Kate Charles S.

Maglasang DENT

SAS 2: Dental Anatomy (Macro Anatomy) in Operative Dentistry

I.DENTITION
diphyodonts—born with two sets of teeth (Primary and Permanent).

Primary teeth (aka Baby teeth/Milk teeth/Deciduous teeth)

•First set of teeth to erupt and consists of a total of 20 teeth
•Maxilla and mandible each has:
-Six anteriors = Four incisors and Two canines
-Four posteriors = Four molars

Permanent teeth (aka succedaneous teeth)

• second set of teeth to erupt = 32 teeth.
•aka succedaneous teeth, as they succeed or replace the deciduous teeth.
•Maxilla and mandible each has
-Six anteriors = Four incisors and Two canines
-Ten posteriors = Four premolars and Six molars

II.CLASSES OF TEETH:
Incisors
•located near the entrance of the oral cavity
•primarily attributed for an
- aesthetic smile
- facial soft tissue contours, and
- speech
• function = cutting or shearing food

Canines (aka cuspids)

• located at the corners of the dental arch
• function = seizing, piercing, tearing, and cutting food
• crucial role in aesthetics and lip support

Premolars (aka bicuspids)

•serve a dual role in function
-similar to canine = tearing of food
-similar to molars = grinding of food.
•characteristic of the permanent dentition and not present in primary dentition.

Molars
•large, multicusped, and multirooted teeth
•most posterior teeth in quadrant
•main grinders and act as the fulcrum during mastication
III.PARTS OF A TOOTH
ENAMEL
•outermost layer
•hardest substance of human body.
•highly mineralized structure
-containing 95−98% inorganic matter (mostly hydroxyapatite)
• translucent in nature
•the external shape to the tooth and protects the underlying dentin and pulp

•Enamel thickness:
-varies from on tooth to another
-thicker = incisal or occlusal
-progressively thinner = at the cementoenamel junction

• incisal ridges of incisors =2.0 mm

• cusps of premolars = 2.3–2.5 mm
• cusps of molars = 2.5–3.0 mm

•color and appearance may be affected by

-fluoride exposure during tooth development (fluorosis)
- exposure to medications (Example: Tetracylcine staining)
 Kate Charles S. Maglasang DENT

SAS 2: Dental Anatomy (Macro Anatomy) in Operative Dentistry

I.DENTITION
diphyodonts—born with two sets of teeth (Primary and Permanent).

Primary teeth (aka Baby teeth/Milk teeth/Deciduous teeth)

•First set of teeth to erupt and consists of a total of 20 teeth
•Maxilla and mandible each has:
-Six anteriors = Four incisors and Two canines
-Four posteriors = Four molars

Permanent teeth (aka succedaneous teeth)

• second set of teeth to erupt = 32 teeth.
•aka succedaneous teeth, as they succeed or replace the deciduous teeth.
•Maxilla and mandible each has
-Six anteriors = Four incisors and Two canines
-Ten posteriors = Four premolars and Six molars

II.CLASSES OF TEETH:
Incisors
•located near the entrance of the oral cavity
•primarily attributed for an
- aesthetic smile
- facial soft tissue contours, and
- speech
• function = cutting or shearing food

Canines (aka cuspids)

• located at the corners of the dental arch
• function = seizing, piercing, tearing, and cutting food
• crucial role in aesthetics and lip support

Premolars (aka bicuspids)

•serve a dual role in function
-similar to canine = tearing of food
-similar to molars = grinding of food.
•characteristic of the permanent dentition and not present in primary dentition.

Molars
•large, multicusped, and multirooted teeth
•most posterior teeth in quadrant
•main grinders and act as the fulcrum during mastication
III.PARTS OF A TOOTH
ENAMEL
•outermost layer
•hardest substance of human body.
•highly mineralized structure
-containing 95−98% inorganic matter (mostly hydroxyapatite)
• translucent in nature
•the external shape to the tooth and protects the underlying dentin and pulp

•Enamel thickness:
-varies from on tooth to another
-thicker = incisal or occlusal
-progressively thinner = at the cementoenamel junction

• incisal ridges of incisors =2.0 mm

• cusps of premolars = 2.3–2.5 mm
• cusps of molars = 2.5–3.0 mm

•color and appearance may be affected by

-fluoride exposure during tooth development (fluorosis)
- exposure to medications (Example: Tetracylcine staining)
•produced by cells = AMELOBLASTS

DENTIN
•Second layer of the tooth
•bulk of the tooth
•covered by
- enamel = crown portion
- cementum = root portion
•composition:
-70% Inorganic material hydroxyapatite crystallites
-20% Organic material
(apprx 90% type I collagen and 10% non collagenous proteins)
-10% water

• thickness
- coronal aspect of the tooth = 3.0−3.5 mm

• dentinal tubules
-small canals that extend through the entire width of dentin
-from the pulp to the DEJ.
-more in number = pulp
-reduce in number and diameter = approaching dentinoenamel junction (DEJ)
•produced by cells = ODONTOBLASTS

PULP
•Contains nerve and blood vessels = provide nutrition to the tooth
•Nerve = can only detect PAIN regardless of what the stimulus is.
• two parts:
-Pulp chamber (coronal portion)
-pulp canal (root portion)

CEMENTUM
•thin layer of hard dental tissue covering the anatomic root of teeth
•composition:
-45-50% inorganic material (hydroxyapatite crystals)
-50-55% organic matter and water
• avascular (no blood supply)
•produced by cells = CEMENTOBLASTS

PERIODONTAL LIGAMENTS
•Connects the tooth to the bone
•Serves as shock absorbers
•Serves the following functions:
- attachment and support
- sensory
- nutritive and
- homeostatic

FAQs
When do the first PERMANENT TEETH usually erupt?
answer:
on average at the age of 6 years old. Although girls may have them erupted earlier than boys by 6 months on average.

How to differentiate between dentin and enamel during tooth preparation

Answer:
dentin usually is distinguished from enamel by:

•Color and opacity:

-Dentin is normally yellow-white and slightly darker than enamel.
In older patient = darker, become brown or black when it has been exposed to oral fluids, old restorative materials, or slowly advancing caries.
•Reflectance:
-Dentin surfaces = more opaque and dull, less reflective to light
-enamel surfaces = appear shiny
•Hardness:
-Dentin is softer than enamel
- provides greater yield to the pressure of a sharp explorer tine, which tends to catch and hold in dentin.
•Sound:
- Enamel = scratchy sound on probing with a sharp explorer tine, which is not apparent in dentin.
SAS 3: Definition and Classification of Carious and Non- Carious Lesions

CLASSIFICATION VIA LOCATION

Pits and Fissures

- organisms present: gram (+) cocci, S. Sanguinis, S. mutans
- Caries characteristics: expands as it penetrates into enamel
(inverted triangle shape in radiograph with its base located at the DEJ area)
- Clinically may look much smaller than the actual lesion
- Affects a greater area of the DEJ than does a comparable smooth surface lesion.

Smooth enamel caries

- usually near the gingiva or under the proximal contact areas
- Lesions starting on smooth enamel surfaces have a broad area of origin and a conical, or pointed, extension toward the DEJ.

Root surface caries

- has less well-defined margins, tend to be U-shaped in cross section from
- an enamel covering
- Caused mainly by gingival recession with age
- Microbes : actinomyces sp are prevalence

GV BLACK CLASSIFICATION OF DENTAL CARIES

Class I
- pits and fissures on occlusal third of molars and Premolars
- occlusal two-thirds of molar’s and premolars (lingual and buccal pits of molars)
- lingual part of anterior teeth
Class II
- proximal surfaces of molars and premolars
Class III
- proximal of anterior teeth surfaces (central incisors, lateral incisors and
canines) WITHOUT involving the incisal angles

Class IV
- proximal of anterior teeth surfaces INCLUDING incisal angles
Class V
- cervical or gingival one-third of facial and lingual surfaces of
anterior and posterior teeth
Class VI
- cusp tips of molars, premolars and canines

II. TERMINOLOGIES

CARIOUS LESIONS

Primary caries
- a caries lesion not adjacent to an existing restoration or crown

Secondary caries
- adjacent to an existing restoration, crown, or sealant.
-aka caries adjacent to restorations (CAR), recurrent caries (implying that a primary lesion was restored but that the lesion reoccurred)

Residual caries
- carious lesion that was not completely excavated prior to placement of restoration
-may be done intentionally by the dentist to avoid pulpal exposure

Active caries
- biologically active = ongoing tooth demineralization
-color = Light brown to yellowish
-texture = mushy
Inactive caries lesion
-biologically inactive at the time of examination = suppressed tooth demineralization and currently stalle
-Aka recurrent caries = caries process has been arrested but that the clinical signs of the lesion itself are still present

NON-CARIOUS LESIONS

ATTRITION
- The physiologic wear and tear of dentition.
- May be caused by bruxism (grinding of teeth at night)

ABFRACTION
-A notched lesion at the cervical portion of a tooth
-commonly the premolars and canines
-Caused by microflexion of teeth during function causing micro breakage of the enamel rods in the cervical area

ABRASION
- A mechanical notching at the cervical area or at the incisal area depending
on the cause of the lesion
- Commonly seen in the premolar area opposite to the dominant hand of the
patient in abrasion caused by wrong method of toothbrushing (horizontal brushing).
- Seen in incisal edges of carpenters and tailors caused by holding pins/
needles with their teeth

EROSION
- A chemical dissolution of tooth surface
-commonly caused by lemon sucking or other acidic substances
- commonly seen in the lingual surface of the dentition in patients suffering from
gastroesophageal reflux disease.

