>> Dental Material (II) >> Lec # (4) >> Composite (part 2) PLZ chick your seat number

on E-learning or the group on FB so that next lecture you set in your own seat At first the Dr. just wanted to clarify something from the dental amalgam lecture which is that when we talk about spherical and admixed in surface area in the reference it says that spherical amalgam surface area will be a greater or available to react with mercury and in the slides it says that low surface area of spherical amalgam requires less mercury they are two different things if we for example add the surface area of the irregular particles it would be more than the spherical but when we talk about the area that is available to react in the environment the spherical particles all of its surface area is going to be out there to the environment the irregular particles some of it because of its shape won't be exposed to the outer environment and so not all of the parts are there for reacting with mercury while spherical amalgam all of its surface would be exposed to mercury so they are two different things one is that how much area is exposed to the outer environment (spherical > irregular) and the other is how much of sum surface area is there (irregular > spherical) both are correct because they are two different things >> Now we talk about composite the slides are on E-learning and the slides of next lecture as well (glass ionomer cement)

Clinical handling of composite: Composite is used for many types of cavity preparations, before they used to use it only for anterior teeth; because it is not very strong, newer composite (hardened) could be used both anteriorly and posteriorly, so they can be used in class I preparation, class II, III, IV, V so any surface that is involved can be restored with composite, but in some places we prefer amalgam, in the posterior part of the mouth especially if the cavity is large, if it is not too big composite can be placed there with no fears that the filling will fracture there and have to replace it. So when you want to select whether you want composite or not you need to look at two things mainly: -Esthetics: if you want to make a strong restoration posteriorly amalgam is your first option but if you're looking the esthetics or esthetics is important for you pt. go for composite anteriorly the option is always very easy it is composite always the force is not very high and you need something that is similar to the natural tooth shade (color) Anteriorly you might choose microfills or microhybrids they give a nicer surface when you finish and polish them compared to normal hybrid composite or macrofill composite -Strength demands Posteriorly hybrid will do well they companied esthetics and strength Many types are available and you can choose according to these criteria what you want your restorative material to provide Whether I want esthetics strength or both

Shade guide: We talked about shade guides last semester we talked about heo croma value Shade guides are now available and it has got several shades that you can select from to have the appropriate composite filling There are many ways to do shade selection; there is certain light you need to make selection under, some dentists place a small composite material on the tooth and cure it to see whether the shade is matching there is certain guide lines we need to follow for example you shouldn't use the dental unit light (orange), you should not use fluorescence light the best light is the natural day light, not in the early morning not during sunset during the day this is the best light to select your shade under Another thing if your pt. is wearing colorful clothing this will affect how you see the color so you need to cover the upper part of the pt. with an apron which is usually colored light blue or light gray which will not affect how you see the colors wave length (so it will not let you see color differently) it is a neutral color, so you need a neutral back ground so you can select the shade properly, even if the pt. is wearing a bright lipstick she should remove it all of these things can affect how you see colors because it is just a wave length that is sent to your eyes then it will be interpreted into your brain So we have a neutral back ground and use normal day light it will help you select best accurate shade that is suitable for your pt. And it is better to select the shade before you do cavity preparation; when you do cavity preparation you drill teeth and you may dehydrate them because of the drilling which will change their color

Another thing when you want to select the shade and use the shade guide you need to place some water on it (on the taps) because natural teeth have saliva all over so when you want to compare between the pt. teeth and the shade guide you need to wet it with water because natural teeth are wet by saliva, dry tooth look differently they have a different shade All of these are guide lines you need to be aware of, shwai shwai you are going to memorize them Shelf life: When you want to store your composite or your bonding agent and so you need to follow the manufacturer instructions keep them away from heat or light because they can activate setting of the material Some of the composite are available in small containers so each one of which is designed for one pt. (disposable) by this it helps to disinfect and to avoid cross-contamination between pt.s And always when you want to take part of the composite from the syringe (from the container) you need to use a clean instrument and not use it with other pt.s to prevent cross-infections and when you take a piece of composite you need to cover it Keep it away from light so we need to cover composite keep away from light to prevent setting or initiation of setting because later on if it starts to set before you start working with it it will be very hard or start becoming hard it will not follow properly in your cavity and you will not be able to manipulate it easily Isolation: Composite is a technique sensitive material it is very sensitive to moisture contamination (no saliva no Bld at all) it needs to be very

well isolated from the oral cavity you need good isolation to maintain good bond (strength) between composite and tooth structure if contamination occurs it will compromise your bonding and your material as well (setting of the material) the material will not bond properly to enamel and dentine if there is saliva or Bld all around which will lead to microleakage later on which will lead to sensitivity and recurrent caries so you would need to repeat the filling again pay more money which is not good for your pt. he will not be happy Always maintain good isolation when you want to work with composite as soon as you finish your cavity and you want to start your filling restoration >> isolation We can use cotton rolls like in slide #34 we can use what is called rubber dam which is placed around the tooth (or teeth) and you will learn how to place it later on We have a light cure unit blue light comes out of it Sometimes if your cavity is subgingival we can place something that can push the gingival a little pit away from the margins of your cavity which we call a retraction cord it is like a small rope that is inserted between the tooth and the gingival margin it will push the gingival away which will help control the bleeding and it will expose your cavity margins, they will be clear to you so that will know where to place your composite So the retraction cord is placed between the gingival and the tooth so all the cavity margins are exposed you can place your restoration you know where your cavity ends you're not going to place extra and have trouble removing it later on

