Resin composite restorations (2)

Advantages of resin composite as a post restorative material: 1. Esthetics. Some patients prefer all their teeth to be filled with composite which is tooth colored, unlike amalgam which is silver (unaesthetic). 2. Conservation and preservation of tooth structure. If we compare composite preparation to amalgam preparation we notice that in composite prep we are more conservative because we depend on the adhesion of the composite on the tooth structure by using the adhesive or bonding agent, while we need mechanical retention for the amalgam prep. - The prep tends to be shallower. For example in class V and class 2 the cavity can be shallower. - The prep tends to have narrower outline form. We dont need the retentive form or the mechanical retention like in amalgam. - Prep has rounder line angles. In amalgam we have definite line angles while in composite we have more rounded line angles. (Refer to slide 2) This is an example of a tooth that is prepared for composite, we have 2 one distal and one medial cavity and occlusal and buccal pit, for composite we can prepare these cavities separately but if we are going to prepare for amalgam we have to connect these cavity preparations together to make it like an MOD because we need more retention. So again for composite we have more conservation of tooth structure.
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3. Another advantage is adhesion to the tooth structure. For amalgam we must remove all the undermined enamel because amalgam doesnt add to the strength of the tooth structure so we have to remove it because under occlusal forces the undermined enamel might fracture later on, for composite sometimes we can leave some undermined enamel tooth structure because the composite strengthens the remaining tooth structure by binding to the enamel and dentin tooth structure. So the comp can strengthen the remaining tooth structure where as amalgam cant by the advantage of the bonging. 4. Low thermal conductivity. Amalgam can transmit heat for example while drinking hot drinks whereas composite has low thermal conductivity compared with amalgam. We compare composite to amalgam because they are both direct restorations, and also compare it to GIC to some extent. 5. Elimination of galvanic current. We said that this is an disadv of amalgam 6. Radio opacity. This means on the radiograph it appears white. Why is this important? To know that there is restoration, to detect for recurrent caries in margins, if we have open gap between the restoration and the tooth, or overhangs. Before they use to use microfilled composite which are not radio opaque so we cant tell if there is a restoration, they look like the tooth structure or like an empty area. But now all the available composites are radio opaque. 7. Alternative to amalgam. This is an adv, so now have more choices if we cant put amalgam we can put composite for post teeth.

As any other material weve taken in dentistry we have adv and disadv so we dont have an ideal material for direct restoration, each one has adv and disadv. When we do restoration we have clinical situation to compare to adv disadv, indication of each material and then we choose what material to use that is best suitable for the case that we are going to treat clinically. Disadvantages: 1. Polymerization shrinkage. As we said in the last lec how when the composite polymerizes, the double bonds will become single bong leading to volumetric shrinkage, the volume of the composite will decrease, so when this happens it might affect the tooth, there will be a gap between the tooth and the restoration, because when we put the material its soft its not polymerized then we use the light to cure it, once the composite polymerizes the volume will decrease, we call this polymerization shrinkage. So there might be a gap, this gap will cause what >> (the 2nd and the 3rd disadvantages) 2. Secondary caries. 3. Post operative sensitivity. Because we have a gap now so the fluids can pass through the gap into the dentinal tubules leading to sensitivity. U should know that the polymerization shrinkage in the post teeth is more because your binding to more tooth surfaces (mesial, distal and so on) like when you bind to class 1 u bind to how many surfaces > 4, therefore there will be no relief of polymerization shrinkage, whereas in class 3 we bind to less surfaces. So the highest polymerization shrinkage is in class 1 and less in class 2 and it keeps decreasing in the other classes. It s not imp to know details its just imp to know that polymerization
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4.

5.

