Académique Documents
Professionnel Documents
Culture Documents
Amalgam, for years the most widely used direct restorative material, is gradually being replaced by
composite resin. The problem with composite restorations in general is that they are technique-sensitive
and time-consuming to place correctly, unlike their amalgam counterparts. Although dental science has
yet to find a bulk-fill, tooth-colored material that is as simple to place as amalgam, practitioners can
reduce the stress and difficulty of performing this common dental procedure by using appropriate
materials, techniques, and tools designed specifically for predictable outcomes using direct composite.
They can also offer patients the benefits of new smart restorative materials to help prevent, arrest, and
reverse tooth decay using minimally invasive methods.
There are few materials in the history of dentistry that has undergone as much of an evolution as
composite resin. The face of restorative dentistry changed forever when successful bonding to enamel
and dentin was achieved. Since then, the goal of clinical and material science has been to find a simple
predictable approach to the composite restorative process.
However, with composites, the clinician must first control the clinical environment using isolation
techniques. After isolating the operative area to control moisture contamination and using a specially
designed matrix systemie, a sectional matrixeach increment of composite placement typically
requires: (1) etching; (2) rinsing; (3) drying; (4) desensitizing; (5) placement of adhesive; (6) light-curing;
(7) placing a base or liner, if needed (8) light-curing; (9) placing the increment of composite; and (9)
light-curing. Several increments may be placed and cured before final sculpting of the occlusal surface
of the restoration, checking and adjusting the bite, then placing an optional surface sealant to protect the
marginal areas of the composite restoration.
The traditional method of placing composite in increments of no more than 2 mm (Figure 2) was meant
to facilitate curing and to avoid polymerization shrinkage, which research suggests is no longer a major
concern with many of todays advanced materials.3 The technique of layering, however, carries a greater
potential to introduce voids into the restoration. Bulk-fill flowables, which are meant to serve as dentin
replacements, can be cured in increments of up to 4 mm (Figure 3). While these materials do have the
potential to eliminate many of the voids by decreasing the number of layers in the restoration, they are
typically not designed with the physical properties required to withstand forces of occlusion and,
therefore, an additional capping (enamel layer) is required.4 There are also bulk-fill packables that can
be placed in 5-mm increments (Figure 4); among them is a sonically placed bulk-fill composite system
(ie, SonicFill, Kerr, www.sonicfill.kerrdental.com) that provides sufficient physical properties to withstand
functional forces without the need for a capping layer.5
Replicating Proximal Contact and Contour
In most instances, the Tofflemire universal matrix used for amalgam is not appropriate for use with
composites (Figure 5). There are now a variety of sectional matrices designed specifically to replicate
not just the proximal contact but also the proximal contour (Figure 6). They are positioned between the
restoring surface and adjacent proximal surface and use a ring to gently push the teeth apart, creating
proximal contact and allowing for ideal anatomic placement of a sectional band, which is concave on the
inside and convex on outside, and can replicate the convex contour of the natural proximal tooth surface.
They include Composi-Tight 3D XR (Garrison Dental Solutions, www.garrisondental.com), V4
ClearMetal Matrix System (Triodent, www.triodent.com), and Palodent Plus EZ Coat (DENTSPLY
Caulk, www.dentsply.com). When a sectional matrix is placed correctly, very little finishing with rotary
instruments is required.
Depth of Cure
According to a study by Campodonico et al, depth of cure, less than filling technique, is the main issue
for practitioners using todays materials.3 Various methods for achieving this are discussed in the section
on Bulk Fill Technologies in Composite Materials.
that those areas that are hard to condense are adequately covered and protected with resin. The
flowable material also uniformly wets the surface of the adhesive, lessening the chance for voids
between the adhesive layer and the composite. Next, a nano microhybrid is placed in 2-mm increments,
as described above, until the final increment is sculpted into the proper anatomic form and the occlusion
is checked and adjusted as needed. Sculpting and shaping composites using instruments that can
impart a convexity and not decimate the occlusal anatomy, such as a needle interproximal finishing
diamond, are recommended. This means not using an elliptical or round bur that imparts concavities that
destroy the anatomic form of the occlusal surface.
Finishing and polishing the placed composite involves more steps, including the use of rubber abrasives
and a bristle brush with an impregnated polishing medium or diamond paste. After polishing, marginal
areas are re-etched for a few seconds to make sure the surface is clean, then a surface sealant is
applied to fill minor remaining discrepancies between the composite and the tooth that cannot be seen
or felt with an explorer but may still exist.
Alternative Approach to Incipient Caries
Clinicians commonly approach treatment of incipient lesions by treating them either aggressively upon
detection or by waiting until it is deemed necessary. A new type of resin material (ie, Icon, DMG
America, www.dmg-america.com) is a resin infiltrate that provides a barrier to prevent acid infiltration
and progression of proximal decay, which could later require the need for more aggressive treatment
methods. Icon resin infiltrate works by blocking the influx of hydrogen ions, a byproduct of bacterial
metabolism that prevents calcium and phosphate ions from leaching out of the tooth. This material,
which is virtually a sealant/protectant, is placed via a membrane device after etching and drying the
proximal surface of the tooth. According to the manufacturer, Icon reinforces and stabilizes
demineralized enamel without drilling or sacrificing healthy tooth structure.
