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Composite Resin Restoration

What are the main components of composite restorations? 1. 2. 3. 4. Resin matrix (organic phase) Fillers (inorganic phase) Coupling agents Initiators

# Resin matrix the organic phase of the composite, mainly composed of Bisphenol-A-glycidyl-methacrylate (BIS-GMA), UDMA, TEGDMA. # If we have resin alloys, we have to keep in mind that the resin or the matrix part is the weakest and least wear resistant so we need to add fillers to improve the physical properties. # Types of fillers: Quarts, silica, glass. Why we add them? To improve the coefficient of thermal expansion, we need to be as close as possible to the tooth structure. If there is a huge difference between the CTE of the tooth and the CTE of the restorative material this will create more stresses during exposure to the thermal changes, and this will affect the bond strength between the restorative material and the tooth structure. So we added the filler to 1. decrease the polymerization shrinkage 2. To increase the wear resistance 3. To improve the density and hardness 4. To improve the translucency

Classification of composite restorations

# based on the filler size (macrofill, midifill, minifill, microfill, nanofil, and hybrid) Note: hybrid type is the one we use in the clinic, and it is a collection of two types of filler particles (micro type to improve the esthetic and another type of larger size to improve the mechanical properties of the composite restoration) #based on viscosity (conventional, packable, and flowable) Packable is higher in viscosity and flowable is lower in viscosity. Example of a high viscosity material used in the dental clinic is Impression compound Example of a low viscosity material used in the dental clinic is fissure sealants

Physical properties of composite restorations

1. Polymerization shrinkage as a result of curing the resin the range is 2-7 %. The shrinkage will cause forces and stresses on the tooth and the restoration 4-7 mPa Subsequent effects of polymerization shrinkage a. Staining b. Recurrent caries 1

c. Postoperative sensitivity 2. CTE of composite is 2-3 times higher than the CTE of the tooth. (Glass ionomer has a higher compatibility of thermal expansion) This difference of CTE means that the restorative material will shrnk more on cold and expand more on heat so imagine the stresses every time you eat an ice cream or have a hot drink

Handling characteristics
1. Composite restorations is a little bit viscous, so when you apply it especially the first layer in your cavity you might encounter some sort of difficulties to adjust and adapt that piece against the walls and the floor of the cavity. You have to make sure that you condense the composite well against the walls of the cavity, to avoid voids incorporation. The ideal viscosity to work on is to have it not sticky to the instrument and at the same time easily manipulated not to be hard so you can shape your restoration before curing and also you dont want it to slough down will you are curing. It should be able to hold it self against the walls until u cure it. HELPFUL TIP: bring a piece of gauze and put it over the bonding agent and then little bit wipe your instrument so that composite will not stick to it and in the same time it will not dilute the composite restoration. Basic steps: a. Acid etch (the Enamel after acid etching should appear frosty white, dentin on the other hand should not be very dry it will dissect the dentin and weakens the bonds). b. Apply the bonding agent and light cure it for 20 seconds, be sure that you apply a thin layer of bonding agent, do not apply thick layer, on radiograph it will appears a radiolucent line beneath the restoration, which will be mistakenly interpreted as a recurrent caries. c. Apply composite. (Layering technique) dont place it as a bulk. The maximum thickness is 2 mm. why? For maximizing the effect and penetration of light curing. And maximize the degree of conversion of the composite restoration. If you are using a darker color you can increase the curing time. Polychromatic restoration: poly means many, chromatic means color, so we might use more than one color to build a tooth. Because we know that the cervical part of the tooth is darker than the incisal part of the tooth. So sometimes you need to go and use darker color first and then lighter color. advice: when you are going to put the last layer of composite place it as a one layer, slightly overfilled, otherwise the demarcation between pieces will appear after curing making the finishing struggling. d. Check the occlusion using articulating paper and interproximal area using a dental floss. Notice: it is important to place the matrix and the wedge before etching and bonding, because if you dont do this the etching and bonding will affect the adjacent tooth. Do we need to apply bonding agent between the composite layers? No, because they are chemically bond to each other. There are free radicals between the composite itself which initiate the polymerization reaction. Curing time for composite is 40 seconds, some needs 60 seconds because it differs from one company to another. So always check the manufacturer instructions.