Isolation can be done with cotton rolls can be done with cord dam placement in cases of subgingival cavity a retraction cord can be placed between the gingival and the tooth so that it will push the gingival away and make the margins of the cavity clear to you In slide 35 we can see a light activated composite which is provided by a syringe there can be disposable tips to use one for one pt. only and then you throw it away on the right you can see what we call plastic instrument it is similar to the plastic instrument in your kit it is used to place composite they are made specially so the composite will not stick to your instrument it makes placing the composite easier in the pic down left you can see two paste composite no longer used now mostly we use light cure composite one component one paste that is cured or sets by light activation

Slide #36: In cases of class III cavity preparation which involves the mesial or distal surfaces of anterior teeth you want something to help you adapt your filling inside the cavity and reproduce the margins (contact) between teeth to do that we need to place a band around the teeth the one that is used for composite is called a Matrix strip/band which is made of cellulose and it is transparent (why should it be transparent?) so that light can go in through and cure composite so it helps to make a smooth surface and to reproduce the mesial or distal surface of the tooth if this strip was made of metal light won't pass through and no curing of the composite! A small wooden wedge is also used to prevent excess from going subgingivally you will learn about these in the lab

You will see them and learn how to use them to prevent excess filling, to maintain good contact between teeth to prevent excess composite from going subgingivaly When you place composite you need to make sure that when subject it to light the light will go through all of the layer that we placed you have to make sure that the light has passed through the whole thickness of the layer to cure it to insure setting That is why increment should be maximum two mm thick when you have a large cavity that is 4 mm deep you need to place at least two layers of composite reach one is two mm thick a layer of two mm thickness is okey in regards to the light penetration it will be able to penetrate it from top to bottom and insure good setting a composite that did not set will it will be weak it will shrink more it will break off We need a layer that is not more 2 mm in thickness when we place it in the cavity so you should not fill the whole cavity once and for all 2mm layer so when we cure it with light it will pass all through and set the whole material If the bottom did not set it will be weak it might break off it may shrink and microleakage may occur The material that has not set very well its components might be harmful and make some damage if we look at those materials and their components individually it might be harmful but when the whole material sets it will be okey So a complete setting should be done so that we guarantee that there are no damaging components out of the material

So incremental filling of the cavity should not be more than 2 mm or less more than 2mm is not acceptable Q: what is there in the two pastes composite? A: base and catalyst

You can see in slide #37 incremental placement of composite we have two examples of class II cavity with several ways of placing composite you can place it horizontally or you can place one diagonally and then horizontally it doesn't matter as long as you follow the guide lines maximum 2 mm thickness if you have a composite that has a dark shade it will not allow light to pass easily compared to a composite with a light shade because the dark one will absorb some of the light that is passing through so when you use a composite with a dark shade the increment should be less than 2 mm 1 mm for example So the shade of your composite will affect the increment of the filling or the layer darker shades should be placed in thinner increments to make sure that the light will go all the way through because they are dark in color they will absorb the light before allowing it to go through to the bottom Etching and Bonding: Unlike amalgam composite needs some tooth preparation before you actually put the restorative material In amalgam we prepare the cavity wash it (clean it) place amalgam and thats it In composite it is a different story you need to prepare enamel and dentine in a certain way so that composite will bond to enamel

and dentine this bond is called micromechanical (how is that done?) by two steps Etching and Bonding Etching basically means that you are placing a certain concentration of an acid on enamel and dentine this acid will create roughness on enamel and dentine it will remove some of the minerals it will open up dentinal tubules so there will be micro holes or pores on the surface of enamel and dentine the surface will be rough a rough surface provides better adhesion or better bond compared to a smooth surface So to create such as rough surface an acid is added in the form of a gel which is phosphoric acid (con. 35-37%) It is placed on enamel and dentine after cavity preparation for few seconds and then it is washed away and the tooth dries when they looked at it in the microscope they saw that it created roughness holes and pores on the surface of enamel and dentine dentinal tubules are open and this rough surface will bond composite better because when you place it it will flow into these pores or holes and lock it will not be detached easily After doing this etching (placement of the acid on the tooth surface) there is another step just before placing composite placing a bonding agent which is a liquid it is made of resin it will help to make a connection between composite and the tooth surface so it will act as an intermediate layer without this bonding agent composite will not be attached to the tooth surface one of the reasons is that tooth surface is hydrophilic composite is a hydrophobic material so you need something in between that will be able to attach itself to the tooth surface and to composite it will have two arms so it will form what we call a hybrid layer so this bonding agent is placed and it is light cured so you have to