FAQs
Is there a treatment for NON CARIOUS LESIONS?
Answer:
ALL non carious lesions may be restored with COMPOSITE RESTORATIONS granting:
(1) the lesion has not damaged the pulp of the tooth involved and
(2) the cause of the lesion has been identified and resolved e.g., teeth grinding habits have been stopped.

What will happen to the carious lesion left in the residual caries?
Answer:
since the residual caries are sealed off with the restorative material, the bacteria will be not get the nutrition they need so they will die subsequently and get eliminated by your
body’s immune system

SAS 4 Advanced Carious Lesions

the more enamel demineralization = more weak & collapse of surface covering

DEJ is lesser resistance amongst the surface than enamel or dentin.

Necrotic dentin is wet, mushy, easily removable mass with bacteria present.

sclerotic dentin is the e ideal final excavation depth due to its natural blocking barrier of toxins and acids penetration.

Affected dentin
-zones 2 and 3
-softened, demineralized dentin without bacterial invasion.

Infected dentin (outer layer)

- zones 4 and 5 is softened
-with bacteria present
-includes superficial, granular necrotic tissue and the softened, dry, leathery
dentin
- superficial, granular necrotic tissue and the softened, dry, leathery Dentin
- selectively stained in vivo by caries detection solutions = 1% acid red 52 (acid rhodamine B or food red 106) in propylene glycol

solution stains (1% acid red 52)

- irreversibly denatured collagen in the outer carious layer, but not the reversibly denatured collagen in the inner carious layer
-more conservative tooth preparation becos it differ two layers that’s not easily be detected tactilely

-slowly advancing lesions = remove softened dentin until sclerotic dentin zone is reached
-rapidly advancing lesions = indicates extent of infected dentin

-For deep lesions = excavation that risks pulp exposure

-deep carious lesion, no history of spontaneous pain, no normal responses to thermal stimuli nor a vital pulp = needs a deliberate, incomplete caries excavation

indirect pulp capping = placement of thin layer of calcium hydroxide on the questionable dentin remaining over the pulp.
A direct pulp capping = placement of calcium hydroxide directly on exposed pulpal tissue (a pulpal exposure) and the surrounding deeply excavated dentinal area.

BOTH indirect and direct pulp capping = stimulate reparative dentin formation these techniques rapidly is being

SAS 5: Fundamentals of Tooth preparation

I. INITIAL TOOTH PREPARATION STAGE

• extension of the external walls of the preparation at a specified, limited depth
• to provide access to the caries or defect and to reach the peripheral sound tooth structure
• placement and orientation of the preparation walls :
-resist fracture of tooth & restorative material from masticatory forces principally directed with the long axis of the tooth
-prevent dislodgement or retain restorative material

This stage comprises:

1.Outline form and initial depth

- all unsupported or weakened enamel = removed
- All infected tooth structure = removed
- All margins should be placed in a position = to allow finishing of the margins of the restoration

2. Primary Resistance Form

-shape and placement of the preparation walls = withstand fracture
- Achieve horizontal floor
-Restricting the extension of external walls to allow strong cusp and ridge areas
-Rounding internal line angles to reduce stress concentration
-Reducing and covering weak cusps

3. Primary Retention Form

-shape or form of the preparation = prevents displacement of the restorative material by tipping or lifting forces
- external tooth walls = CONVERGE occlusally (In Class I and Class II convention preparation)
-In composite restorations = through micro mechanical bonding (bonding agent to the tooth and bonding agent to the composite)

4. Convenience form
-shape or form of the preparation = provides adequate observation, accessibility and ease of operation in preparing

II. FINAL TOOTH PREPARATION STAGE

-the preparation should be inspected carefully for other needs, with very conservative amalgam or composite restorations
-the preparation may be complete after initial tooth preparation except for
(1) desensitizing the prepared dentin walls and
(2) etching and priming the prepared walls

This stage comprises:

5. Removal of any remaining enamel pit and fissure, infected dentin, or old restorative material, if indicated
-for deep carious lesions, removal of infected dentin is always indicated
-Affected dentin may be left in the cavity.

6. Pulp protection, if indicated

-placement of liners and bases to aid in pulpal recovery, pulp protection or both
7. Secondary resistance and retention forms
-because many preparation features that improve retention form also improve
resistance form, and the reverse is true, they are presented together.
-The secondary retention and resistance forms are of two types:
• Mechanical preparation features:
includes vertically oriented retention grooves to provide
additional retention for the proximal portions
• Horizontally oriented retention grooves:
mainly used for Class III and Class IV
• Retention coves:
for incisal retention of Class III amalgams

8. Procedures for finishing the external walls of the tooth preparation

-finishing the preparation walls is the further development, when indicated, of a specific cavosurface design and degree of smoothness or roughness that produces the maximum
effectiveness of the restorative material being used.
-OBJECTIVES:
•Create an optimal marginal junction between restorative material and
tooth structure
•Afford smooth marginal junction
•Provide maximum strength or the tooth and the restorative material near
the margin.

9. Cleaning, inspecting and desensitizing

-spraying of air and water = remove any physical debris BUT careful to avoid
desiccation of tooth.
- 2% Chlorehexidine = disinfection of Chlorehexidine
- 5% glutaraldehyde and 35% 2-hydroxyethyl methacrylate (HEMA) =
Desensitization of cavity prepared for amalgam restoration

FAQs
How do you correctly hold a hand instrument?
Answer:
modified pen grasp
- the middle finger, index finger and thumb all rest on the handle as close to the junction of the handle and the shank
-The middle finger rests on the shank, and the thumb and index finger are opposite each other on the handle.
- the most common grasp used.
Inverted pen grasp
- very seldom used,
- sometimes it is used for cavity preps utilizing the lingual approach of an anterior teeth
Palm and thumb grasp
- the most powerful grasp
- most effectively used on the maxillary arch
-It’s similar to the grasp used for holding a knife while paring the skin from an apple.
Modified thumb and pen grasp
- allows much of the palm and thumb grasp but also permits more delicate control.
-It works best when you can rest the thumb on the tooth being restored or on the adjacent tooth.
-It also works best on the maxillary arch.

What will happen to the carious lesion left in the residual caries?
Answer:
since the residual caries are sealed off with the restorative material, the bacteria will be not getting the nutrition they need so they will die subsequently and get eliminated by your
body’s immune system

SAS 6 Review of Restorative Materials Used in Dentistry

The four categories of materials are metals, ceramics, polymers, and composites.

METALS
-shares valence electrons among all of the atoms in the solid, instead of forming local ionic or covalent bonds
-polycrystalline solids
-grains can be composition (single phase) or several different phases (multiphase) and metal alloys have no phase-prone to chemical and electrochemical corrosion (mostly this one
in oral cavity)

CERAMICS
-chemically intimate mixtures of metallic and nonmetallic elements
-ionic or covalent bond; often ionic for simple and both bonds for complicated
-semicrystalline composition
-can be corrode as active, passive and immune
-classification are crystalline or noncrystalline or both, silica based, oxide formed from metals, simple structure or derivative
-common inceramics are semicrystalline, silicates, oxides, and derivative structures

POLYMERS
-nonmetallic elements that are long molecules, large size and weight
-polymerization reaction classification are chain-reaction polymerization (rapid monomer addition to growing chains) and stepwise-reaction polymerization (random monomer
addition)
-chain reaction polymerization stages are activation, initiation, propagation and termination (AIPT)
-accelarator increase activation and inhibitors/retarders prevent initiation

COMPOSITES
-physical mixtures (or blends) of metals, ceramics, or polymers
-in dentistry, its a blends of metals, ceramics, or polymers
-dispersed (filler) phase mixed into a continuous (matrix) phase

physical properties
-coefficient of thermal expansion - increase temparature, expansion of atoms
-percolation - thermal expansion and contraction differences between tooth and resto material; ingress and egress cycle of fluids
-heat flow

-Munsell color system - hue, value and chroma

HUE = the color itself
-(e.g., blue, yellow, orange)

VALUE = the amount of lightness or darkness.

-the number portion of the shade guide (A2, A3, A3.5).

