Conservative Dentistry

Lecture # 5
Dr. Zakareya Al Bashayre
Today we will talk about a very important subject
which is
" DIRECT TOOTH–COLORED RESTORATIONS "
and we mean by that specifically ( COMPOSITE ).

HISTORICAL BACKGROUND :




  
- Historically we(dentists) started restorations
for anterior teeth using silicate cement. It is a
combination of phosphoric acid & aluminosilicate
glass powder . this was introduced in 1871.

COMMENT:Amalgam can't be used in anterior

teeth,only in posterior teeth. Gold was used
extensively on anterior teeth although it's not
tooth-colored material but it was acceptable to
use,and the gold type which used was " GOLD
FOIL RESTORATION " , gold is made of foils
& these foils were used to be inserted inside
the cavity,adapted according to the shape of
the cavity until it's completely filled.

‫ ا‬: 

- Due to many disadvantages of silicate cement,

there was continuous searches & development of a
new acceptable material with better
characteristics , so we came to use
Autopolymerizing acrylic resin , that was in 1945.

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 - Then research continued & we reached to the
Filled Resins or composites , in 1960's.

- Then there was the introduction of Glass

ionomer cement in 1972.

- In 1962 Bis-GMA was introduced .

- In 1970's, Acid etching & microfills was

introduced & these are only chemically cured .

- Then we introduced Light cured composites

which were in 2 kinds : flowable ( flows by itself
inside the cavity) & packable ( you pack it inside
the cavity ).

- Then in this century there was the new

introduction of nanofills .

Now lets talk more about :

1. SILICATE CEMENTS :

ADVANTAGES :
- Excellent aesthetic qualities because the color of
silicate material is like the color of the tooth .

- Silicates can leach fluoride ( so they resemble glass

ionomer in this property ) .

- It has anticariogenic effect

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 - Have coefficient of thermal expansion that is
compatible with that of the tooth i.e) no microleakage
(shrinkage), means if I have a bar of 1mm of silicate &
it's subjected to heat , maybe it will expand by 12% , &
if I have a bar of tooth & subjected to heat then it
should expand by (sth) like 12% maybe 10 , 12 , or 13.
So the difference between expansion of the material &
expansion of the tooth is compatible means it's within
the range , it's not largely different. If the tooth
expands more than the material there will be
compression , if the material shrinks more than the
tooth there will be microleakage then the problem is
development of recurrent caries .

DISADVANTAGES :
- Get stained ( discolored ) & dissolved easily in oral
fluids .

- has low tensile & compressive strengths :

Tensile strength is the ability to resist pulling , the
opposite is the compressive strength which means the
ability to resist pushing ( hug-like ).
(definitions are from the glossary of dental material
Dr.Leila )
EXAMPLE: if you are trying to compress amalgam
inside a cavity , you are putting an increment of
amalgam on the top of other & try to compress it
( please go please go ) , this is the compressive
strength ( resistance of amalgam to withstand
compression ) .

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 Low compressive strength means silicate cement can be
easily taken out of the cavity .
NOW what is SHEAR STRENGTH ? if I put a bar of glass
on another bar , try to slide them together ( in
opposite direction at one line 180˚ ) .

- It's irritant to the pulp , why ? simply because of

phosphoric acid .

2. AUTOPOLYMERIZING ACRYLIC RESIN :

This material is used in dentures , & was used
successfully as filling material but due to its many
disadvantages it wasn't used any more .

DISADVANTAGES:
- Low abrasion resistance .

- High coefficient of thermal expansion .

- polymerization shrinkage .

- High recurrent caries rate .

- Lack of color stability .

3. FILLED RESINS OR COMPOSITES :

ADVANTAGES:
- Higher compressive & shear strengths .

- less coefficient of thermal expansion .

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 - less water sorption . i.e.) if you put a bar of cured
composite in water it will absorb some water
(negligible amount).

In the previous 3 points the comparison is between

composite & glass ionomer .

Linear thermal expansion coefficient is the

fractional change in length of a bar ( of composite
for example ) per degree of temperature change .

4. GLASS IONOMER CEMENT :

- It bonds chemically to enamel & dentine .

NOTE: * Composite bonds by micromechanical means .
*Amalgam bonds by mechanical means .

- leaches fluoride , like what ??? e7zero ?!

- but the structure of GI is weak means it doesn't

resist forces of mastication , means wear away ; y3ne
after 6 months you will find a concavity rather than a
filling .