subject it to light for 20 sec usually once it is placed you can start adding composite You add the 1st layer of composite and cure it the next layers will bond chemically to each other because they are the same material So you don't etch and bond between each layer only on tooth surface Q: why bonding agent is not used in amalgam? A: because amalgam will not be able to flow in these micro pores and holes and interlock itself with them particles are too big and in amalgam it sets as one block it will change the shape of your cavity rather than making the surface rough so the whole cavity should be shaped in a certain way particles are too big You can see in slide #39 the etching gel the color is usually blue green it is placed on both enamel and dentine it is called total etch technique (involves enamel and dentine) after it is removed the color of enamel will be chalky white because the enamel has been deminerelized a little pit and dehydrated bonding agent is a liquid it is added using a brush or a small sponge on the tooth surface and light cured and then composite is added In slide #40 you can see acid etched enamel do you notice the rough surface? These are enamel prisms if you remember them (>.>) So when you place your composite there will be tooth surface into which the bonding agent will flow and composite a hybrid layer and your composite material This hybrid layer is composed on one end of bonding agent and composite on the other end bonding agent and enamel and dentine

When you finish and place the final layer of composite the surface of this layer will be a little pit sticky because it is exposed to oxygen it will not be cured properly only a very thin surface layer it is a sticky layer so we wipe this layer with some cotton or when we do the finishing and polishing to smoothen the filling this layer will be removed so it will not cause any problem but this layer is oxygen inhibited layer because it is in contact with oxygen it will not be cured properly it is a very small surface layer (thin) and usually removed when you do finishing and polishing of the filling And as we said we need to maintain good isolation so if during your restoration contamination happens you need to do etching and bonding again (even for a few sec of contamination with saliva or Bld means your whole surface is contaminated because they have bacteria have debris which will block your micro holes or pores so you will not have a rough surface) and contamination will prevent the flow of your bonding agent to cover all areas the larger the surface area for bonding is the better the bond so the surface needs to be clean and rough Q: does the bonding agent go into the dentinal tubules? A: it goes into the dentinal tubules Q2: why is that? A2: it will cause retention I will show you a picture next lecturesSs and I will show you how bonding agent goes into dentinal tubules and cause retention Q: not heard :S A: no bonding agent could be used to prevent sensitivity (in ppl that have sensitive teeth)

(ya jamaa3ah shoo fe? Ya3ne bes2al sha3'lat mohemeh!! ) Some people have sensitive teeth so bonding agent is used and goes into the dentinal tubules and prevent things from going inside and stimulating the nerve endings so it can be used as a desensitizing agent (Dentinal tubules have inside fluid and at the end of which we have nerve endings) For amalgam we use another bonding agent which is called a burnish (it is made of resin) in terms of research they say that amalgam doesn't cause sensitivity as much as composite it is related to the composition of the material it is related to the size of the particles that can go into dentinal tubules in composite the chance is bigger compared to amalgam but they try using it to improve the bond between amalgam and tooth structure and it is not really that effective but if you want to minimize sensitivity another material which is called abarnish (not sure of the spelling) is used and we will talk about it in another lecture (cement lecture) Sometimes when you do a cavity and you don't have time to place your composite you need to place some sort of a temporarily filling send your pt. home when he comes back again you place your composite (7ashweh mo2aqateh ya3ne) as the Dr. do in the markets in case of anterior teeth you cannot place zinc oxide eugenol as a temporary material (they should not be placed under composite because eugenol prevents the setting of composite so when the pt. come you need to remove your temporary filling you might not remove it completely there might be some remnants of zinc oxide eugenol inside the cavity which will prevent complete setting of composite later on when you place it and it may cause staining of composite.

