:Low shrinkable Composites

:Outline
Teriminology
Concept of shrinkage
Effects of shrinkage
Types of low shrinkable composites
How to decrease polymerization shrinkage
Polymerization shrinkage : it is volumetric
change( volume decrease) that take place during
polymerization reaction due to progressive polymetric
chains build up
Composite shrinkage: it restricted by adhesion of the
material to the cavity wall which generate the stress at
interface
Composite polymerization: can be divided into 2 phases
a)pre gel phase: the reactive species present enough
mobility to rearrange and compensate for the volumetric
shrinkage without generating significant amounts of
internal & interfacial stresses
when the degree of conversation approaches 10-20% , the
network is extensive enough to create a gel, leading to the
start of the post gel phase
b) post gel phase
the continued polymerization shrinkage in association
with elastic modules development, generate stress within
material, at the tooth/restoration interface and in tooth
structure

:stresses

stress development depends , among other factors on the

other interaction between shrinkage, elastic modulus and
degree of conversation in each material
In general , an increase in conversation during
polymerization reaction elevates the shrinkage and elastic
modulus which cause greater stress
Hence it can be understood that stress is an act of balance
between shrinkage, degree of conversation , stiffness
: Polymerization shrinkage can be lead to
a)poor marginal seal (microleakage)
b)marginal staining
c)Recurrent caries
d)postoperative sensitivity
Stresses build up as a sequal to this shrinkage may lead to
:
Cuspal flexure
Cracking of enamel margin
Breakdown of adhesive bond
Propagation of hairline cracks in the remaining dental
tissue
-:Types of low shrinkable composite
N Durance
Kalore
Filtek B90
: To decrease the polymerization shrinkage
a)Altered light curing cycle

soft start curing (start curing with low intensity then gradual increasing in intensity to allow the reactive
content to rearrange to allow more relaxation & decrease
polymerization shrinkage)
Ramped curing- Delayed curing
b)Three- seated light curing
;c)Controlled stress reduction
optimizing the c- factor-1
Application of a thick elastic bonding resin (1 st stress -2
breaking layer)
Application of low elasticity module base lining( 2 nd -3
stress breaker layer)
:Optmizing C factor
C- factor : it is the ratio between bonded / unbounded
surface
classV=1/5=0.2 (has the least stress)
classIV=2/4=0.5
classIII=3/3=1
classII=4/2=2
classI=5/1=5 ( has the most stress )
Incremental layering optimize c -factor (use multi layering
technique)
Application of thick elastic bonding layer(1st stress
:breaking layer)
Brush thinning rather than air thinning -

Stretching of elastic resin leading to stress relaxation from polymerization of the stiffer composite filling
:Liner under composite resin (2nd stress breaking layer)
Flowable composite (has high matrix content ,more elastic ,it stretch to allow for stress reduction & more
relaxation)
Resin modified glass ionemer;(sandawitch technique)The material will absorb the volumetric changes and can
stretch or flow to allow stress relaxation

"Anterior & posterior composite resin"

:Outline
Shade selection
Cavity prepration
Adhesive bonding
Light curing
Composite build up
Posterior composite restoration
Anterior composite restoration
Tooth morphology
Finishing & polishing
Shade selection: (1st step before dental procedure)-1
In any esthetic procedure ; shade selection is the first
step prior to prepration
Dehydration will cause the shade to be too whitish, the tooth surface should be moist
Teeth should be clean ,if not , do prophlaxis(scaling & polishing)

select the shade which match the adjacent -always keep the tooth natuarally moist,it depend on the
patient's saliva never use air-water tip
switch off the light of dental unit use natural day light if possible,(morning appointment) avoid direct sunlight
imply the 5second ruleno lipsticks or bright light clothes use a neutral patient towel (blue or grey never yellowish or pink)
patient's back reclined 45 degreeobserve the shade at arm-length distance patient's corner of mouth at the level of dentists eye Use tooth cervical third to determine dentin shade, & inscial third to determine enamel shade
If inscial edge fracture , determine enamel shade from adjacent
Match the shade of fully cured composite buttons then select the suitable shade
Squinting eyes a little bit during shade selection, let the cones in retina more sensitive to colour perception
Use the composite shade tab & place it at the same level of tooth (not front or behind them)

:Adhesive cavity
: The success rate of the adhesive restoration depend on
cavity prepration(1
technique of build up(2
types of material(3
:tips for cavity prepration*
only remove the carious tooth structure -

use round bur to remove coronal carious enamel to exppose dentin then excavate soft carious dentin & then
remove hard remaining spot carious through the smallest
round bur
use round diamond stone to finish the prepration ; the adhesive cavity should be round & smooth to allow more
adaptation of composite
if there is old restoration remove it first then remove carious and after that remove the undermind enamel
All margin should be on sound enamel (no carious or undermind enamel) , except in case of labial surface of
anterior teeth ,undermind enamel should not remove
if labial surface include in the prepration do long bevel,beveling increase the surface area for better bonding &
gradual transition in shade without presence the
demarcation line between the tooth structure and
composite (optic illusion)
in classII if there is no sound enamel on the seat of proximal box, do margin elevation using resin modified
glass ionemer
if you are planning to do 2 visit composite, do not finish the cavity prep at the same visit
use water coolant (to prevent the enamel & dentin burn out for better bonding)
in case of multiple cavities ,dont connect between tooth island are 0.5mm or more
:Adhesive bonding
Tips for adhesive bonding: adhesive bonding is composed
of
isolation-1
It is mandatory, best isolation achieved using rubber dam