CHROMA/SATURATION = the intensity of the color

-surface properties
-wetting - contact angle
-good wetting = low contact angle,
partial/poor wetting = almost 90*,
nonwetting = almost 180*
-hydrophilicity (water-loving), hydrophobicity (water-hating)

SAS 7: introduction to Pulp Protection

I.FACTORS LEADING TO PULP PROTECTION

- Heat generated by rotary instruments
- Some ingredients of various materials
- Thermal changes conducted through restorative materials
- Forces transmitted through materials to the dentin
- Galvanic shock
- The ingress of noxious products and bacteria through microleakage

Other potential pulp irritants include:

- Injudicious cutting of dentin
- Chemical irritants like monomer and acids
- Thermal and electrical irritants
- Fluids like saliva and bacteria as a result of micro leakage
- Mechanical condensation during condensation that will force materials into dentinal tubules

Liners and bases = placed between dentin (and sometimes the pulp) and the restoration to provide pulpal protection or pupal response

Protective needs for a restoration vary = depending on the extent and location of the preparation and the restorative material to be used

The selection of liners or base =based by the purpose it is expected to serve.

II. OBJECTIVES FOR PULPAL PROTECTION

To understand the actions of these agents = needs to recall the anatomy and physiology of dentin.

Normal coronal dentin includes dentinal tubules that contain cellular

extensions (ondontoblastic processes) of the cells(odontoblasts) that originally laid down dentin during dentinogenesis, these columnar cells remain as a layer
along the periphery of the dental pulp, partially embedded in poorly mineralized dentin (predentin), and with processes extending outward into dentinal tubules.

The processes are surrounded by dentinal fluid when they do not contact the
walls of the tubules.

In response to mild, long term chemical or mechanical insults :

- processes slowly recede toward the pulp
- processes occludes the tubules with peritubular dentin by depositing
hydroxyapatite crystals

Strong insult or near to the pulp (or both):

- the odontoblastic processes are retracted more rapidly from that region
- thin local bridge of hydroxiapatite is created across the affected tubules

- If the insult produces fluid flow(in/out of

the dentinal tubules) = pressure change is
sensed by mechanoreceptors = patient sensitivity

- If leakage of chemical irritants form

biomaterials or bacteria = inflame the pulp

Tooth preparation with rotary instruments generates cutting debris, some of which is compacted unavoidable into a layer on the cut surface = smear layer

The dentinal smear layer

-produces some degree of dentinal tubule sealing, although it is 25-30% porous.
-The smear layer is an effective barrier. Because it is partially porous but cannot prevent slow long-term diffusion.

-To produce a thin film liner = liner ingredients are dissolved in a volatile nonaqueous solvent
-The solution is applied to the tooth structure and dries to generate a thin film.

- solution liners (or varnish) = Any liner based on non-aqueous solvents that rely on evaporation for hardening
- suspension liners = liners based on water have many of the constituents suspended instead of dissolved and
RDT or thickness of the remaining dentin = most important consideration for pulp protection in restorative
-Other considerations include
(1) adhesive material used
(2) type of restorative material used

PROTECTION PROCEDURES
(MEDICAMENT/LINER/SEALER)
Shallow excavation Moderate Deep excavation
(RDT >2mm) excavation (RDT<0.5mm)
(RDT 0.5-2mm)

Amalgam Sealer Base/Sealer CaOH/Base/Sealer

(use LINER)

Composite Dentin bonding Dentin bonding CaOH/Dentin bonding

system

Gold inlays and Cement Base/Cement CaOH/Base/Cement

inlays (useLINER)

Ceramic, Porcelain Dentin bonding Dentin bonding CaOH/Dentin bonding

Restoration system, Composite system, Composite system, Composite
cement cement cement

SAS 8 Classification of Pulp Protection Materials

RDT or thickness of the remaining dentin = most important consideration for pulp protection in restorative

large amount of dentin destroyed/excavated = base would be appropriate (1-2mm thick)

cements that are thicker than 2mm = termed bases

-function to replace lost dentin structure beneath restorations.
- provide thermal protection under metallic restorations
- to increase the resistance to the focus of condensation of amalgam,
- to block out undercuts when taking impressions for cast restorations.

The only distinction between a base, a cement, and a cavity liner is their final
application thickness.

1. Cements for luting =15-25 µm.

2. Cavity liners (either solution or suspension liners).
-Liners (placed as thin coating) = 5 µm
-provide a barrier to chemical irritants
-not used for thermal insulation or to add bulk to a cavity preparation
-do not have sufficient hardness/strength to be used alone in deep cavity
Indication(for liners):
-When ally extended metallic restorations that are not well bonded to the tooth structure
-are not insulating such as amalgam and cast gold, or with other indirect restorations.

composite (Direct & indirect),

ceramic, and (RMGI) restorations routinely
are bonded to the tooth structure.

UNLESS :
- extremely close to the pulp tooth prep
- pulpal medication concerns

Thin film liner (1-50µm) subdivided into:

- solution liners / varnishes = 2-5µm
- suspension liners = 20-25µm

Thicker film liners (200-1000µm = 0.2-1mm)

- aka cement liners.
- are selected primarily:
for pulpal medication and
for thermal protection

3. Bases have a final thickness of approximately 1-2 mm (they may be thicker depending on the amount of dentin that has been destroyed).

Bases
- restorative substitutes for dentin excavated by caries / tooth prep
- function:
barrier against chemical irritation
thermal insulation
resist the condensation forces on a tooth when placing a restoration.
-Also, the clinician can shape and contour base materials after placement into the cavity preparation.

IMPORTANT:
-a base should not be used unnecessarily
-Using of bases in cases where it is not indicated will only compromise the retention of the restorative material

Following steps for applying composite restoration in order:

1 - Isolate the prepared tooth

2 - apply etchant for 10-15 seconds
3 - wash off etchant solution
4 - Apply bonding agent
5 - cure bonding agent
6 - apply composite material and cure
FAQs
Why is a dry field needed?
answer:
-cements that are placed under dry conditions have maximum strength.

dry field:
-prevents delayed expansion of amalgam.
-affords maximum bonding of composite restorative materials to the tooth.

saliva = remineralize the enamel that was etched = cause weakening of micro mechanical bond

SAS 9 LINERS

LINERS
-thin layer barrier for pulp and dentin protection from reactants (restoration/oral fluids) that may enter from microleakages
-acts as electrical insulation, thermal protection, some pulpal treatment (pulpal inflammation relief), and facilitation of dentinal bridge

-types = (1) solution liner/varnish are non-aqueous based that is evaporation-dependent for hardening while (2) suspension liners are water based having constituents suspended on
it.

SOLUTION LINERS
-thin layer to seal off tubules
-composition are 10% copal resin in a combination of ether, alcohol, and acetone
-organic solvent based & hydrophobic or water insoluble
-2-5 µm thin film
-single coat covers 55% of the surface and addition of second thin layer covers 80-85% of the surface
-not be placed over composite restoration = prevent resin polymerization = prevent hardening of resin
-setting by physical reaction (drying)

SUSPENSION LINERS
- dry more slowly, thicker films
-water solvent based & hydrophilic or water soluble
-20-25 µm thick film
-easily abraded off
-provides protective seal around exposed dentinal surface
-prevents galvanic shock
- setting by physical reaction (drying)

note
the thicker the liner = more thermal insulation
1-1.5 mm of insulation is acceptable practical thickness
closer the tooth preparation to the pulp = thick liner or base

SAS 10 10 Eugenol and Calcium Hydroxide

EUGENOL (ZOE)
-discomfort relief from Restorations that are highly polished
- slightly acidic and produces palliative or obtundent actions (but in low conc only, high conc = irritate pulp)

CALCIUM HYDROXIDE
-deepest portions of the preparation
- extremely caustic and acidic (pH >11)
-induce formation of reparative dentin.
-Calcium hydroxide liners= reaction of calcium ions from calcium hydroxide particles
-Excess calcium hydroxide = reserve source of calcium and hydroxyl ions.
- may degrade over time = won’t provide mechanical support
- overlay with a resin-modified glass-ionomer base

-Water affect chemical setting of eugenol-based and calcium-based liners

-moisture = accelerates ZOE setting time
-calcium ions = accelerates calcium hydroxide–based liners
-calcium hydroxide reaction initiation = a must to dissociate moisture from air/dental surfaces but not too much dried
-too much dried= introduce moist cotton
-Eugenol and calcium hydroxide cannot be
mix because eugenol rapidly chelates calcium ions in a strongly exothermic reaction

It provides effective adhesion of these varnish and sealants due to attractive forces between the adhesive and bonding surface.
Both these responses are natural defense
mechanisms to insulate the pulp from
-it can pose risk for degeneration ameloblastchemical, thermal, mechanical, or
-will go further = possibly death of odontoblasts and challenges
biological their tubular extensions below the lesion = mild inflammation of the pulp.
-has the antibacterial properties