After isolating the tooth and placing wedges to separate the teeth, the affected tooth surface is prepared
with a 15% hydrochloric acid gel to etch the decalcified surface of the lesion. Next, the surface is rinsed,
dried with ethanol (drying agent), and further dried with air. The Icon resin infiltrate, which has a high
penetration coefficient, is applied onto the lesion, the excess is removed as necessary, and the material
is light-cured. The manufacturer recommends applying a second layer of the infiltrate, followed by
additional light-curing, to ensure maximal protection.
allows for ion release over time. This ion release at the margins of the restoration can help to protect the
area from acid attack and promote remineralization as needed.6-10
Open Sandwich Technique Using Glass-Ionomer Cement for Dentin Replacement in Deeply
Excavated Lesions
For more deeply excavated lesions whose dentin will have more tubules exposed and less peritubular
dentin to which to bond, glass-ionomer cement forms a chemically fused seal, and its high fluoride
release and internal remineralization help to prevent future decay. Therefore, this material can serve well
as a base or liner in deeply excavated lesions (Figure 6).11-15
Open Sandwich Technique for Root Caries
In the case of a patient requiring a Class II cavity preparation whose margins may be on root surface,
glass-ionomer cement can be placed as a liner or base followed by a composite cap to complete the
restoration (Figure 7). For the open sandwich technique, the glass-ionomer cement base extends to
the internal surface of the matrix and will be in contact with the intracrevicular environment for purposes
of ion exchange.11,16
are completed to place the restorative material. Clinical and radiographic follow-up are important to
determine the success of the procedure.
Conclusion
A wide variety of materials have been created in response to dentists desire for products that can
simplify the placement of esthetic Class II composite restorations, whose placement can be highly
stressful due to the technique-sensitive and time-consuming layering process. Although there is not yet a
bulk-fill material comparable to amalgam in terms of ease of placement, composite restorations, as a
rule, can be placed far more conservatively. Smart materials designed to combat demineralization and
recurrent decay are welcome advances, as are bulk-fill products that enable the clinician to more quickly
and easily complete the posterior restorations that are such a significant part of the general restorative
dental practice.
References
1. Bracho-Troconis C, Trujilio-Lemon M, Wong N, et al. Characterization of NDurance: a nanohybrid
composite based on new nano-dimer technology. Compend Contin Educ Dent. 2010;31(Sepc No 2):5-9.
2. Patras M, Doukoudakis S. Class II composite restorations and proximal concavities: clinical
implications and management. Oper Dent. 2013;38(2):119-124.
3. Campodonico CE, Tantbirojn D, Olin PS, Versluis A. Cuspal deflection and depth of cure in resinbased composite restorations filled by using bulk, incremental and transtooth-illumination techniques. J
Am Dent Assoc. 2011;142(10):1176-1182.
4. Leprince JG, Palin WM, Vanacker J, et al. Physico-mechanical characteristics of commercially
available bulk-fill composites. J Dent. 2014;42(8):993-1000.
5. Goracci C, Cadenaro M, Fontanive L, et al. Polymerization efficiency and flexural strength of lowstress restorative composites. Dent Mater. 2014;30(6):688-694.
6. Naoum S, Ellakwa A, Martin F, Swain M. Fluoride release, recharge and mechanical property stability
of various fluoride-containing resin composites. Oper Dent. 2011;36(4):422-432.
7. Nakamura N, Yamada A, Iwamoto T, et al. Two-year clinical evaluation of flowable composite resin
containing pre-reacted glass-ionomer. Pediatr Dent J. 2009;19(1):89-97.
8. Daisuke T, Seitaro S, Koji Y, Masato H. Saliva protein which adsorbs to composite resin containing SPRG filler. The Japanese Society of Conservative Dentistry. 2010;53(2):191-206.
9. Saku S, Kotake H, Scougall-Vilchis RJ, et al. Antibacterial activity of composite resin with glassionomer filler particles. Dent Mater J. 2010;29(2):193-198.
10. Taizou I, Seitaro S, Koji Y. Application to the tooth coating material of the glass filler containing acid
reactive fluoride. The Japanese Society of Conservative Dentistry. 2009;52(3):237-247.
11. Francisconi LF, Scaffa PM, de Barros VR, et al. Glass ionomer cements and their role in the
restoration of non-carious cervical lesions. J Appl Oral Sci. 2009;17(5):364-369.
12. McLean JW, Powis DR, Prosser HJ, Wilson AD. The use of glass-ionomer cements in bonding
composite resins to dentin. Br Dem J. 1985;158:410-414.
13. Mount GJ. Clinical placement of modern glass ionomer cements. Quintessence Int. 1993;24(2):99107.
14. Christensen G. Glass-ionomer-resin restorations. CRA Newsletter.1992;16(3):l-2.
15. Mount GJ. Clinical requirements for a successful sandwichdentine to glass ionomer cement to
composite resin. Aust Dent J. 1989:34(3):259-265.
16. Sawani S, Arora V, Jaiswal S, Nikhil V. Comparative evaluation of microleakage in Class II
restorations using open vs. closed centripetal build-up techniques with different lining materials. J
Conserv Dent. 2014;17(4):344-348.
17. Roggendorf MJ, Krmer N, Appelt A, et al. Marginal quality of flowable 4-mm base vs. conventionally
layered resin composite. J Dent. 2011;39(10):643-647.
18. Pashley DH, Tay FR, Imazato S. How to increase the durability of resin-dentin bonds. Compend
Contin Educ Dent. 2011;32(7):60-66.
19. Ilie N, Bucuta S, Draenert M. Bulk-fill resin-based composites: an in vitro assessment of their
mechanical performance. Oper Dent. 2013;38(6):618-625.
20. Juloski J, Carrabba M, Aragoneses JM, et al. Microleakage of Class II restorations and microtensile
bond strength to dentin of low-shrinkage composites. Am J Dent. 2013;26(5):271-277.
21. Van Ende A, De Munck J, Van Landuyt KL, et al. Bulk-filling of high C-factor posterior cavities: effect
on adhesion to cavity-bottom dentin. Dent Mater. 2013;29(3):269-277.
Posterior_Composites:Using_the_Latest_Materials_and_Techniques
#sthash.vbuLod6p.dpuf