing provisional onlays, crowns and bridges *More expensive than acrylic, but wear less, and shrink less, and produce less heat when polymerized. Easier to repair with flowable composite *However, they are more brittle than acrylic - Other types of composites can be used as a temporary material not a temporary filling but temporary crown now if any of you have ever a crown or a bridge placed in his oral cavity what the dentist does that he prepares the teeth and takes an impression and send it to the lab then lab will send you a porcelain or a metal crown, until the lab prepares this crown we need some sort a temporary restoration to cover the tooth thats why we need temporary crowns until the permanent crowns are done , usually the material thats used to make this temporary crowns are made of acrylic material the material which is similar to the denture material , now variations is a dental material made of composite which gives better shape stronger material and less shrinkage and produce less heat ,the disadvantage is composite is more expensive than acrylic .

Physical properties

Biocompatibility ---> Polished composites are tolerated by soft tissue. Bonding agents protect pulp by sealing tubules In terms of biocompatibility if your filling is well polished has a smooth surface then , minimal plaque accumulation , minimal irritation for the soft tissue . Underneath composites we usually use a material to bond to enamel and dentine we use bonding agents , now these bonding agents once theyre applied to enamel and dentine they can seal dentinal tubules this will minimize any leakage underneath the filling it will also minimize sensitivity because its blocking dentinal tubules and you know dentinal tubules reaches the Pulp , so once you seal it youre actually protecting the Pulp Strength ---> Larger filler composites are stronger in tension and compression In terms of strength , larger fillers are stronger but less polish-able . Wear ---> Lower filler content increases wear. Composites wear more than amalgams Polymerization shrinkage *Composite shrink away from cavity walls *Minimized by incremental placement. *Can cause postoperative sensitivity, & pressure on tooth. The major problem in composites is polymerization shrinkage , more fillers mean less shrinkage and we can minimize shrinkage of the material if we place it in layers rather than one bulk , so if you have a cavity which is 4 mm deep you need to place the composite in layers 2 or 3 layers , the maximum thickness of the layer is 2 mm , so its better to place it increments this will minimize shrinkage , because once you place a layer and cure it then you place another layer it will flow and occupy any space was created by shrinkage and so on until you reach the surface , and sometimes even on the top layer we can add a layer of flowable composite or pit and fissure sealant

that will close any gaps or voids on the surface so layering is very important in composite to minimize shrinkage or the effects of shrinkage because it can cause postoperative sensitivity and cause pressure on the tooth because when the composite shrinks and its attached no enamel and dentine it will pull enamel and dentine with it as it shrinks and this can cause fissures which can cause sensitivity and pain so :- The lower the shrinkage , the lesser the sensitivity and pain that is associated with composite , usually these patients might feel sensitivity for two weeks after placing composite filling this is normal . Now this is one outcome of shrinkage , newer composites they shrink-less to avoid for example staining which indicates that theres microleakage .

This is an electron microscope image and we can see there is a gab between the composite and the tooth and its large , so bacterial can easly enter it and cause damage , so we need it minimal as possible .

Thermal conductivity : composite has low thermal conductivity similar to enamel and dentin .

Coefficient of thermal expansion (CTE) : greater than enamel and dentin so it will expand and shrink in a different way from enamel and dentin , so this will cause more gab formation between the composite and the tooth because the reaction to heat or cold is different and this will cause debonding or leakage . so we need to add more filler to decrease this coefficient of the composite to be slightly closer to enamel and dentin . elastic modulus and water absorption : because the material contain resin there is a chance to absorb some water , so more resin content less filler more water absorption , and vice versa less resin more filler less water absorption . fillers make the material more rigid so the elastic modulus become higher . radiopacity : depends on the component . barium and strontium have high radiopacity , quarts has low radiopacity ( radiolucent ) . in the anterior composite we prefer to use a translucent material because its shape will be more natural , but for posterior teeth its not an issue we can use the material that has high radiopacity , so it depends on the clinical application .

Composite is used for all sorts of restorative procedures from class I to class IV ( I think from 1 to 6 ) , so its used in the occlusal surface of posterior teeth , proximal of it , proximal of anterior . Etc

Now the selection depend on the clinical situation esthetic or strength :

-Esthetic demands: Microfills , and microhybrids are good choices - Strength demands: in posterior teeth and stress bearing areas, hybrids and macrofills composites .

shade guide :

