Key for success for anterior composite restoration:

1. Shape reproduction (three dimensional shape reproduction)

2. Shade reproduction (layering technique)
3. Maintenance (long term success not only immediate success)

(they will be discussed from point 3 to 1)

Maintenance
1. The selection of a good quality composite and proper application techniques.
2. Proper use of an appropriate bonding system
3. Use of a light curing system that is capable of delivering enough energy to properly complete the polymerization
process. Consequently, any technical error committed during one of those 3 steps, can result in clinical failure.
4. Proper cavity design (specially in class IV)

1. The selection of a good quality composite and proper application techniques

Resin composite material
 Great advancements have been made in composite materials over the years
 Macrofill composites were highly filled, large-particle-sized materials exhibiting great strength and low esthetic
properties

Classification of resin composite according to filler content: (lecture)

1. Macrofill: difficult in polishing so used only as a core build up material. (strength,  appearance)
2. Microfill: perfect surface properties after finishing and polishing but has low strength so used in non-stress bearing
areas. Uses: (appearance,  strength)
a. Some companies construct the enamel shade only of composite using microfill type.
b. Has low modulus of elasticity so it accommodates tooth flexure, thus it’s used in class V cavities and abfraction.
3. Hybrid: combines properties of strength and esthetics.
4. Microhybrid: hybrid composite and in between its particles lay some microfillers. Not used commonly now.
4. Nanohybrid: hybrid composite and in between its particles lay some nanofillers, used in anterior AND posterior
restorations. Surface luster and acceptable strength. So it’s the most common type used now due to its universal use.
(appearance, strength)
5. Nanofill: excellent surface finish and polish, but low strength so used only anteriorly. (appearance,  strength)

Microfill (slides)

 In 1978 the 1st microfill material was developed and has since been the premier material for simulating the
enamel surface.
 Best material for simulating the enamel surface both esthetically and biologically.
 Owing to their small-sized, uniform, spherical particles, microfills exhibit the greatest long term polish and the
best wear resistance; they are the most plaque resistant and exhibit a refractive and reflective index closest to
that of the enamel surface.
 Most closely simulate the enamel surface in color density, polishability, light refraction and reflection, in both
the short and long terms, and give the natural vitality of a finished enamel surface.
 Have a translucence that most closely resembles enamel, thus allowing tints to shine through. When microfill
composites are used, fracture toughness must be addressed.
 Contraindication for a microfill: use in high-stress areas because of its lowered fracture toughness
Microhybrids (slides)

 Microhybrids were 1st developed to compete with microfill materials owing to their higher strength properties.
 Although microhybrids are not as polishable or as compatible with the tissues as microfill composites, their
strength and opacity are extremely helpful in simulating the strength and support characteristics of the dentin.
 These composites work well for: posterior restorations and because of their increased opacity, for masking of
dark or discolored areas.
 Their esthetic properties are not as good as those of a microfill.

Nanofills (slides)

 The most recently developed composite materials

 Considered today’s universal material, exhibiting qualities of immediate polishability and great surface
smoothness.
 Strong, demonstrate low shrinkage and offer good opaquing qualities
 Recommended for use on their own or underneath a microfill, expect in areas where extreme color changes are
needed
 Their translucent quality allows the vitality of the tooth to be apparent when the light reflects through them.

2. Proper use of an appropriate bonding system

Bonding protocols
Different classifications of adhesive systems:
1. According to generations
2. According to method of treatment of smear layer (etch and rinse “total-etch”, self-etch, Glass ionomer, Universal)
N.B: total etch is a misnomer, it’s better to call it etch and rinse.

Etch and rinse “total-etch” adhesive system:

1. Etch & rinse, then primer, then adhesive (3 steps)
3. or Etch & rinse, then apply primer + adhesive (2 steps, used in our uni clinics)

Self-etch adhesive system/smear layer modifying adhesive system:

-The smear layer is not removed, it’s incorporated in the adhesive layer
1. No rinsing step, etchant and primer in one bottle, then separate adhesive
2. Or all in one single step
N.B: all in one step is not the best as every step in bonding has a certain function.