Anterior Composite restorations

2 Class III

Class IV Class V (on anteriors)

Class V is done on anterior and posterior teeth

Class III restoration

Definition: restorations which are located on the proximal surfaces of anterior teeth not including the incisal edge It is diagnosed either clinically or radio graphically. It is done with indirect vision. (Lingual access) > The advantages of restoring the proximal lesion from the lingual approach 1. The facial enamel is conserved for enhanced esthetics. Direction of the bur> If palatal then I come from the marginal ridge of the tooth near the adjacent, and then incline toward the tooth of concern. That will reduce the chance of damaging the adjacent tooth. Fig 12-6 Orientation of the bevel: Functional and esthetic bevel: they are both used to increase the retention, and the esthetic bevel is also done to improve the esthetic appearance Esthetic bevel width is 1-2 mm, while the functional bevel width is 0.5 mm Bevel is put on the incisal wall of the cavity, because the enamel there is higher in quality and quantity comparing with the cervical wall.

Sometimes you need to approach your class III cavity from the facial side. When the tooth is rotated and the access is easier from the labial aspect of the tooth.

Indications for a facial approach include the following: 1. The carious lesion is positioned facially such that facial access would significantly conserve tooth structure. 2. The teeth are irregularly aligned, making lingual access undesirable. 3. An extensive carious lesion extends onto the facial surface. 4. A faulty restoration that originally was placed from the facial approach needs to be replaced. # start your cavity preparation using a high speed hand piece and once you are in dentin use the low speed, if the tooth is cavitated you can start with the slow speed but sometimes you need to largen the cavity to reach all caries underneath. When removing the caries use the largest bur that fit in the cavity not the largest bur in the clinic. Clinical tip for two adjacent class III, one is very small and one is moderate. What are you going to do is start with the small one then the larger.

Class IV restoration
Definition: restorations which are located on the proximal surfaces of anterior teeth and including the incisal edge Possible etiology: trauma, simple caries It is diagnosed clinically or radio graphically. You have to check the occlusion before you start restoring a tooth with class 4, to check any supra-eruption from the opposing tooth. So you always have to examine your patient when their mouth is opened as well as when it is closed. Functional and esthetic bevel, some make scalloped bevel to decrease the demarcation between the restoration and the tooth Tech> check occlusion> use the wedge > acid etch > bonding > curing > composite> curing>finishing When you light cure a composite restoration it is preferable to bring the light from the tooth side, so that the light will pass through the tooth structure, because light cure composite tends to shrink toward the source of light. So by this way when it shrinks it will shrink towards the tooth not away from it. And this will strengthen the bond between the restoration and the tooth. Sometimes we have to do small class 4, and we can use cellulose strip or cellulose crown. You have to condense the composite very well because it is easy to create voids there. Last layer is done as one layer it will make your adaptation and finishing easier. Do not make it too thick. Some people tend to restore large class VI restorations using pins, but it is not used any more, because of its inferior esthetics and it will cause discoloration because of corrosion products and if the bond breaks up for some reason, the restoration will be hanged only by the pins.

Class V Restoration
Smooth surface caries in the gingival third of the tooth It is diagnosed clinically. We cannot see the depth of class V on radiograph, because a radiograph is a two dimensional image. On the radiograph we can see the extension gingivally but not the depth of the cavity. We have to know the extension gingivally, because if it extends to the root surface, we have to consider that bonding to cementum totally differs than dentin and enamel Mostly seen in smokers Keep in mind when we have class V restoration you need to think can I reach all the caries lesion, if caries is underneath the gingival, sometimes it works with the retraction cords to retract the gingival a little bit, sometimes you need to do more invasive procedures to reach all the caries. So you have to estimate the case before you begin your work. 4