To produce the best esthetic result what you can do is place the composite on the patient mouth and then cure it to the light to see how close its matching between it and the natural tooth . now we have what we call it the shade guide that show us different shapes of composites , and by this we can match between this composite and the patient tooth and select which one is similar . Its very important when we use the shade guide not to use the fluorescent light ( neons light ) , the best light to use to match the composite with the patient tooth is the normal day light ( not in the morning , not in afternoon , just the normal midday light ). So this is the best light source to match between the composite and the patient tooth . shelf life : always you need to pay attention to the package of the composite material to see the expiry date or sometimes you need to place it in the fridge and in a certain temperature range just to keep it useable as long as possible like 2 3 years and this is average shelf life . if we use the material after expiry date its properties will change so you need to pay attention to that . ** now the composite material is very sensitive material so it need to be isolated from blood and saliva contact in the cavity , so must be complete isolation in composite technique to inhibit contamination and the tooth surface should be clean from any saliva , blood , small particles that result from cavity preparation . The ways to isolate the tooth from the rest of the cavity : we can either use rubber sheet (( rubber dam ) it placed around the tooth to isolate the tooth from the cavity ) or use cotton nods (not clear ) . Sometimes we need to expose the margins of the cavity by pushing the gingival somehow by using small ropes called retraction codes , and put it between the tooth and the gingiva to push it away , so there will be a complete isolation from blood and saliva , and expose the margins of the cavity that are subgingival . .so these small ropes push the gingival and absorb any saliva or blood .

The composite is soluble , its supplied by a syringe other ways its supplied by a tube .

Now if my cavity in the proximal surface of the tooth and need to reproduce the adjacent tooth contact to make good contour and smooth surface we use matrix stripe ( made from cellulose and its transparent ) . this stripe is put all around the tooth in order to produce good contour and smooth surface and it should be transparent because I want the light to pass through to my filling .

the incremental placement is important to : - minimize the polymerization shrinkage - allow the curing light to penetrate properly from upper to lower layer . Incremental placement and good isolation are the major things about composite . We can put the incremental layer horizontally or one layer is vertical , or incrementally layer by layer but not more than 2 mm thickness , if the shape of the composite is dark we can put it 1 mm thickness to make sure light will pass all the way through . ** in amalgam we use mechanical retention ,now in composite we us micromechanical retention and thats mean : we need to treat the tooth ( enamel and dentin ) by a material that will give a rough surface , now the adhesion to the rough surface is better than smooth surface ( the retention will be better ) , so the composite will be able to flow on the irregularity of the enamel and dentin and it will be retained . because of this irregularity there is microholes so we named it micromechanical retention . now to create this surface we need amaterial basically is an acids and it will remove some mineral from enamel and dentin , its phosphoric acid and the concentration of it is 34 37 % and we apply it for a certain amount of time then you wash it . once the tooth is dry the color of namel and dentin was changed ( will be chokywhite like snow ) . so the acid will remove part of the

mineral , make the dentinal tubule open up and create rough surface on which we can put our material later on. So the etcher is phosphoric acid . after doing that we need one more step before putting our material ,we will apply a liquid which is called bonding agent , it will bond itself to enamel and dentin by micromechanical retention , and it will bond to composite chemically ( because its made from the same material of composite ) at the same time . this bonding agent is made up from resin and its liquid you applied using a Brush on enamel and dentin after etching and its set by light like composite . So 3 main steps : Etching , bonding agent and cure it by light then we put layer by layer of composite to fill the cavity completely , which bond chemically to bonding agent .

The etcher ( acid ) can be liquid or jell and the jell is better because you can control the area that you need to put the jell on ( the jell doesnt low every where ) .

So we have in the mid ename and dentin , bonding agent and composite , this arrangement cause a specific interaction called the hybrid layer and its the bonding agent attach to composite and penetrate tooth structure .

Once you applied the first layer of composite and cure it by light, the other layers will bond chemically to each other because of same content . the surface layer will have a sticky surface because it will be exposed to the air and wont be completely polymerized ,we call it air inhibited layer , the solution is when you finished you will remove this layer and its a small layer can be removed by cotton and end up with a completely polymerized composite .

Now once you completed etching accidentally there is some saliva you need to repeat it , because this caontamination will lead to accumulate of saliva on the rough surface and will inhipit bonding agent to flow on it so the material will fall down .

Some of the material we talked about in the summer course is zinc oxide eugenol material its an impression material some variation of this material can be used as a temporary filling material we call it zinc oxide

eugenol filling material

Now the presence of eugenol in term of composite , Its prevent the complete sitting of composite, If the sitting is incomplete the material will be weak so if u have a deep cavity and u want to place al liner or a base to protect the pulp u cant place zinc oxide euginol base or liner underneath composite

Light-curing:

e as possible to composite The curing time is from 20 40 sec usually the bonding agent is 20 sec and the composite it self 40 sec not less than that because it will not set properly the whole thickness of the layer it said in the slide use more time but the dr. said the better option is to use thinner layers rather than increase the curing time

Finishing and polishing: sandpaper discs,fine, ultra-fine diamonds.