SAS 11 BASES

high powder-to-liquid ratios = increase the final compressive strength and reduce the concentration of potentially increase the final compressive strength and reduce the
concentration of potentially
-thick mix=sticky & difficult margin adaptation seal the outer ends of the
tubules = To protect against
these event
Zinc phosphate cement and resin-reinforced ZOE cement
-bases before 1960s
Polycarboxylate cement
-1970.
Glass-ionomer cement
-1985 to 1994
-provide chemical adhesion, good mechanical strength, potential fluoride release, well-controlled setting, and rapid achievement of strength.

before
-first calcium hydroxide liner then base = provide mechanical support and stress distribution
-The base plus tooth structure walls be varnished then amalgam placement
- zinc phosphate cement the varnish done prior to cement

Currently
light-cured calcium hydroxide + glass-ionomer materials = liner and base

For indirect restorations, provisions = prevent dislodgment of the base during impression taking or temporary restoration removal.

specific liners and bases

-amount of remaining dentin thickness (RDT),
-adhesive materials,
-type of restorative materials used

dentin sealers (more frequently used than dentin bonding systems or varnishes ) = seal amalgam tooth prep
dentin bonding systems or varnishes = the deepest portions of preparations

≥1.5-2 mm of RDT shallow tooth excavation

-chemical protection not pulpal protection needed

amalgam restoration
-two thin varnish coat, a single coat of dentin sealer or a dentin bonding system then restored

composite restoration
-bonding system (etched, primed, coated bonding agent) then restored

sealer for amalgams and bonding system for composites = chemical protection.

moderately deep tooth excavation = apply liner only (ZOE or calcium hydroxide)

ZOE cement = eugenol acts as obtundent, thermal insulation, to inhibit composite polymerization

small RDT / pulp exposure / extensive dentin is lost

-use calcium hydroxide
-0.5 to 1 mm of set calcium hydroxide liner = resistance for amalgam condensation forces
-cement base be applied over the placed calcium hydroxide liner

amalgam tooth prep

-a spherical amalgam type = less condensation pressure
-sealer applied prior to final amalgam resto placement

Solution liners (varnishes)

-brittle and thin
-provide only chemical protection for days to weeks.

Sealers maintain = better than varnishes.

Bonding agents = years
Traditional calcium hydroxide liners = continue to dissolve, lose 10% to 30% volume over 10+yrs
SAS 12 BASE MATERIALS

Primary Bases
-close proximity to the pulp
- provide protection from toxic and thermal irritants
-calcium hydroxide (for amalgam & tooth-colored restorations), zinc phosphate/polycarboxylate cements ( for gold), glass ionomer are available
Secondary Bases

-zinc phosphate cement over calcium hydroxide base

-placed over a pulpal exposure
-serves as a placement or substitute for protective dentin that has been destroyed

1000 -2000 um or 1mm-2mm = thickness required for pulpal protection

Note:
Fluid flow of dentinal tubules = main cause of pulpal sensitivity
Fluid flow = detected by mechanoreceptors by edge of pulp
th
Decreased fluid flow = reduce tooth sensitivity = related to 4 power of tubule radius

ZINC PHOSPHATE
-oldest
-powder = zinc oxide (w/ small magnesium oxide by ratio of 9:1)
-liquid = orthophosphoric acid.
- as luting agent for the cementation
- base material when need of high compressive strength
-superior strength compared to other cements, retention depends on mechanical interlocking
-mixing very rapidly will decrease final compressive strength
-very acidic (pH of 3.5) & cause irreversible pulpal damage (but dapat cavity varnish (2 coats) place para ma avoid)
-antibacterial effect (questionable?)
-good pulpal protection from thermal, electrical and pressure stimuli
-Uses: cement (inlay, crowns, ortho band), insulative base, temporary restorative material

-high compressive strength = used as base in amalgam restoration

-excellent thermal insulation (by 1mm thick)
-poor electrical inisulation
These are insulating in nature &
-low tensile strength has sealing effects of the bonding
-brittle in nature ( lacks chemical adhesion, only mechanical means)
agent = NO NEED for liners &
bases

mixing
-use cool mixing slab = increase working time & shorter setting time after placement in mouth
-addition of a small amount of powder to the liquid = increase working time
-addition of small increment powder every 20 seconds until creamy texture
-high powder-liquid ratio and a superior cementation medium through
low viscosity,
stronger final set, &
lower solubility of the set cement
-low powder to liquid ratio = low viscosity

ZINC POLYCARBOXYLATE
-first system developed via chelation type of adhesion
- liquid = aqueous solution of poly acrylic acid and copolymers
-powder = zinc oxide and magnesium oxide

compare to zinc phosphate

-slightly lower compressive strength
-higher tensile strength

- powder/liquid ratio, with more powder = greater strength

-adequate strength for amalgam condensation,
-mild pulp effect enough to eliminate the need for sublining
-low thermal conductivity

advantage
-can bond to tooth structure (meaning ADHESION thru chelation)
-ability of the carboxylate groups in the polymer molecule to chelate to calcium in the tooth.

disadvantages
-thickness
-short working time.

recent innovation in these cements (an encapsulated version of the Durelon)

-mixed and expressed from a capsule = overcomes short working time and excessive thickness

Mixing
- glass slab mixing cements (polycarboxylate) as its nonabsorbent surface
-The liquid portion must not be refrigerated rather dispensed just prior to use. Reason is volatility of water = raising the viscosity
-a glossy appearance is seen when mixing = free carboxyl groups presence needed for good bonding to the tooth
-must load the cement on the tooth prior to loss of glossy appearance

ZINC OXIDE EUGENOL (ZOE)

-soft, sedative-type cement
- insulate base, and interim caries treatment
-powder= zinc oxide
- liquid = eugenol (has a palliative effect on the deal pulp)

-zinc oxide & eugenol conventional mixture = weak.

-“reinforced” or “improved” ZOE cements introduced (called reinforced ZOE or ZOE-EBA)
- EBA (orthoethoxybenzoic acid) = addition of polymer reinforcement and alumina
- EBA attempts to reduce the solubility , increase strength
-powder = zinc oxide and 20% to 40% finely divided polymer particles (polymethyl methacrylate) ; zinc oxide powder is surface treated by an aliphatic mono carboxylic acid
(such propionic acid) =good strength, toughness, abrasion resistance

Reinforced ZOE
-basing large and complex cavities
-withstand amalgam condensation pressure
-soluble in oral fluids

US Army invention in Vietnam war:

ZOE aka Intermediate Restorative Material (IRM), which is fortified with plastic powder.

advantages
-High strength than zinc phosphate
-Excellent abrasion resistance
-Good sealing properties ( tho Pcx & ZnPC have better sealing than ZOE)
-Low solubility ( tho Pcx & ZnPC have lesser solubility than ZOE)

contraindication
-On dentin or enamel prior to bonding: compromises bonding
-As base or liner for composite resins: eugenol interferes with polymerization
- allergic to eugenol
-Direct pulp capping: eugenol is a pulpal irritant when in direct pulpal contact
SAS 13 Glass Ionomer Cement

Glass-ionomers
-materials consisting of ion–cross-linked polymer matrices surrounding glass-reinforcing filler particles
- earliest based GI = polyacrylic acid liquid + aluminosilicate powder (containing calcium and fluoride)
- acidic liquid solution (pH = 1.0) = dissolves portions of the periphery of the silicate glass particle, releasing calcium, aluminum, fluoride, silicon, and other ions

-Divalent calcium ions are chelated quickly by ionized carboxyl side groups on polyacrylic acid polymer chains, cross-linking the chains and producing an amorphous polymer gel.

Acid-base reaction
-consist of basic glass and acidic polymer

During the next 24 to 72 hours:

-the calcium ions replaced by aluminum ions = produce more highly cross-linked matrix = now mechanically stronger

-During the maturation involving aluminum ion cross-linking, silicon ions and unbound water = produce hydrated silicate (an inorganic co-matrix)

-carboxylic acid side groups = capable of chelating surface ions = chemical bond (at all internal and external interfaces)

Set material of GI
- modest properties compared with composites
- relatively good adhesion
- fluoride releasing ions = incorporation into neighboring tooth structure to suppress caries

--------
HISTORICAL DEVELOPMENT

original glass-ionomer cements

-hybrid formulation of silicate and polycarboxylate cements.
- used aluminosilicate powder (from silicates) + polyacrylic acid liquid (of polycarboxylates)
-earliest commercial product = aluminosilicate polyacrylic acid (ASPA)

liquid and powder modifications were soon incorporated to improve:

- the physical, chemical, and mechanical properties.
- early materials = very technique sensitive

Mixing, placement, and early intraoral conditions = crucial to the properties achieved

Glass-ionomers
-are hydrogels
-hydrophilic (dental composites = hydrophobic)

The presence of water = difficult to provide equal esthetics and mechanical strength compared with dental composites.