Universal adhesive system (used in our uni clinics)

-can be used in an etch and rinse mode (best to be used with enamel)
-can also be used in a self-etch mode (best to be used with dentin)
-In this way, it is used in a selective etch mode (best for both) which means you etch enamel 1st, rinse, then apply adhesive on all
tooth structure.

 Etchings systems used to mainly depend on micromechanical retention and resin tags.
 The gold standard used to be etch and rinse adhesive system (3 steps type) because the self-etch had many problems as
compromised durability (poor maintenance) even though it is the least that causes hypersensitivity.
 In the 90s kuraray © released self-etch adhesive that was equal to the gold standard of the 3 step adhesive system by
incorporating MDP monomer which causes very efficient chemical bonding to tooth structure via nano layering improving the
maintenance of restoration, it was released under the name of clearfil and was the most popular self-etch adhesive at that
time.
 After 10 years, the patency of this invention (incorporating MDP monomer) was expired and other companies started to use
MDP monomer too. Now, many brands like GC, dentsply, and 3m brand incorporates MDP in its adhesive to form the universal
scotchbond.
 Before this, you would see the bottle named scotchbond only without the word universal (the word universal indicates the
presence of MDP monomer).

N.B: If you see a bottle titled single bond, without universal, in our clinics then it means etch and rinse (2 step)

Universal bond is termed universal because:

1. It can be used in etch and rinse mode and self-etch mode.

3. Use of a light curing system that is capable of delivering enough energy to properly complete the
polymerization process.

 Any light curing unit has a built-in radiometer which measures light intensity of the light emitted from the unit. Every
month you should check up on the light curing unit and measure the light intensity emitted by the use of radiometer.
 A brand new light curing unit will emit light of 750 intensity and after a year it might emit light of 450 in intesnity only
(you wouldn’t know as the light cure would still keep lighting normally, you can only know by a radiometer measurement).
 Each composite increment requires 20 seconds of light curing for ideal degree of polymerization, so in case of an old light
cure which emits only light intensity of 450 the degree of conversion would be decreased. However, it will still result in
complete surface hardness, but after 6 months it will undergo brownish discoloration.
 This is explained by the lowered degree of conversion which decreased from 70% (best degree of conversion) to 40% after
one year, which means there will be high residual monomer content that leaches out in the oral environment and causes
adsorption of stains (coffee, tea), hence the brownish discoloration.
 When buying a light curing unit, you should know two important things:

a. The wavelength range of the emitted light: should be within the range of the photo-initiator found in the type of
composite you’ll use in the restoration. Camphorquinone which used to be a common photo-initiator in composite is now
being replaced as it causes discoloration of the restoration by aging. The new photo-initiators used now have different
wavelengths than camphorquinone, so you must buy a light cure with a wide range (not narrow spectrum) of wavelengths.
Some composites contain both camphorquionone (10%) and lucirin (10%) to decrease the discoloration by aging and
ensure to target at least one of the initiators.

b. The light intensity: must be continuously monitored by the use of a radiometer. Even if you still see the blue light from
light cure unit, it does not indicate that light emitted is at its full intensity.

4. Proper cavity design (specially in class IV)

Ex: Class IV is subjected to high stresses because 2 of the stress-bearing areas are missing (marginal ridge which is also a
line angle in anterior teeth), unlike class II in posterior teeth only the marginal ridge is lost. That is why the design depends
on the length of the defect.