We dont do the bevel cervically, because we will lose the thin enamel there and that will affect our bonding. When you use a retraction cord, be sure that you put in a lateral direction not in a vertical dimension. Why? Because we dont want to change the biological depth, we only need to retract the gingival tissue. The retraction cord provides gingival retraction and some sort of isolation because it absorbs the gingival crevicular fluids. Pay attention if the patient has thin gingival, dont put the retraction cord too early because that will cause recession, so put it only in the period you want to work on, in that particular area. Sometimes we use rubber dam and this is the ideal, and here you are not worried about anything other than your work. Overhangs should be checked with the probe along the interface between the restoration and the tooth structure; sometimes it is covered and masked by the gingival. So it is really important to check these critical areas. Cervical matrix it is basically a matrix used to shape the final layer of composite restoration and remove the excess and then we cure through it. It will create a smooth surface and it will get rid of oxygen inhibited surface layer of the composite restoration. In class V restoration we prefer to use microfilled composite why? 1. Because it has smaller fillers, so it is more polishable other than other types of composites. 2. The load on the cervical third of the tooth is somehow minimal 3. The modulus of elasticity of the microfilled composite is not high. As we dont want stiff material to be put there. Because the tooth will tend to flex around the cervical part and if it is hard it will cause stresses leading to breakage. So you need a relatively flexible material to flex with the tooth at this critical part. In class V we can use other restorative materials like Glass ionomer, RMGIC and compomers. (If you do not know them go and revise) Be careful when we you do finishing for class V restoration, dont traumatize the gingival.

Posterior restorations
Class I Class II PRR The ideal circumstances for placing posterior composite restorations page 299 from the reference PRR: preventive resin restorations When we use it? Superficial caries not including the fissures and then we can apply a layer of fissure sealant to cover the other fissures.

Class I
The margins should not be beveled. Because if we are applying a thin layer of composite, and under the occlusal load, there will be a risk of fracture. And this will affect the cavosurface margin leading to microleakage. So prior to light curing it is important to shape your composite restoration, you have to create the grooves, the fossae and the slopes of the cusps 5

Class II
The margin should not be beveled. Special consideration: A good proximal contact is not easy to be created with composite. The reason is that the thickness of the matrix band will take from the space between the two teeth, and the inability of the composite restorations to hold itself against the matrix and against the adjacent tooth. While in amalgam we condense it against the matrix and it can hold itself until we place another layer. Composite cant hold itself; it will slump a little bit. so we have to mix some sort of solutions. Solutions are 1. Use sectional matrix 2. Pre-wedging the tooth before starting our restorations will create extra space which will be filled with the restoration leading to better proximal contact. 3. Holding the matrix with the instrument against the adjacent tooth until you finish the curing of that layer, and when you add another layer, the latter cured piece will hold it for you. 4. Sometimes you can put pre-polymerized composite as 1st layer . That is you bring a piece of composite and you cure it extra-orally and then place another layer of uncured composite inside the box and then place this procured piece inside the box it will act as a wedge and it will help you to hold it against the adjacent tooth. And then you cure it. 5. Use conical light tip you can hold it and place it inside the cavity These are a sectional matrix , as it has retention pin the matrix itself , different shapes , one way of create better proximal contact with the adjacent tooth .

Wedge placement : you have to place the wedge below the contact point in order not to affecting the matrix , otherwise you will affect the final contour of the restoration , you put it the base down ward toward the gingival and the tip upward ( toward the contact point ) ( ). Some said we use metal matrix band for composite restoration ? yes we use metal cuz clear matrix band is thicker in dimension and rend to create further space , and they dont create good proximal countor . So we use the metal matrix band ( its thinner ) and after we remove It we have to cure the composite form the bottom and the lingual side . We can't cure the composite form these side ( bottom , lingual ) when we have the matrix band . So we remove the matrix band and further cure it facial and lingual .