MODIFICATIONS/DEVELOPMENT OF GI

copolymerization + maleic acid, itaconic acid, or tartaric acid

-modification of original polyacrylic acid
-to increase the stability of the liquid and modify its reactivity

Powder particles were reduced in size and modified = by additional types of powder particles for reinforcement

Ag-Sn particles (amalgam alloy particles) = admixed to produce an amalgam substitute

- “miracle mixture” in 1980s
- time of mercury controversy about safety of amalgams
- far inferior properties to amalgam,
- not well received as a restorative material.
- would not adhere strongly to the Ag-Sn alloy particles
silver-palladium (Ag- Pd) was substituted
- generates a passivating oxide film of palladium oxide
- chemically reactive by chelation with polyacrylic acid.

-These mixtures, termed ceramic-metal (cermet) mixtures

= much stronger than unmodified glass-ionomer cements
= poor esthetics
= not be highly modified, or else not set
= mostly as core materials

Due to limited modification success of GI:

-Less indicated for liners, bases, cements, cores, and root canal filling materials,
-More indicated for restorative material

GI restorative filling
-not esthetic nor strong as composites
-hydrogel in nature = water reduces light scattering and decreases mechanical strength

hybrid or resin-modified glass-ionomers (more composite-like GI)

-early 1990s
-reformulated ionomer-based materials with alternative filler particles or matrix setting reactions = more composite-like
- usually light-cured
- less technique sensitive
-may be finished at the time of placement
- still acid-base reactions
- display some chemical behavior of traditional glass-ionomer materials
-stronger than traditional glass-ionomers,
- recommended for Class V restorations and can be used for Class I and II restorations in primary teeth

polyacid-modified resin composites (compomers)

-named before as “isosit” (combining terms ionomer + composite)
-possesses a combination of characteristics of composites and glass-ionomers
- essentially polymer- based composites that’s slightly modified to permit fluoride release.
- superior mechanical properties than traditional and resin-modified glass- ionomers

(add notes/info below)

atraumatic restorative treatment (ART) technique
-Use GI as temporary filling
-in rural regions of underdeveloped countries, where routine treatment was not possible, untrained dental personnel could use ART until the patient could access dental facilities.
-based on a self-cured version of conventional glass-ionomer (mixed as powder with liquid) capable of high fluoride release
-A frank lesion = partially excavated without dental instruments.
-An ART restoration = rubbing the powder and liquid materials together between the tips of the thumb and forefinger, then is inserted into the tooth excavation.
-permanent restorative material for deciduous teeth instead of choosing amalgam, composite, or other options.
-survive with only minor management for 4 to 5 years.
-simpler procedure than the alternatives
Giomer
- attempt to retain some traditional glass- ionomer properties = precured and pulverized particles of glass-ionomer as an additional dispersed phase within a compomer
- not truly competitive with composites as permanent filling materials in posterior locations
-inferior properties than composite filling for posterior

SUMMARY OF GLASS IONMER HISTORICAL EVOLUTION

The original cement (GIC) is hydrophilic because of the water content required to dissolve thepolyacrylic acid chains and maintain the ion-cross-linked hydrogel.

Hydrogels (bottom middle) are neither as strong nor as esthetic as dental composites (upper right).

Early experiments focused on replacing some of the fluoroaluminosilicate filler with metal or cement particles. These metal modified glass-ionomers (MM-GIC) were not esthetic,
but have been used as cores.

Replacing part of the hydrogel with water-soluble, light-curing monomers and polymer phases generated resin-modified glass-ionomer (RM-GIC or RMGI).

Complete replacement of the matrix with typical composite chemistry but inclusion of the fluoride-releasing matrix phases or glass produced compomers (composites capable of
releasing F ions).

Modification of compomers by blending in precured glass-ionomer phases as particles produced giomers.

------

Clinical Considerations.

-chemical adhesion and fluoride release.

- little clinical evidence indicates that glass-ionomers produce better restorations than composites.
- macroshear bond strengths of 6 to 12 MPa = Adhesion of conventional glass-ionomers (not resin-modified or copomers) to enamel or dentin or both .
- compared to 22 to 35 MPa = dentin bonding agents bond strengths
- aqueous systems and wet tooth structure well
- have relatively high viscosity
- do not adapt readily to micromechanical spaces.

-Glass-ionomer adhesion =mechanical retention and chemical chelation.

- In most cases, good mechanical bonding is much more important than chemical bonding.

The potential of glass- ionomers for chemical bonding is only an advantage in situations = impossible to produce effective micromechanical retention.

fluoride-containing silicate cement restorations = no associated secondary caries, Similar success has never been shown for glass-ionomer.

Two factors influence effects of fluoride ion release.

-levels of fluoride ion release are relatively low
-Release is proportional to the concentration available to diffuse from the matrix or residual silicate particles through to the restoration surface.
-release is relatively high during the first few days after the reaction, but that rate of release decreases rapidly to low levels as fluoride concentration is depleted in the matrix

absence of significant secondary caries with glass- ionomers is not evidence of a fluoride ion effect
secondary caries (well-placed posterior composites) = less than 3% at 10 years, even in the absence of fluoride release

Esthetic problems = replacement or repair in much less than 10 years

Fluoride release from restorations may not be a major advantage if other factors do not favor long-term service.

-Fluoride releasing materials may have therapeutic effects

-Most indicated with high caries risk (reduced or no saliva flow, and
patients with oral diseases that accelerate the pathogenic activities associated with caries)

gingival areas with little/no enamel = GI liner extended =reduce caries risks if microleakage occurs

Fluoride release (GI or other) = diffusion limited and affected by the concentrations in the matrix, the glass filler particles, and the surrounding

For glass-ionomers
- initial high burst of fluoride ion release = high concentration of fluoride ions remaining in matrix immediately after setting
-acid dissolution of outside edges of powder particles releases a large amount of fluoride into the matrix.
-fluoride ions diffuse quickly out of the matrix at external surfaces.
- ions from the matrix are replaced only very slowly by fluoride ions diffusing from the particles.
- actual long-term release rate for fluoride ions = much lower

glass-ionomers exposed to high fluoride ions from other source ( topical fluorides, fluoride rinses, or fluoride- containing dentifrices):
-concentration gradient temporarily is reversed
- fluoride diffuses into the glass-ionomers
-called re-charging process

Biocompatibility
-initial mixing -possible sensitivity and pulpal irritation
-As reaction proceeds = pH increases from near 1 to 4 to 5.
-As setting reaction nears completion = final pH 6.7 to 7
-potential pulpal effects (from low initial pH) = limited to area adjacent to material
Reason = Because the acid groups are attached to polymer
molecules that have limited diffusibility

if RDT less than 0.5 mm = needs calcium hydroxide liner to protect dentin surfaces from direct contact with unset glass-ionomer
problems when fluid-filled dentinal tubules are direct contact with setting cement:
-High ionic conc. in unset glass-ionomer = cause dentinal fluid to diffuse rapidly outward into the cement = produces a minor fluid movement (sensed by pressure receptors near
pulpal odontoblasts) = cause pulpal sensitivity or pain
-unset components (such as hydrogen ions) = may move into tubules and toward the pulp

Tubule fluid = buffer the ions (when the RDT is adequate) and prevent pulp chemical irritation

The key to successful use of these materials is strict attention to specific techniques.

-Lower risks for postoperative sensitivity= resin-modified GI and compomers

To increase mechanical strength= GI mixed at higher powder-to-liquid (or filler-to-matrix) levels than similar ones used for luting.

The reduced matrix content = decreases the risk of postoperative sensitivity or pulpal problems
SAS 14 Dental Adhesion

Adhesion = process of solid/liquid interaction of one material (adhesive or adherent) with another (adherend) at a single interface
-dental adhesion aka dental bonding
-adhesive joint =result of interactions of a layer of intermediate material (adhesive or adherent) with two surfaces (adherends) producing two adhesive interfaces
example pit-and-fissure sealant bonded to etched enamel
-Bond strength = initial mechanical load that generates final fracture divided by the simple, geometrically defined, cross-sectional area of the bond

- type of bond strength test = categorize as initial mechanical loading direction and not the resolved loading direction

-tensile or shear bond strengths - majority

-macrotensile bond strengths= apprx half of the value of shear bond strengths

Microtests (microtensile bond strength tests)

-smaller test area dimensions
- strengths two to three times larger than in macrotests.
-lower flaw concentration
-crack propagation from flaws in the neighborhood of the adhesive -majority

- Microshear tests are used as well.

Classification
1.Physical bonding
-van der Waals or other electrostatic interactions = relatively weak
-only if surfaces are smooth and chemically dissimilar.