N.B: stress bearing areas are: 1. marginal ridge (ex: isthmus portion in Class II), 2. line angle, 3. cusp tip.
Designs depend on the extend of the defects

A. Large defect: If 1/3 of the tooth and more is lost, you don’t depend on bevel alone for retention, you need:

1. Chamfer finish line (for proper stress distribution)

2. Corrugated bevel (to increase surface area for macromehcanical & micromechanical retention)

Chamfer finish line by round bur
Rough corrugated bevel
Finishing of the preparation by finishing
stone/rubber cup to prevent accentuation of
the corrugation by smoothening and
rounding it, for proper color degradation
without demarcating lines

B. Small defect

1. Rough corrugated bevel only (no chamfer finish line is needed)

2. Length of the bevel is equal to length of defect or greater by 0.5mm
(ex: if length of the defect is 4 mm, the bevel would be 4-4.5mm)

Shade reproduction (layering technique)

For proper shade color reproduction, the operator should understand the optical properties of the tooth, properly select
the shade, shade map of the required tooth to be restored, then select the appropriate layering technique according to
existing condition.

Optical properties
Not all restorations require the use of layering technique, it’s only used when you want to restore special optical
properties that are naturally found in some of the patient’s teeth. If there’re no optical properties in the patient’s teeth,
then you will use universal composite only.

a. Opalescence: the incisal third has a translucent area among the dentin mammelons, this area has a bluish effect
under transmitted light. When the light is reflected through the enamel, it appears reddish orange.

It’s found only in young ages. This could be used in smile makeovers in old patients (ex: 60 years old) where all his teeth
will be replaced, so you construct teeth with opalescence effect to provide a youthful appearance.

Opalescence effect visible with a dark Opalescence effect less visible when patient occludes due to
background (oral cavity) due to reflection of the teeth behind. That’s why when you restore
contrast. opalescence, you should evaluate it on a dark background.
b. Fluorescence: dental hard tissues (particularly enamel and the ADJ/DEJ) also fluoresce when struck by invisible/short
wave ultraviolet light, reflecting it back as visible, bluish longer wavelengths. Therefore for successful integration,
dental materials should possess fluorescent properties.

In other words, fluorescence is the absorption of light by a substance and the spontaneous emission of light in a longer
wavelength within 10-8 of activation.

All natural teeth have fluorescent properties owing to enamel. By aging, the enamel wears, thus fluorescence of teeth
decreases; making it more matte and dull. When choosing composite type, you should look for the one with the closest
florescence value to enamel which is written on the packaging. The type of fillers (ex: barium..etc) is responsible for this
property in composite. Since porcelain has closer resemblance to teeth in terms of florescence, shine/luster and
hardness more than composite, they started adding ceramic fillers to composite.

c. Translucency: for successful restoration integration, accurate replication of translucency is considered to be almost as
important as value. The translucency of natural enamel (and restorative material) is strongly influenced by its thickness.

 Cervical 2/3rd of tooth is more opaque than incisal 1/3rd. Any degree of translucency requires enamel shade,
that’s why in class V you don’t have to use layering technique, you can use only body shade or universal shade
without the use of enamel shade, you can only apply enamel shade in the last layer to provide lusterous
appearance.
 Degree of translucency differs from one area to another in the tooth, there is transluceny towards marginal
ridges and increases towards incisal part till it creates the oplaescence effect.

d. Characterization:
-Not found in all teeth; hence the term characterization.
-It’s the 4th or 5th step during layering of composite.

Characters

1. Incisal halo effect: white line at incisal edge (usually found in young age)
2. Intensive white spots, clouds or bands: such as in fluorosis
3. Chromatic spots or bands, ex: amber “orange”, brown, white. Amber effect or orange discoloration is sometimes
found at incisal 1/3rd.
4. Dentine lobes of varying color (dentin mamelons)
5. Milky lakes: in between the dentin mamelons/lobes and incisal edge/halo, there are white flakes that you want to
reproduce in your final restoration.
Composite is sold according to the shade:
1. Universal composite/universal shades:
Includes basic shades only, doesn’t have enamel and dentin shades; used in the whole restoration. The kit consist of 8 or 12 tubes.
Example: A1 universal, A2 universal, A3 universal, B1 universal, C1 universal, D2..etc, where ABCD resemble color of tooth “hue” and
the number represents the lightness or darkness “chroma”.