No breaking to isolation until finishing & polishing

During retching & bonding protect the adjacent teeth
using colloid strip or Teflon tape
In situation when isolation is difficult use self etch
adhesive
:etching-2
Selectively etch the enamel; after 10 sec fill up the cavity to allow for dentin conditioning
When you rinse make sure there are no residues of acid remaining to clean the pores & open dentinles tubules for
bond infiltration
sec acid etching for enamel 15-20Avoid over etch as it cause many problems 1)decrease surface energy
decrease hybrid layer 3) prevent bond infiltration (2
( decrease bond strength) 4)open dentinles tubules cause
postoperative hypersenstivity
In case of bleeding in cavity after etching ,etching should be return but in less than 15 sec to avoid overetching
Rinse use air-water tip for 30-40 sec (double etching time) Dont over dry just 2 sec of gentle air drying, the cavity should be moist enough for primer , if the cavity over dry
with dull appreance ,apply water on microbrush &place
oncavity for moisturize it
bonding-3
Apply the dentin bonding agent even beyond cavo surface
margin

Rubbing the bond with microbrush to ensure complete

covering the cavity then air thinning then apply the 2 nd
layer of bond
Leave the bonding agent to infiltrate for 20 sec before cure it
: Tips for light curing*
Time of curing according to composite manfucture (within 20 sec)
Curing distance (no distance is better) but try to not touch tooth for infection control
Light output is 1000mW/cm2 (optimum), and not over 1000mw to avoid burn out composite
Light output not less than 600 mW/cm2To ensure the sufficient curing use blunt instrument tip :Factors affect the curing efficiency
-Intensity of light cure
Distance between tooth & light cure tip Thickness of composite:Tips for composite build up
Build up layer by layer (increamental technique) to decrease the polymerization shrinkage
Dont break the isolationMatricing is compulsory with classII,classIII,classIV even in absence of adjacent teeth
Use a composite with darker shade for dentin build up -Build anatomical restoration from inside- out

Always pack your composite against tooth structure, except on proximal seat pack on matrix
Dont over manipulate it otherwise gap may be formed ,(composite is very sticky)
2nd stress breaking layer (use flowable composite),Use it in proximal seat
SDR (smart dental replacement)it is low shrinkage flowable composite , its consistency is viscous use as bulk
fill restoration or increamental fill technique, it replace
dentin &remain overlying composite in deep cavity
Use proper instrument for optimal composite handling (gold plated instrument) or plastic instrument with flat end
:Posterior composite
In classII start build up with proximal seat , transform class
II into class I
Place 2nd stress breaking layer first in proximal seat then
build up the wall of proximal cavity
Once convert classII into classI start building up composite
cavity by incremental layering technique
In case of deep cavity, base layer should be place in the
floor ,zn phosphate become historical ( bec its acidic
effects cause pulpal irritation)
The most recent pulp capping material use in deep cavity
is Theracal (calcium silicate resinous base )
Maximum depth of full cure is 2mm start with darker
shade(layer thickness shouldnt be more than 2mm)
Never beveling occulusally
Apply oxygurd or liquid glycerine on last surface of
composite to avoid formation the oxygen inhibiting layer
that inhibt the complete curing process

Occulusal stamp ( perfect anatomical occlusal surface)

put sepereting medium on occlusal surface of carious (1
molar
Apply opaldam (gingiguard) on occulusal surface & put (2
microbrush on it to handle the opal dam & cure for 20 sec
Apply composite inside the cavity & above it place Teflon (3
layer & cure then remove teflon gently
proper occulusal stamp with accurate anatomical (4
landmarks is obtained
: Modeling resin filling material
-It apply on the outer surface of composite before curing
Prevent the stickness of compositeIt resbonsible for better composite adaption inside the cavity
:Anterior composite restoration
Get at least one enamel shade and one translucent composite for esthetically demanding case
-Diagnostic wax up & putty index are highly recommended
When using the rubber dam including the contralateral tooth to check the morphology
-It is okay to do anterior composite on 2 visits
First visit : do a primary impression+ cavity prepration+ temporization (eugenol free)
Second visit : make putty index for composite build up Buccal enamel should be inserted in one increment to avoid lamination
If contamination occur after 1st increment remove it &
-start again

:Putty index
place the putty on the palatal surface of anterior teeth but avoid putty to rap around inscial edge for easier
building composite, start with palatal sheal with enamel
shade
use teflon tap to cover adjacent teeth for better isolation and protect them from etching & bonding
Use sectional matrix to close the proximal wall mesially & distally to act like close cavity for more easier adaptation
Start build up composite & apply 3 lobes of composite to act like mamellons for better natural look
:Tooth morphology
:Finishing & polishing
Finishing : contouring , shaping & smoothening of
restoration
Polishing: it is step occur after finishing when the surface
gain a high luster and enamel like texture
:Clinical tips
Work gradually toward finer grids Use abrasive stone , finishing carbide bur , abrasive strips , abrasive wheel, rubber cups & points
Use intermittent touches to allow for cooling (pulp
-affection)
Use water coolant especilaay during working on the surface texture
Eg: soflex (3M) , fini (pentron) , compomaster (shofu)
Rubber cup : finishing for cusp tip & cusp inclination

Wheel/Disc: use in side finishing the grooves & line angles

(transitional line angle) ,use in roundation the mesial &
distal in posterior
Finishing stone: (colour coding )
Colour coding according to the smoothness (particle size) ,
the smaller particales ,the smoother surface , less cutting
efficiency & more finishing ability
: Finishing stone
white-Yellow
Red: Prepration stone
Blue
Green
Black
: Patient care& instruction
-Routine gentle tooth brushing
- Interdental flossing
-Use of waterpick
-Avoid abrasive or diamond pastes