2.Chemical bonding
-bonds between atoms formed
-due to dissimilar atoms = bonding is possible & limited
-low bond strength

3.Mechanical bonding
-undercuts and other irregularities that produce interlocking of the materials
-The microscopic degree dictates the magnitude of bonding.
-most dental adhesion= mechanical bonding

BOTH Grinding & Acid etching are common method for producing surface roughness for better mechanical bonding

3.a) Grinding
- produces gross mechanical roughness
-leaves 1 to 3 µm thick smear layer of hydroxyapatite crystals & denatured collagen

3.b) Acid etching (or conditioning)

-dissolves smear layer and produces microscopic relief with undercuts
- micromechanical bonding = microscopically interlocked is < apprx 10µm

Requirements for Adhesion

-needs microscopically intimate interface
1.good wetting = good bonding
-Wetting = measure of the energy of interaction of the material
-A liquid that wets a solid spread readily onto the solid surface.
-complete wetting = 0 contact angle
2.surfaces being joined are clean
-Clean surfaces = high- energy state, rapidly absorb contaminants
If contaminants are not excluded, the adhesive interface becomes weak.
-standard process = apply solvents or acids to dissolve or dislodge contaminants.

Bonding Strengths.
- measured by shearing the adhesive or adhesive joint to produce fracture
-measured as a single cycle stress to fracture.
-clinical situation =fatigue much more important
-single-cycle loading = fatigue is too complex to be simulated routinely for laboratory bond strength tests.
- Dentin is stronger than composite, which is stronger than the dentin bonding agent.
-well bonded interfaces = fracture occurs within the dentin bonding agent or is driven into the adherends
-not well bonded = the fracture occurs along the weakest interface
-depend on the degree to which wetting occurs.
-Cut dentin contains a smear layer, is moist, and is not micro- mechanically rough.
-Selective etching = removes some or all of the smear layer, local wetness control, and produces a micromechanically rough surface.
Dentin =hydrophilic
dentin bonding agent = hydrophilic.

SAS 15 Dental Bonding System Part I SUMMARY

adhesive dental joints aka as bonding system

Enamel Bonding Systems

- unfilled/lightly filled liquid acrylic monomer mixture placed onto acid-etched enamel
The monomer flows into interstices between and within enamel rods
- depends on resin tags becoming interlocked with the surface irregularities created by etching.

Macrotags and microtags = basis for enamel micromechanical bonding.

1.macrotags - resin tags bet. enamel rod peripheries
-unimportant = reason fracture occurs in the neck of the tag
-2 to 5 µm
2.microtags- finer network of thousands of smaller tags form across the end of each rod where individual hydroxyapatite crystals have been dissolved, leaving crypts outlined by
residual organic material
-more important = reason of large number and great surface area of contact

Dentin/Enamel Bonding Systems

-aka dentin bonding systems
-include ingredients that etch (E), prime (P), and bond (B) to dentin and simultaneously produce enamel bonding

similar bonding agent to enamel-only bonding systems

bonding system primer (P)

-depends on hydrophilic monomers = to wet easily hydrophilic dentin
-2- hydroxyethyl methacrylate (2-HEMA or HEMA)
-bond strength to the intertubular dentin along the cut dentin surface
-90% or more of dentin bond strength = mechanical bonding.

Early enamel- only or dentin-only bonding systems

- hydrophobic
-directly to the surface of the dentin smear layer.

Macroshear bond strengths = less 6 MPa because that is the strength of the smear layer to sound dentin
dentin etching (E)= 10 to 12 MPa
hydrophilic primers = 18-20 MPa

Coupled with hydrophilic primers, bond strengths = increased to 22 to 35 MPa.

strength theoretic limit of future dentin bonding systems = higher/greater than that for enamel
-80-100 MPa
-reason = dentin is more resistant to shear fracture
-unknown dentin limit bonding= due to more water in dentin than enamel
- dentin bonding systems longevity may not be as long as that of enamel

remnant smear layer and into the inter- tubular dentin and to fill the spaces left by dissolved hydroxyapatite crystals.276 This action allows acrylic monomers to form an
interpenetrating network around dentin collagen.

When polymerized produces:

hybrid zone(interdiffusion zone or interpenetration zone) = vary from 0.1 to 5 µm deep.
-Excessive etching = decalcify dentin from 1 to 10 µm deep.

HEMA = key ingredient in priming in many bonding systems

Bonding three-component systems:
-etching (E)
-priming (P)
-bonding (B)

Phosphoric acid solutions

-remove the smear layer on enamel and dentin efficiently
-Dentin =remained wet or rehydrated

Two-component systems were devised that employed

-phosphoric acid etching plus priming/bonding (total etch, E + nPB)
-etching/priming with bonding (self- etching, nEP + B)

self-etching primer (SEP)

- employing acidic monomers in water-dominated solvent systems
-dissolve smear layer
-dissolve hydroxyapatite
-polymerize to generate a hybrid zone

Total-etch bonding systems

-more reliable bonding = greater efficiency of smear layer removal by phosphoric acid solutions.
-very low pH (typically 0.2-0.8) = great buffering capacity

SAS 16 Dental Bonding System Part II

Amalgam Bonding Systems

-seal underlying tooth structure
- bond amalgam to enamel and dentin.
-dual characteristics to achieve optimal wetting

Amalgam = strongly hydrophobic

enamel and dentin = hydrophilic

comonomer =wetting agent

-capable to wet hydrophobic or hydrophilic surface.

4-methyloxy ethyl trimellitic anhydride (4-META)–based systems

-frequent bonding system used
-monomer molecule contains hydrophobic and hydrophilic ends

-Macroshear bond strengths (joining amalgam to dentin) = low by 2-6MPa

-Poor micromechanical bonding at the interface of the amalgam with the bonding system.

develop micromechanical bonding= much thicker layers (10-50 µm)

- produce micromechanical laminations of the two materials (Fig. 4-59).

Thicker bonding agent films = adding thickening agents to the unset bonding materials or by applying many (five to eight) applications of bonding material

primary advantages (amalgam bonding agents) = dentin sealing and improved resistance form, increase in retention form is not significant.

Adhesion of amalgam to tooth structures unnecessary when satisfactory retention and resistance forms of tooth preparation already exist.
primary indication
-when weakened tooth structure remains
- bonding may improve the overall resistance form of the restored tooth

use of dentin sealers = for only sealing amalgam preparations

-(GLUMA 2; Bayer Dental Products) was the primer component of a dentin bonding system
primer monomers or polymers
-same film to varnish except film have better wetting characteristics and produces a more impervious surface.
- categorized as a dentin sealer
- dentin sealers also are known as dentin desensitizers= not routinely used to seal dentin under amalgam restorations.

Bonding systems used below insulating restorations, such as composite, do not use traditional liners and bases except when the tooth excavation is extremely close to the pulp
(RDT <0.5 mm).

traditional calcium hydroxide liner = pulpal medication, to stimulate reparative dentin

Porcelain and Ceramic Repair Systems

hydrofluoric acid etching= repairs fracture (PFM or ALL ceramic resto)

- produce micromechanical relief
-silanating the etched ceramic material to enhance wetting and create chemical bonding, applying a bonding system, and adding composite to replace the missing material

-not a long-term solution to the problem but immediate alternative rather than complete replacement of the original restoration

-Wetting of ceramic different than for dentin

sandblasted and etched

-enhance metal retention
If the substrate being repaired includes exposed metal alloy on a portion of a porcelain-fused-to-metal restoration, the metal should be sandblasted and etched to enhance retention.

Cast Restoration Bonding/Luting System

- retained in teeth by appropriate preparation design and by dental cements

-Adhesion = cement adaptation to surface irregularities of enamel and dentin (dental luting cement)
-prevent the restoration’s dislodgement

SAS 16 Dental Bonding System Part II continuation

Cements
-chemically adhesive (polycarboxylate or glass-ionomer)
- most bond strength = mechanical adhesion
-poor wetting, high viscosity, and relative thickness of luting cement

cement fails =fractures propagate to cement along restoration or dentin interfaces

cement is more hydrophilic and wets dentin well

-fractures propagate within cement and follow the weakest portion in the joint
The adhesive joint is improved by

-the strongest cements (composite or resin cements)

-roughening and etching surfaces (casting surfaces and dentin surfaces)
- using bonding systems on both surfaces
- minimizing the cement thickness in the adhesive joint

SAS 17 Pit and Fissure Sealants

Pit-and-fissure sealants
-late 1960s.
-alternative to tooth preparation and restoration techniques for elimination of caries-prone pits and fissures on occlusal surfaces
- objectives to eliminate the geometry that harbors bacteria & to prevent nutrients reaching bacteria in the base of the pit or fissure

Sealants to occlude portions of these sites that are not self- cleansing
- tends to overfill the area
- only modest wear resistance, contact area wear and food abrasion may wear it away quickly from naturally self-cleansing areas where it is not needed.