Basic shades:
A orange (most of the population)
B yellow
C yellow gray
D orange gray
Most of the population is A, then B so kits must has A and B. That’s why C and B are bought upon special order only and
not included in the kit.

2. Dual shade composite: A1 dentin, A1 enamel. Dual= every basic shade is available in both, enamel and dentin

3. Polychromatic/trilaminar: every basic color is available in at least 3, or more shades. Enamel shade, dentin
shade/opaque shade, body shade, translucency/incisal shade, color palette for characterization (blue, orange, white,
black..etc)
N.B: Different naming according to manufacturers:
The company which names the darker shade dentin, names the lighter shade body.
The company which names the darker shade opaque, names the lighter shade dentin.

Shade color selection for natural layering could be achieved:

1. Manually: using shade guides (used for universal composite)
a. Classical vita shade guide:
-Arrangement according to hue/chroma: (hue is the color, chroma is the lightness/darkness)
A (Brown/orange, 1-4)
B (Yellow, 1-4)
C (Yellowish grey, 1-4)
D (Reddish/orangish grey 2-4)
1 is lightest and vice versa.

Chroma
A1, A2, A3, A3.5
B1, B2, B3, B4
C1, C2, C3, C4
D2, D3, D4 Classic vita shade guide

-Arrangement according to value (translucency)

B1, A1, C1, D2, B2, A2, A3, D3, C2, D4, C3, B3, B4, A3.5, A4, C4
 Imp: note the translucency arrangement starts with B1..etc as written above, which means B1 is the most translucent of all)
 When you bleach teeth, you should order your shade guide in terms of translucency/value.
 In this way you can use these rules to apply the layering technique using universal shades, you know that B1 is the most
translucent so you’ll use it to restore translucent areas..etc

Value and Chroma arrangement

N.B: classic vita shade guide is made from ceramic material so
sometimes after shade color selection, the color of the
composite restoration doesn’t match (as composite and ceramic
have different fluorescence). Moreover, the same shade from
different manufacturers can sometimes be different, there is no
consistency.

To solve this problem:

1. Usually composite is accompanied by its own shade guide Composite shade guide Composite resin samples of A2 shade by
different seven manufacturers
supplied from the manufacturer made from the same material of composite you will use in the
restoration.
2. If you use classical vita shade guide, you must know its rules and perform confirmatory tests by using composite beads.

Composite beads: If you’re confused between two universal shades, ex A3, A3.5 and want to confirm your choice from the vita
guide, apply both beads next to each other BEFORE the use of rubber dam and without prior
etching, then cure it as curing might slightly change color.. You can then simply remove the
beads by excavator when you’re done. In this way you can use the universal shade in
layering technique by confirmatory composite beads and knowing its rules (translucent
shades, dark/light shades..etc)

Summary: manual shade guides include:

1. classic vita shade guide 2. guide supplied from manufacturer made from Composite beads
composite 3. composite beads.

Color recipe:
For shade color selection in Dual shade or polychromatic only (NOT universal), kits are accompanied by either:

a. Shade wheel

b. Conversion chart
Example:
If you choose shade A1, then choose A1 dentin, A3 enamel
If you choose A2, choose A2 dentin, A3 enamel
Shade A4, A4 dentin, A4 body..etc

C. Custom made shade guide (Color recipes):

Some manufacturers provide you with recipes for creating your own shades but it consumes a lot of material

Prefabricated namel shells supplied by the manufacturer

In dual shade: Some manufacturers provide you with pre-fabricated enamel shell
constructed from composite or material similar to it with different degrees of
translucency (5-6 only). It also provides you with different dentin shades, so you inject
dentin chosen into the enamel shell you chose and evaluate the final color. If not
suitable, remove with any tool and re-choose another one.

Conclusion:
1. If you’ll use universal shade, perform shade guide by vita shade guide
2. If dual or polychromatic, perform shade guide by color recipe which is different according to manufacturers