Abrasive strips and needle-shaped diamond burs are used. Polishing pasts can also be used. If u want to make sure that the upper layer of composite has no holes at all ,,good smooth surface ,, a layer of flowable composite or some time a layer of bonding agent on top , it will give u smother surface which mean good polashiablite and good esthetic appearance . Different type of light curing machine are available It depend on the light source tensity mean shorter curing time Ex : Plasma arc curing units (PAC), Argon laser units Some of them are cordless so you handle it without having a cord attached to the device Some of them corded

Precautions for light curing

These device should be checked regularly to make sure that the intensity of light doesnt decrease over time . Premature set of composites When we use composite you need always to cover it keep it away from any light source a.e light from the dental chair , natural light it can initiate the reaction so we have to keep the composite in a dark area to prevent pre mature sitting of the material . Eye protection The light that come out from the curing unit can cause damage to the patient eye or your eyes as a dentist it can cause cataract so we need to protect the patient eye using special glasses some time a certain shield could be placed so that when you are placing the light cure unit and you are curing your composite you dont actually directly look at the blue light . Heat generation not all the unit produce heat but if you are very close to the pulp and you might think that if I use the light as close as possible to tooth it can generate heat and cause damage to the pulp , I can place a liner or a base in deep cavity

Light curing unit, protective glasses and shield

Modification on composite to give them a better quality, more attractive Are called Compomers Polyacid modified resin meaning the incorporate acid inside them manily arclic acid now this material , they clam that it can release fluoride . now in comber to another fluoride releasing material such as glass ionomer cement , the amount of fluoride it releases is very small . Because the fluoride within the composite material is actually captured by the resin and the risen doesnt allow it to release as much as we wanted to

The main material that is able to release fluoride to prevent the caries is glass ionomer cement So in compomers they try to modified composite to get advantages both from composite and glass ionomer cement in one material . These material set by two mechanism I. One of them is light curing mechanism main one II. acid base reaction why { because it have the acrlic acid incorporated into it] And they can shrank so you need to apply them in layers and require a bonding agent so similar to composite material

Indirect esthetic materials can be use

Either to restore labial surface of the tooth Missing cusp of the tooth or destroyed cusp we call it onlays In cavities in the proximal surface we call it inlay Can be used as a crown general speak for esthetic material except the composite we cant make crowns Indirect composite Manly it can be used in this cases Veneers remove part of the enamel in the labial surface .5mm then u take an impression and then to lab will prepare a veneer for u to

replace the missing structure in composite u can do this directly without take an impression if u got for example staining in tooth surface , shape of tooth is abnormal u remove [part of the enamel and then applied composite, shape it and we are done we can use regular composite or modified composite reinforced So they can be used directly or indirectly after taking an impression So if u use directly method u use a regular composite if u want to use it indirectly by taken an impression we can use the modified composite or any enforced composite that are made stronger Now one advantage of using this technique because the lab technician is curing the composite in the lab shrinkage occur out side the cavity so , once you cement it inside the patient mouth there are no more shrinkage because the material is already set we simply attaching it to the cavity Restorative materials used: Conventional composite Fiber reinforced composite. Fiber source is carbon Kevlar, glass fiber, polyethylene ( to improve strength). Particle-reinforced composite: heavily filled (70-80% by weight) with ceramic particles to improve wear resistance. These types are mainly used of indirect restorations that require impression and lab work

When we talked about rubber impression material addition silicon .. we said that they can be used for bite registration and for indirect restoration how dose this happen once you drill a cavity in the tooth you take impression using alginate now you want to pour your impression you are not going to pour it in gypsum ,, you actually pour it in rubber material in addition silicon rubber material to have a cast So this cast will not be made of gypsum it will be made out of rubber On this model u can add composite to make a restoration cure it and then take it out, and place it in the patient mouth if you dont remember this type of rubber material go back to the impression material slide So one way of using rubber material to make models out of them for this sort of filling material Now in term of taking the shade of the composite to the teeth of the patient three things to consider What is the basic color of the patient toothhue how intense is the shade chroma and how dark or light the shade of the tooth is value The process of selecting the shade is group effort you the patient and the assistant are involved to select the shade This is the shade guide it have what we calls taps made of crowns of central incisors and it dived to A,B,C. so you select one or two from them bring it close to the patient tooth put water on it because

normally your teeth are covered with saliva the shade of your tooth is different when its dehydrated using normal day light You always need to select the shade before cavity preparation , The tooth should be cleaned no stain no debris U can use natural day light some time u can use more tha one light sources and select something in between shade that look good underneath both light sources because usually most of us they are not always under natural day light usually we are in the offices, lecture hall , libratory were is artificial light so we can use two light sources select prober shade for both light sources Teeth may have different shade under different light sources metamerzime Female patients should be asked to remove lipstick, and colorful clothes should be covered A neutral background should be used (e.g. blue apron) to cover the cloth of the patient Several tabs are held close to patients teeth and select the prober one Some people have certain stains on there teeth and they tell you I want the stain to be back I dont like my tooth to be absolutely white or same color from gingival third to insicial third I need some staining in the gingival third I need it to look a little bit yellowish just to match the against teeth { enamel is thin in the cervical third ] so some time

we need to use two shades for the same tooth especially if am doing a vianeer ,, same as enamel We have Graduation in shade from inscial to gingival ends Some time a photograph can be taken before but we dont do that usually in the clinics Some types of composite are called body composite or dentine composite ,, it is shaded more yellowish than other type of composite so you can use enamel composite, composite that have similar shade to enamel so layering procedure can be done to produce best esthetic result