6. 7.

shrinkage is more in post teeth than in ant teeth and in class 1 more than in any other class. Decrease wear resistance. When 2 materials come together one material will take from the other, this is what we call wear. Because on the occlusal surface of the post teeth, when we restore class 1 or 2 the force is more, so the wear is going to be more in the post but this is overcome with the new composites called universal composite and we can use it for both ant and post restorations. They still wear but to a lesser extent. Other mechanical properties. You took them maybe in dental material, fracture toughness, high degree of elastic deformation, and CTE. All of these have also improved with the newer composites because of the filler loading increase; like in nanocfillers, they have improved physical properties. Now the CTE in composite is very important because its different form the tooth structure, in GIC the CTE is similar to dentine but composite CET is higher, meaning if we have hot or cold the material will either contract or expand so because of this composite and d entin will expand and shrink at different degrees leading to cracking and crazing of the tooth which will cause tooth fracture later on (and also fracture to the restoration). But in GIC because the CTE is very close to dentine, so they used to call it a dentine replacement material because they expand and shrink at the same degree. Water sorption. Composite can absorb or adsorb water, but this is also improved in the new composites. Variable degree of cure. And this is more in the self cure than the light cure, during the mixing the two pastes. But now variable
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degree of cure in the depth of the composite and thats why we have to cure it in increments because the light does not exceed 12 mm of increment. 8. Inconsistent dentin boding (marginal leakage). Also this is important. Although composite adheres to tooth structure this is an adv, but the adhesion has some problems. 9. Technique sensitive. so we have to have moisture control , we have to be very delicate when we acid etch the dentine, too much water and too much dryness is not preferable, we have to have in between because it will affect the bonding this is what we mean by technique sensitive, and moisture control (no blood no saliva no water) during placement.

Indication for post composite, where should we put it: 1. Esthetics should be a prime consideration. So if the pt is willing to put an esthetic restoration in his post teeth then esthetics is the prime consideration because its tooth colored. 2. The faciolingual width of the cavity prep should be restricted to no more than one third of the intercuspal distance and in class 2 the gingival margin should be on the enamel. Which means in class 1 the occlusal coverage for composite should be minimal, y3ni if the width which is the faciolingual width or we can say the isthmus width in class 1 should not exceed 1/3 of the intercuspal distance this is theoretically, sometime we dont stick to this rule sometimes I put composite even if the cavity prep was more, but ideally speaking it should be this way, we said the wear resistance is less with composite so if
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more tooth structure is removed, this means more composite is exposed to forces leading to wear. For class 2 gingival margin should be on enamel, this is imp, we have 2 problems here 1) if the gingival margin extends below CEJ or below enamel, moisture control will be difficult, 2) bonding to enamel is better than bonding to dentine, and so if we go deeper into the gingival floor we will start binding to dentin, so binding to enamel in the long run is more reliable than to dentine. 3. Centric occlusal stops should be primarily on enamel. This is relatively the same as the 2 nd point, which if the occlusal table increases the occlusal forces or the occlusal stops or occlusal touching will be on enamel. We want it more on enamel than on the restoration. 4. The pt should not exhibit excessive wear from the clenching or grinding. We call this parafunctional habit, and this is reflected by the pt, how do we know? They will develop wear facet on their teeth which is the loss of some enamel on the occlusal surface this means the pt has parafxnal habits, when pt has bruxism (when pt tends to press on their teeth while they are sleeping). Btw the teeth must touch each except during eating so if they have parafunction, that means that the pts teeth come in contact in times other than eating, y3ni more than the functional habits (eating) >> resulting in loss of enamel tooth structure 5. The tooth must amenable to isolation. Moisture control. Now we are going to talk about something which is related to class 1 composite...it is easy, it doesnt need a lot of talking
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because in class 1 we want to remove caries and put composite as usual. (The dr said she wanted to add on the slide) Before we talk about class 1 were going to talk bout PRR it is something like class 1 but we do it with composite we call it preventive resin restoration: Limits preparation to pits and fissures that are carious. If the resultant cavity is limited to narrow and shallow opening of the fissures, a resin sealant (fissure sealant) or flowable composite is placed. If the additional tooth structure is removed, resin composite is placed in the cavity and then remaining fissures and composite are covered by fissure sealant. Which means sometimes the occlusal fissures as u saw when we were practicing caries removal in the lab on natural teeth, sometimes ur in between if its occlusal caries or fissure caries or staining, so sometime Im not sure if it is or not and the pt is high caries risk so Im not going to send him home because Im not sure, so what we do usually is PRR. I open the fissures or grooves with a small round bur on high speed just to investigate them, if we have deep fissure and stained fissures and we are not sure those are carious or not, because its very difficult sometime to diagnose caries on occlusal. Btw the occlusal caries cant appear on the radiograph, 7ata if we took bitewing, only if they become involved in dentine they will appear. So if the fissures are deep and stained I use a very small round bur on high speed and open the fissures, then we do acid etching and put fissure sealant to block the fissure on all the occlusal table (opened and not opened or if they arent carious). Now lets say that we discovered that there some caries
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(in the first situation it was limited to enamel, it didnt got to dentine so we put sealant or flowable composite), but if it extended to dentine then we have to etch, bond, composite then we cover all the fissures and composite with sealant. Both of these situations are called PRR.