ONE SAY : You can't use GI in posterior teeth while

you can use composite in posterior teeth ???
Experiments done to improve the strength of GI how?

GI + SILVER CERMET

So by adding silver, GI becomes stronger .

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 OTHER SAYS : You can't use GI near the pulp because
of the acid which will irritate the pulp & because it
bonds itself to enamel & dentine together & this make
it more irritant , so can we use lining material
underneath this GI ? yes .

SO EVERYTIME THERE IS DEVELOPING &

MANUFACTURING OF NEW PRODUCTS OF GI TO
IMPROVE PROPERTIES . SO KEEP UP-TO-DATE

Now coming back to the most extensively used material

in anterior teeth ( and by some dentists maybe used in
posterior teeth also ) :

COMPOSITE FILLING MATERIALS :

COMPARISON :

COMPOSITE SILICATE

Less insoluble in oral more

fluids
Less toxic to the pulp More

Higher compressive Low compressive

strength because it strength (doesn't set
sets very hard very hard)

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 COMPOSITE UNFILLED RESIN

lower coefficient of More

thermal expansion
Discolor less more
More abrasion Less
resistance

How to check for abrasion resistance ? by scratching ;

apply a pressure on the surface of composite material
by the tip of probe , you will not be able to scratch the
surface of composite easily .

THEN
WHAT'S INSIDE COMPOSITE ?
( COMPOSITION-PHASES )

- Mainly it's composed of the

ORGANIC PHASE = MATRIX

- INORGANIC PHASE = FILLER

- INTERFACIAL PHASE = COUPLING AGENT

1) ORGANIC PHASE :

- Made up of (mainly) Bisphenol-A-glycidylmethacrylate

( BIS-GMA )

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 - Shrink less & don't penetrate dentinal tubules &
cause irritation .

- smaller molecules of methylmethacrylate in unfilled

resins diffuse through the dentinal tubules more &
shrink more than BIS-GMA .

INGREDIENT FUNCTION

Triethylene glycol Reduce viscosity of the

dimethacrylate (TEGDMA) BIS-GMA to increase
wetting ability of resin
(adapt very well in the
cavity)
Inhibitors Prevent premature
polymerization
Ultraviolet light absorbers Prevent discoloration
Coloring agents
initiator DIKETONE
CAMPHOROQUINONE
(catches the light ,
initiating setting rxn)

2) INORGANIC PHASE :

- Made of fillers like quartz , borosilicate , barium

sulphates ( mentioning these names boro- , barium-
reminds us about barium meal which is important for
radiopacity ) .

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 - The higher the filler content , the greater the
resistance to wear by forces of mastication .

- Fillers reduces shrinkage & coefficient of thermal

expansion .

- Fillers increase compressive & tensile strengths .

FILLER SIZE & TYPE CLASSIFICATION :

A- MACROFILLED RESINS or CONVENTIONAL

RESINS :
- contains inorganic particles like quartz & borosilicate
glass , 5 - 75 microns .

- has a problem : cannot take high polished ( try to

polish it to make it glossy & shinny but you can't
achieved this ) .

- Mainly used for posterior teeth .

- has another problem : if large particles are chipped

off what left is a space , this space is retentive to
plaque & oral fluids , means it will be staining
surrounding the filling .

The upper picture on slide # 17 represents macrofilled

resins .

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 B- MICROFILLED RESINS : (the intermediate picture
on slide #17)
- contain small particles measuring 0.02- 0.04 microns

- can take high polish .

- used for anterior teeth ( class 3 & 4 ) why ?

Wear resistance is not so good , so they are used
where the forces of mastication is minimal i.e.) on
anterior teeth .

C- HYBRID RESINS or BLENDED RESINS : ( the

lower picture on slide # 17 )
- contain a mixture of macrofilled & microfilled
particles . so it gives the advantages of macro & micro
fills .

- used universally i.e.) for anterior & posterior teeth .

There is a newer classification of composite based on

particle size :

- megafills
-macrofills
-midfills
-minifills
-microfills
-nanofills

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 DISADVANTAGES OF COMPOSITE MATERIAL :

1. Technique Sensitivity i.e.) if you can't control

moisture you can't use composite .

2. polymerization shrinkage which leads to :

a) marginal leakage ( space between filling material &
tooth ) , then bacteria from saliva can enter the space
causing b) recurrent or secondary caries , then from
substances of liners dissolved , opening dentinal
tubules causing c) postoperative sensitivity may come
from any stimulus cold or heat .