So it you want to temporize your anterior tooth you can place another thing like glass ionomer cement which we will talk about next lecture In cases of light curing it is good to always follow manufacturer instructions more it will not have any effect less it will prevent good setting so stick to the recommended curing time stated by the manufacturer In general composite that we work with here bonding agent needs 20 sec composite 40 sec so each layer 40 sec subjected to the light it will set Thicker layers and a dark shade few researches say it will have no effect the best way to do it is to minimize the thickness of the layer so in terms of darker shade or deeper locations always use thinner layer of composite Finishing and polishing: to produce a nice shiny tooth surface (fe 7ad jala6 el Dr. w eza bedhum yekamlo 7aki yetla3o barah w fe shab msh daroore yetala3 3aleehom w yetsahwan maho 2abel shwai 7aka ma3hum :P ) Certain material is used to produce a smooth surface these materials are abrasive they have a rough surface usually we start with a rough material that is placed in a hand piece then we go smoother and smoother to produce a fine smooth surface so first we need to remove excess with a rough disc for example and then we go to smoother discs to produce the shiny smooth surface you will be familiar with all of these in one of the lectures at the end of the coors Some dentists when they finish the filling and do finishing and polishing they place another layer of bonding agent on the top just

to make sure if there are any small holes or voids on the surface of the composite they will be filled with this bonding agent they will get a better surface a smoother surface preventing any bacteria from going in Light curing units: There are many instruments that can be used for light curing one of them is based on halogen bulbs (here we mean the type of gas is different) so halogen light bulbs can be used in light curing you should always protect your light source from any dirt for example from any damage from falling over from any remnants from sticking on its surface because it will prevent light from coming out we could put a plastic wrap to prevent any damage or any dirt or composite pieces sticking to it because they will prevent light from properly coming out Some of them might be cordless (wireless) and some of them needs to have a cord that will be attached to electric outlet Some of the light sources may have High intensity light unit which lowers your curing time If the light has high intensity it means that you will have less curing time examples: - Plasma arc units (PAC) and Argon laser units Again the type of gas might be slightly different Precautions: All the time these instruments you need to set them because light become weaker with time You need to subject the composite to light and protect your and the pt.s eyes because they may cause damage to your eyes and they cause cataracts (el mai el zarqah aw el soodah)

If you look directly into this light it might cause damage to your eyes you need to protect yourself and your pt. And also it can produce heat so you should not hold it very close to your cavity especially in deep deep cavities it will be close to the pulp unless you place a liner something to isolate your pulpal floor So in deep cavities it is better to isolate the pulp by placing a liner or a base In slide #46 you can see the light curing unit and a shield all of these can be placed between you and the light and to protect the pt.s eyes from this light Compomers: A modification on composite a Compomer it is a material that has been modified a little pit because they wanted something that is able to release florid so they added what we call poly acrylic acid These materials once activated and placed in cavities they say that they are able to release florid they changed the components they added some acrylic acid and florid so once they set and exposed to the oral cavity they might be able to release florid prevent caries the problem is that after curing after the material sets the resin components might prevent florid from being released properly so a very small amount is released of florid so this is just a modification to composites they are called Compomers we call them polyacid modified resins They are light cured (how do they set?) Part of the setting rxn is also chemical we call it acid base rxn between the resin and the acid that has been added so it has two types of rxns light activation and Acid-Base rxn (chemical set

reaction) they need to be placed in layers and they need bonding agents so similar to composite Indirect esthetic materials: In addition to directly placed in cavities there is composite or resin can be made in the lab you make your cavity or prepare the tooth take an impression to the lab they use composite either normal composite or modified composite which is reinforced they add certain powders to it to make it stronger and make the restoration and then when the lab tech. finishes the restoration for you he send it back to you and you attach it to the tooth So they use it to make veneers which are placed on the labial surface it can be used to make crowns inlays (similar to a class II cavity) involves the mesial and occlusal surfaces or distal and occlusal surfaces for example in slide #49 this pt. has diastema (a space between his two incisors) these teeth were prepared part of the labial surface was removed about half a mm thickness and a veneer was cemented on top the tooth was made larger by this veneer and it caused the space to be closed so >> esthetics if you have staining on teeth this can also be done a veneer which is called in Arabic (qishreh) it looks like the labial surface of the tooth its thickness about .5 mm they bring it and stick it to the tooth This is indirect because you are preparing the tooth taking an impression sending it to the lab lab makes the restoration and they give it back to you Laboratory processed composites: The type of composite used is usually reinforced composite or to save time you take an impression and send it to the lab in the next visit these restorations will be very small blocks and ready to

be attached inside the cavity by using cements (paste) a special type of paste that is used to stick the restoration inside the cavity One benefit of indirect restoration is that the curing happens outside the cavity they will not shrink in your cavity because they are made in the lab Restorative materials used: These composites are either: -Conventional composite -Fiber reinforced composite -Particle reinforced composite They have fibers to make them stronger or particles or normal composite all of these can be used to make indirect restorations In some cases you can do this in your clinic you can prepare the tooth take an alginate impression pour your impression in silicon (rubber) on this model or cast you can do your restoration and then place it in the pt.s mouth if you don't remember this PVS material go back to the lecture in the summer we've talked about it We talked about Shade taking in slide #55 you can see the shade guide and we talked about the guidelines for taking the shade. Good luck to all Forgive me for any mistake Becoming older is not my fav. thing on earth so PLZ don't congratulate on nothing :P :p .