Sealants may require adequate retention (while most pits and fissures have some macroretention)
-limited penetration to the deepest recesses
-by debris in the fault, inadequate access, or sealant viscosity.
-Micro mechanical retention is required as well.
-After gross debridement, isolation, and acid etching of surfaces, sealant is applied
-be adjusted = does not interfere with normal occlusal contacts nor disrupt occlusal paths

Remaining sealant blocks bacterial accumulation occurring in otherwise non–self-cleansing locations

Classification.
1. polymerization method
- self-curing or visible light–curing.
2.based on methyl methacrylate or cyanoacrylate cements.
3. unfilled (or only lightly filled) a
4. based on difunctional monomers
-such as those used for the matrix of composites.

triethylene glycol dimethacrylate [TEGDMA, also abbreviated TEGDM]

-Lower molecular weight species =dilute principal monomer = reduce the viscosity

titanium dioxide = colorant in small amount

- differ look slight from occlusal enamel

clear sealant = difficult to locate during clinical inspection and evaluation on recall.

Self-curing compositions
- advantage of curing quickly enough that they are retained in sites whose orientation may encourage flow away from the area.
-be applied when they are fluid enough to penetrate the pit or fissure = begin to cure before running away from the site

Composition, Structure, and Properties.

flow into small access spaces =primary clinical property

-relative rate of flow in a standard-sized orifice
- Penetration = function of capillary action and viscosity
-site is well cleaned, etched, rinsed, and dried, acrylic monomers( BIS-GMA) = tend to wet the surface reasonably well.
-Low & long time viscosity = to penetrate into the defect site.

Glass-ionomer sealants
-poorer abrasion resistance
-brittle
-prone to fracture

Traditional composites = not good sealants

-because they do not penetrate as easily into pits and fissures because of comparatively high viscosity.

High viscous=don’t penetrate easily

treatment for pit and fissure caries = bonding system adhesive is similar to a sealant material

flowable composites
-Low-viscosity versions of composites
- applications including pit-and-fissure sealants
-better wetting, sufficient flow, adequate abrasion resistance, and good fracture resistance.

earliest flowable composites = pit-and-fissure sealant

- less filler added

SAS 17 Pit and Fissure Sealants continuation

The properties of sealants

-resin matrix component of composite materials
- no evidence that water absorption, chemical degradation

controversy concerning the BIS-GMA monomers in sealants.

BIS-GMA (produced from bisphenol-A and glycidyl methacrylate reaction) could be decomposed into its constituents releasing bisphenol-A.

Bisphenol-A = estrogenic material

-problem of misidentification of TEGDMA as bisphenol-A.
-alternative monomers that did not include bisphenol-A as a precursor.

Clinical Considerations

-Prevention of occlusal caries at defects depends simply on the exclusion of bacteria or their nutrients
-long as pits and fissures remain completely sealed, there is 100% prevention of caries at those sites.
- If the sealant is lost or leaks= risk for caries again
-The sealant may be lost because of failure of the acid etching or the micro- mechanical retention to the acid-etched surface. It is common for saliva or moist air contamination to
interfere with the effects of acid etching.

Loss of sealant from areas that are not self-cleansing = minimal

ideal time to apply sealants = after occlusal surfaces eruption

-difficult or impossible to use a rubber dam.
-use Cotton rolls or absorbent wedges

-for caries risk older patients as result from reduced saliva flow and more difficulty in maintaining good oral hygiene.
- been applied to smooth-surface tooth structures to try to eliminate caries.
but
For smooth surfaces= fluoridated water is effective in reducing caries prevalence.

Fluoride-containing sealants/Fluoride modification of the enamel = not beneficial.

Sealants also are used to repair or seal leaking or failing dental restorations.

-great usefulness in sealing poor margins of amalgam resto-rations for 15 years.

-seal surfaces of incipient carious lesions adjacent to existing restorations.

sealants
-provides outstanding service
-for very low costs.
-a core strategy for early management of caries

- preventive technique has been the use of fluoride varnishes.

fluoride-modified hydroxyapatite
-intended only as temporary films on teeth that extend the contact time of fluoride with existing tooth structure
-remains for many hours, purpose to produce fluoride-modified hydroxyapatite

fluoride-modified hydroxyapatite
-more acid resistant (i.e., more caries resistant)
-accelerating the remineralization of early carious lesions.

fluoride-modified hydroxyapatite
-generally considered as effective as or more effective than topical fluoride treatments.
-contain a film-forming agent, releasable fluoride, solvents, and wetting agents.
-should be reapplied at least every 6 months

The main cariostatic effect of fluoride varnishes = remineralization of early carious lesions.

Fluoride varnishes combination with other preventive strategies, such as sealants, fluoride-containing dentifrices, topical fluorides, and fluoride mouth rinses, and their effect is
only one contribution to caries reduction on pits and fissures and on smooth surfaces.

SAS 18 Composite

composite
- physical mixture of materials.
-typically involve a dispersed phase of filler particles distributed within a continuous phase (matrix phase)
- In most cases, the matrix phase is fluid at some point during the manufacture or fabrication of a composite system.
-has indicated a mixture of silicate glass particles within an acrylic monomer that is polymerized during the application.
-silicate particles:
-provide mechanical reinforcement of mixture (reinforcing fillers)
-produce light transmission and light scattering = enamel-like translucency

-initial mixture fluid = acrylic monomers (moldable for placement into tooth prep)

- matrix flows = adapt to tooth preparation walls and penetrate into micromechanical spaces on etched enamel or dentin surfaces.

Bonding systems
-primarily unfilled acrylic monomer preplaced onto etched tooth surfaces
-1- to 5-µm film
- micromechanically interlocks with the etched surfaces
-seals the walls of the preparation
-copolymerizes with the composite restorative
-may be provided as part of the composite product package
Composites aka:
-composite restorative materials
- composite resins
- filled composites or filled resins
- resin composites or resin-based composites
- resin-containing composites(are modified to include special polymer phases)
-hybrid or resin-modified glass-ionomers (Glass-ionomer cements modified with polymer-containing fillers and monomer-containing matrices)

NOTE ( was mentioned in sas)

Enamel
- composite of 11% water
-2% noncollagenous proteins
- 87% hydroxyapatite crystals by volume

Dentin
- composite of 21% water
- 5% noncollagenous proteins
-27% collagen
- 47% hydroxyapatite crystals by volume.

Historical Development

Early attempts at esthetic filling materials =based on silicate cements

silicate cements

- reactions of phosphoric acid with acid-soluble glass particles = form a silica gel matrix (containing residual glass particles)
- Solubility problems = led introduction of unfilled acrylic systems based on PMMA.

Methyl methacrylate monomer

-contracted excessively during polymerization = permitting subsequent marginal leakage.
-not strong enough to support occlusal loads
-addition of reinforcing ceramic fillers ( principally containing silica)
-original PMMA materials now are called unfilled acrylics.

Particle sizes

-Filler particle size = surface roughness of the ground, finished, or polished composite.
-Filler particles = harder than the matrix

If the particles are very small, the resulting surface roughness is of little concern. This effect is illustrated schematically in Fig. 4-65B. Otherwise, the rough areas may contribute to
light scattering and collection of organic debris or stain.

finishing and polishing procedures = depends on careful use of successively finer abrasive materials to eliminate larger scratches/defects and replace them with smaller ones.

Final finish of the composite surface = result of the combination of filler particle size effects and finishing scratches
SAS 19 Classification of Composite

classified according to the

-components
-amounts
- filler or matrix phases properties

Since the smaller particles indicates a more better

finished characteristic or smoother and greater
wear resistance than those larger particles.

most common classification method is based on:

-filler content (weight or volume percent), filler particle size, and method of filler addition

defined on the basis of:

- matrix composition (BIS-GMA or UDMA) or
-polymerization method (self- curing, UV–light–curing, visible light–curing, dual–curing, or staged–curing)

higher filler levels

- improved almost all important properties of composites
- as filler level is increased = fluidity decreases, more viscous
-large filler particles resulting rougher finished surface

Smaller filler particles = smooth finished surface

-silica fillers = apprx three times as dense as acrylic monomer (or polymer)
-75 weight % filler is equivalent to approximately 50 volume % filler.=

Properties of composites
-proportional to the volume percent of the phases involved
-much easier to measure and formulate composites using weight percentages rather than volume percentages

Early filler particle sizes = 10 to 20 µm in diameter

Early larger particles = 50 µm

At first, there was no need to distinguish the particle size range or ranges of composites because all commercial products were in approximately the same range.

better finishing characteristics and greater resistance to wear = smaller filler particles

macrofill materials
-early filler particles were relatively large, composites based on those large fillers became
-describe the filler particle size and not the method of producing the mixture.

based on the filler particle size or agglomerate size range :

Composite filler particles

- macrofillers = 10 to 100 µm
- midifillers = 1 to 10 µm
 - minifillers = 0.1 to 1 µm
- microfillers = 0.01 to 0.1µm
- nanofillers = 0.001 to 0.01 µm.
- megafillers = Very large individual filler particles

Composites with mixed ranges of particle sizes are called hybrids, and the largest particle size range typically is used to define the hybrid type

state both portions of the mixture:

- homogeneous composite = simply consists of filler particles and uncured matrix materials
- heterogeneous composite = If includes precured composite or other unusual filler
- modified composite =If it includes novel filler modifications in addition to conventional fillers (such as fiber-modified homogeneous minifill)

After the early macrofill composites, the next generation had fillers that were 8 to 10 µm in average size (midifillers) and were originally designated fine particle composites to
imply their improved finishing characteristics. These new materials quickly became popular and were used primarily for anterior resto- rations in place of silicate cements and
direct-filling resins. The category soon became known as traditional or conventional composites, but that designation has become confusing as newer composites continue to
evolve with even smaller particle size ranges. The next step in composite evolution was to use 0.02- to 0.04-µm diameter particles to produce microfill composites. The term
microfiller already was in common use for these particles in nondental applications. Microfill composites also were called fine finishing composites. The small filler particle size
produced high viscosities in the uncured mixes of BIS-GMA with TEGDMA and required the addition of a greater amount of monomer diluent, along with a reduced overall filler
content to maintain a workable consistency.