Advantages of PRR:

Conservation of tooth structure: we dont want to remove tooth structure from the beginning. Enhanced aesthetics. Improved seal of the aesthetic material to the tooth structure. Minimal wear of the tooth, because there is a limited amount of the structure missing. Good longevity: it lasts a long time in the patients mouth. Indications of PRR: PRR is indicated when there is a minimal to moderate loss of the tooth structure, and its not indicated when there is an obvious lesion (we put restoration directly). Technique we use in PRR: - We use a small round bur to open the fissure on high speed because we are cutting enamel - Removal of the carious dentin and the unsupported enamel. - Acid etching and bonding as any composite restoration. - In case of shallow cavity (limited to the enamel), sealant of flow-able composite is used. - Resin composite is used to fill deep areas if the cavity is extended to the dentin - Then the sealant is placed to cover the composite and the unprepared fissures and pits.

Preparation surface

composite in deep areas

fissure sealant all over the occlusal

Class II composite restoration: -

Pre-wedging: it means that we put the wedge

before preparing the tooth, and this has a lot of advantages. The most common issue that occur after doing a class II composite restoration is leaving a light or even a small proximal contact between the teeth, this result in food debris accumulation and may cause irritation to the gingival, so our goal is to keep a good tight proximal contact. This problem was solved in the amalgam restorations by condensing the amalgam against the matrix band

The matrix band we use is thick, so after applying the composite and removing the band it will leave a space between the two teeth caused by the thick matrix band. So in pre-wedging, we put the wedge and the teeth will separate from each other, then we prepare the cavity while the wedge is there, then we put the matrix band and apply the composite with a little bit extra amount, then we remove the wedge and the teeth will come in contact.

The result should not be a very tight contact or a light contact,, just something in between

The other advantage of pre-wedging is protecting the gingival from the bur in class II preparation. And also protecting the adjacent tooth by separating it from the other tooth The preparation of class II composite restoration should be limited to the carious tooth structure. If there is two separate lesions on one tooth we work on each one separately because we are not depending on the mechanical retention. Bevel placement on class II composite is a controvertible issue,, there is an arguments wither to do it or not. The composite should be applied in the cavity by increments, because relatively we have a deep cavity so we are not sure if the light will pass through all the restoration and reach the bottom, also it helps in minimizing the polymerization shrinkage.

Matrix bands: There is two types of matrix bands we use in composite.. There is the metal one and the celluloid strips we have used in the anterior restorations, and each one have advantages and disadvantages. - The metal matrix bands is easier to handle and control , and this is opposite to the celluloid strips which is very hard to control it - The problem with the metal matrix bands that it does not pass light and this is solved by extra light curing the composite from Buccal and lingual areas after removing the bands. - We have another type of matrix band which we use in the private clinics: its called sectional matrix bands and ring, these bands have two advantages: & they are thinner than the metal band Sectional matrix band and ring & the ring can do a little separation between the teeth and replace the wedge.

Finishing of class II composite restoration: - We use a finishing diamond burs to remove the excess composite on high speed, also we use the strips for the inter proximal excess. - And for producing the detail anatomy we use a flame shaped diamond burs - Aluminum Oxide for smoothening.

THE END

DONE BY Afnan Hamad & Abdullaziz Alyahyawi

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