Light reflecting wedges :

We use them in class III and class IV , but in class II without cuz we go to use metal so it will not be effective , I just want you to know that there was something lightless in the market . So You place the matrix band then the wedge, then acid etch and bonding agent , then you start placing your composite restoration . 6

Sandwich Technique or Bonded base technique :

Basically when we have a gingival extension of our restoration or our cavity , so the margin is placed on the dentine or sometime on cementum , so the bond is not effective as to enamel . What we can do is to replaced the gingival part with GI or RMGI and then we put our composite restoration . So 1st we put 1st layer GI or RMGI , we adapt it well , then acid etch and bonding agent and put composite .

Configuration Factor :
Its the ratio between the bonded VS. non bonded restoration surface . For example , you have class V restoration , its bonded from all side except the facial surface , so this create more stress on the restoration , cuz there will be a challenge in the bonded areas between the tooth and the restoration . We want to maximize the strength for these bond , but most of the time this bond exposed to certain factors that will negatively affect it . So if we have more bonded surfaces , we have more stresses at that area . There is a direct relationship between configuration factor and the polymerization shrinkage , or the stress. Cuz when you have more bonded surfaces you will have more stress , then more surfaces exposed to polymerization shrinkage . How to reduce that ? 1) Basically we have to place incremental layer, we dont have to place bulky placement . 2) Some people said we can use 1st layer as flowable cuz it will adapt well to the walls , some said its unbuilt resin its weak we dont use it . 3) Additional increment as we said 2mm : in Class II restoration we put it in oblique layer, in composite restoration by layer and by layer ( the doctor mean in incremental layers ) , then condense against the gingival wall horizontally , then the upper layer applied oblique against the lingual wall , and we cure it in two direction cuz it class II and we have metal matrix , then applied third layer against the buccal wall and cure it . ( as a summary : you must replace every lost wall in alone with composite and cure it ). In Class V if we place bulky replacement we will have a gap especially you have less enamel . SO if you didnt do the Layering Technique we will have a space along the bonded surface . As we said curing most preferably to the restoration throw the tooth structure 7

IF we have for example two adjacent class II on the 6 and class II on the 7 , we can restore them at the same time without undermined the marginal ridge of the adjacent tooth .

Light Curing Sources :

1. 2. 3. 4. Anlagen . Plasma arc . Argon .* Blue emitting die .*

That we use in the clinic is the last two (**) , the wave length are 1040 4060 .

Finishing :
- Try to do it as possible before curing , make it as close as possible same to the tooth structure before using any burs . cuz this will create micro-cracks and will exacerbate cracks underneath the functional mode , which will adversely affect tensile strength of the restoration and of course it will create a rough surfaces . - Use Light pressure with water coolant when you use the hand pieces especially the high speed . - Following the countor of the tooth ( we can use fine needle bur ) , not to traumatize the gingival soft tissue . -What we have ( for finishing ) is : diamond burs( flame shaped , fine needle bur ) , white stones , rubber cups and the strips . - Carbide bur VS . Diamond : diamond is preferred cuz it produce smoother surfaces - White stone we have different shapes : round , flame shape , disc , we have slow speed and high speed as well .

- Discs : in order start from the roughest ( black ) to the smoothest ( pink ) , so Black Purple Green Pink .

- Strips : we have empty area on it in the middle to insert the strip from it in the contact area between the teeth then start finishing .

- Shade : it should be the first thing , you have to make sure that you are using the right light source , not only the artificial , compensation from the artificial and the day light , cuz some people go out at night more than at day .

Composite Shades :
We have A , B , C and D .

A is yellowish . B whitish . C Grayish . D Pinkish . So I look at the patient , if he have tendency for yellow teeth , I dont choose B or D , I go to A ( A 1 , A2 , A3 .. ) . Sometimes you combine more than one color . Choice before dehydration and of course before etching . Sometimes you can use Polychromatic , some for dentine and some for enamel . Take in consideration the patient factor : age , thickness of the tissue , degree of calcification and the people have opaque teeth . ---------------------------------------------------------------------------------------------------------------------------------------------------------Forgive me for any mistake Done by : Sawsan Z. Jwaied