3. Decreased wear resistance but still better than

silicate .

ADVANTAGES OF COMPOSITE MATERIAL :

1. Has very good esthetics .

2. conservation of tooth structure :

extension for prevention is not required because of the
micromechanical retention .

3. Adhesion to tooth structure .

4. Low thermal conductivity ( yes it's not a metal ) .

5. It's a very good alternative to amalgam restoration ,

because amalgam is not environment friendly .

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 ACID ETCH TECHNIQUE :

- Emerged in 1955 by BUONOCORE .

- 30 – 50 % PHOSPHORIC ACID has produced the best

results ( the best concentration is 37% ) .

- Aims of acid etching is to cleanse enamel surface of

any debris . increases enamel surface area available for
bonding . produces micropores (by dissolution of enamel
prisms leaving these micropores of about 10 – 30 µm
deep) into which resins (enamel bonding agent)
interlocks . exposes more reactive surface layer ( area
with higher surface energy ) .
- Duration of acid etching : 15 sec is adequate . then
wash for 30 sec .

- when you apply composite it will bond to the bonding

agent CHEMICALLY .

CLINICAL PROCEDURE :

♦ PROPHYLAXIS :
Clean the tooth with pumice or prophy-paste .

♦ SHADE SELECTION :
It's very important to select the shade quickly & early
during the visit before the clinician's eyes become
tired .
You can make a trial , cure on the paper pad or
unetched tooth surface & compare the shade of the

١٢
 cured composite directly with the tooth then remove it
by the tip of probe .

♦ TOOTH ISOLATION :
We need complete isolation , using rubber dam
( extra-heavy-duty rubber dam )

♦ PROTECTION OF DENTINE :
If there is a need for lining you should line .

♦ ETCHING OF ENAMEL :
Q.) Why gel is better than liquid ?
Gel doesn't flow into gingival sulcus & other
unrequired sites .
Note : it takes longer time to etch fluorosed teeth

♦ WASHING :
Wash away all traces of the acid for double the time
(30sec) , then dry

Good etching will make frosty white (matt)

appearance
‫زي ن ا‬
A chalky white appearance is indicative of over
etching .

♦ APPLYING OF RESINS :
- Apply enamel bondin agent .

- use mylar matrix strip or cellulose acetate crown , to

separate between the required tooth & the adjacent .

١٣
 - The strip also inhibits oxygen from the top surface
layer during curing , so polymerization will be proper .

- Cure the resin bonding agent .

- Each increment layer should not be more than 2mm

thick .

- The light source should be about 1mm from the resin

but not touching it .

- 20-30 sec curing for each increment .

- must protect your eyes with googles or shield .

♦ MATRICING :
- Use either mylar strip or cellulose acetate strip .

- Finish the restoration with flexible abrasive discs

starting from course , medium , fine .

Now Dr started showing pictures :

Slide #36 :we see finishing discs , gold scalpel ,

finishing bur , finishing strip .

Slide #38 : fractured central & lateral incisors , the

next picture shows how they appear after using
composite restoration .

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 SPECIAL HINTS :
- Clean & dry surface
- Remineralization of the etched surface may occur in
48 hrs , so don't worry if you etch the neighboring
tooth .
- Incremental procedure reduces shrinkage &
minimizes marginal leakage .

INDICATIONS FOR THE USE OF COMPOSITE :

1. Restoration of cavities on anterior teeth .
2. Cervical lesions .
3. Hypoplastic lesion .
4. Restorasion of conical lateral incisors .( seen in
slide#46 )
Slide #43 : see how we improve the appearance of
teeth when changing amalgam to composite .

Slide #45 : Diastema closure by composite results in

better appearance .

Slide #47 : missing tooth so we made temporary

replacement until making a bridge .

CONTRAINDICATIONS OF COMPOSITE :
1. In bruxism
2. excessive line preparation like MOD
3. if there is inability to bond to tooth structure
4. if there is poor operating field isolation .

Slide #49 : using composite in PRR .

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 THE SANDWICH TECHNIQUE :
- When there is a cavity from one side in dentine &
from the other side in enamel .
- Restore 1st with GIC then acid etch & add a thin
film(veneer) of composite to the glass ionomer cement
( composite replaces enamel , glass ionomer replaces
dentine )

Slide #52: central groove filled with GI , surrounding

fissures filled with fissure sealant .

☺THE END☺

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