To circumvent part of the viscosity problem, two strategies were developed. The first was to blend precured microfill composite with uncured material. Precured particles were
generated by grinding cured composites to a 1- to 20-µm–sized powder. The precured particles become chemically bonded to the new material, provide islands with better
properties, and can be finely finished. These variants are known as heterogeneous microfills (or organic filler composites). An example is shown schematically in Fig. 4-67 and in a
scanning electron micrograph in Fig. 4-68. Unmodified microfills are called homogeneous microfills. A second approach has been to sinter small filler particles into large but
porous filler particles, impregnate them with monomer, and add the new particles to a microfill com- posite. Within the local region of the sintered filler particle, the material is
highly filled and yet capable of being polished.

SAS 20 Classification of Composite PART II

After it was realized that highly filled microfills were difficult to use, composites were formulated
with mix- tures of particles in the microfiller range and 2- to 5-µm range. These bimodal
distributions allowed higher filler levels and still permitted good finishing. All types of mixtures
are known collectively as hybrid composites. In 2005, the average particle or cluster size for filler
mix- tures for current materials was in the 0.1- to 1-µm range. These composites are called mini-
micro hybrids (or minihybrids and occasionally misnamed microhybrids).
More recently, composites have been developed with nanofillers that range in size from 0.005 to
0.020 µm.74
Some biomaterials that claim to use nanotechnology do not use
nanofiller particles, but rather report their filler particle sizes simply
in terms of nanometers (e.g., 100 nm). Nanosized and near-
nanosized fillers are produced for sol-gel processing of silica,171
polyhedral oligomeric silsequioxanes (POSS; Hybrid Plastics,
Fountain Valley, CA),113 or metaloxide nanoparticles.89 Nanofiller
seems to be ideal for finishing, wear resistance, and mechanical
properties. Nanoparticles also may be clustered or aggregated into large units that can be blended
with nanoparticles to produce hybrids as well. Actual nanoparticles can be different compositions,
producing further complexity in the design. Ultimately, nanofiller should replace all other filler
types in composites.
Although the vast preponderance of filler in com- posite is equiaxed rough particles, there is
increasing interest in fiber-reinforced systems. The main advan- tage of fibers is that they have
excellent strength in the primary fiber direction. It is difficult to pack the fibers or orient their
direction efficiently. Small additions of fibers to regular fillers are effective in improving
properties. The limiting factor is that fibers may be used only with dimensions greater than 1 µm
because of the concerns for carcinogenicity of submicron fibers such as asbestos. Most current
fibers have diameters of 5 to 10 µm and effective lengths of 20 to 40 µm.
Single crystals generally have symmetric shapes and are commonly long plates, behaving similar to
fibers. Their singular advantage is that they are much stronger than noncrystalline or polycrystalline
fibers. The strongest example of a crystal-modified composite is an experimental composition that
employs silicon carbide single crystals.264,265 The crystals are colored and not well suited for esthetic
compositions. In clinical uses in which esthetics are not important, however, these crystal-modified
composites could be extremely valuable.
Another consequence of advances in the control of filler particle size, particle size distribution,
particle morphology, and monomer technology has been the introduction of composites with
specific handling characteristics. These include flowable composites and packable composites.
Flowable composites are a class of low-viscosity materials that possess particle sizes and particle
size distributions similar to those of hybrid com- posites, but with reduced filler content (first-
generation flowable composites), which allows the increased amount of resin to decrease the
viscosity of the mixture. In general, the mechanical properties of firstgeneration flowable
composites were inferior to those of standard hybrid composites.33,287 Since 2002, second-
generation flowable composites have been formulated in such a way that their properties are
almost equal to those of traditional composites. Because flowable composites are made with
specific handling characteristics in mind, their range of advertised clinical uses varies. Within the
range of materials classified as flowable composites, the materials with lower filler content (first-
generation) are intended for uses such as pitand-fissure sealants or small anterior restorations.
Materials with higher filler content (second-generation) have been suggested for use in Class I, II,
III, IV, and V restorations, although they are better suited for only conservative restorative
procedures. The most popular applications for flowable composites continue to be as the first
increment during a composite restoration procedure or as a repair resin for margins or nonoccluding
surfaces.
Packable composites, also referred to as condensable composites, were developed in a direct
effort to produce a composite with handling characteristics similar to amalgam—“packable” or
“condensable.” These amal- gam alternatives are intended primarily for Class I and II
restorations. The composition and properties reported for early examples of this class of composites
suggest that they represent little or no improvement over traditional hybrid composites.142,236 The
distinguishing characteristics of packable composites are less sticki- ness and higher viscosity
(stiffness) than traditional hybrid composites, which allows them to be placed in a manner that
resembles amalgam placement, although they do not truly undergo condensation similar to amal-
gam. Because of this, “packable composite” is a more appropriate description of this class of
composites.
Examples of the filled composite designations are shown in Fig. 4-67. Mean filler particle sizes of
those designations are shown in Fig. 4-69. Mean filler particle sizes often may not correspond to
any actual particle size because of polydispersed distributions. Fig. 4-70 shows examples of the
particle size distributions for several composites. There is no practical limitation on the com-
plexity of filler particle compositions or particle size distributions. New composites may be better
described simply as polydisperse.
In addition to inorganic or composite fillers, it is possible to add crystalline polymer fillers. Some
newer composites include crystalline polymer to supplement traditional fillers. Crystalline polymer
is not nearly as strong as inorganic filler, but it is stronger than amorphous polymer material.
Microfill and hybrid composites tend to use micro- fillers of SiO2. These silica microfillers can be
produced in a variety of ways and are designated with different names. Two basic forms are used in
dental compositions. Colloidal silica is chemically precipitated from a liquid solution as
amorphous silica particles. Pyrogenic silica is precipitated from a gaseous phase as amorphous
particles.114 The properties of each form are slightly different, but the differences have not yet been
shown to produce different clinical properties for composites.
For posterior composite restorations, it also is possible to place one or two large glass inserts (0.5-
to 2-mm particles) into composites at points of occlusal contact or high wear. These pieces of glass
are referred to as inserts (or megafillers). Although they have shown improved wear resistance to
contact area wear, the techniques are more complicated and do not totally eliminate contact-free
area (CFA) wear. The bonding of the composite to the insert is questionable.
Matrix monomers for composites used in the United States traditionally have been based on BIS-
GMA as the primary monomer. UDMA has been more popular in European composites. Initially,
better adhesion or resistance to color change was predicted for the UDMA formulations, but
clinical studies have not been able to document these advantages.
Matrix monomers can be polymerized in a variety of ways. The original composites adopted self-
curing chemistry that was typical of dental denture base com- positions. These composites have
been called selfcured, chemically cured, or two-component systems. Amine accel- erators that
were used to increase polymerization rates contributed to discoloration after 3 to 5 years of intra-
oral service. An alternative system was introduced that used UV light (UV-light–cured) to initiate
polymerization. The curing units required had limited reliability and presented some safety
problems. They were replaced with visible light–cured or lightcured systems.
Light-cured composites are the most popular today, but their success depends on the access of high-
intensity light to cure the matrix material (Fig. 4-71). If the composite thickness exceeds 1.5 to 2
mm, the light intensity can be inadequate to produce complete curing, especially with darker shades
of composite. Filler particles and coloring agents tend to scatter or absorb the curing light in the
first 1 to 2 mm of material. Darker shades and microfills are more difficult to cure. Access to
interproximal areas is limited and may require a special technique to guarantee adequate light-
curing energy. Because of these problems, increasingly com- posite compositions are dual-cured,
combining self- curing and light-curing. The self-curing rate is slow and is designed to cure only
the portions not adequately light-cured. Another approach is to provide staged curing. In some
instances, composite finishing can be complicated by relatively hard, fully cured material. By
filtering the light from the curing unit during an initial cure, it is possible to produce a soft, partially
cured material that can be easily finished. Afterward, the filter is removed, and the composite
curing is completed with full-spectrum visible light.