POSTERIOR COMPOSITE RESTORATIONS

DR. AHMED SAAD

Outline
1) How to choose composite material.
2) How to choose bond.
3) Cavity design.
4) Preparation.
5) Isolation.
6) Case diagnosis.
7) Matrix selection.
8) Finishing & polishing.

Composite Composition
 Inorganic fillers: Silica or zircon, reduce the polymerization shrinkage,
strengthening the composite & reduce water sorption.
 Organic matrix: Plastic material which fillers are embedded in. When its
percentage increases, the polymerization shrinkage will increase.
 Initiators: light initiator or photo-initiator responsible for curing of
composite.
 Pigments.
 Inhibitors: inhibit the action of initiators till the expiry date of composite.
 Silane coupling agent: it connects between inorganic fillers & organic
matrix.
Choose composite according to:
 Situation: anterior or posterior tooth.
 Percentage of fillers: when it increases this will increase the mechanical
properties, decrease the polymerization shrinkage & water sorption
 Shades available.
 Fillers type according to size: macro, micro, and hybrid (microhybrid or
nanohybrid), which has the best mechanical & esthetic properties.
Composite type for posterior restorations:
 Microhybrid composite.
 Nanohybrid composite.

Clinical Protocol
KISS protocol: Keep It Simple & Short.

Diagnosis
It depends on:
 History of pain: onset, duration, relieving factors, intensifying factors.
 Clinical examination.
 X-ray: to define boundaries of the cavity and extension of caries.

Isolation
 Rubber dam isolation is needed to achieve “Stress-free dentistry”.
 Multiple isolation is preferred.

Caries Removal
There are two types of caries:
 Infected caries: full of bacteria and demineralized tooth structure, so can’t
be left in the cavity.
 Affected caries: only change in color, decreased number of bacteria and can
be remineralized again, so it can be left in the cavity.

To differentiate between infected and affected we can use:

1) Excavator: infected caries can be easily removed by sharp spoon excavator.
2) Rose-head bur on low speed handpiece: large carbide bur removes infected
caries only.
3) Polymer bur or smart bur.
4) Caries detector dyes: they stain affected and infected caries, apply for only
10 seconds then wash.
Management of Deep Caries
1) Complete caries removal then direct pulp capping.
2) Partial caries removal from periphery especially the dentinoenamel
junction (as disinfecting the area will lead to pulp exposure), then indirect
pulp capping.
Success of direct pulp capping depends on:
1) Pin point exposure, free from signs & symptoms.
2) Under rubber dam isolation.
3) Bleeding control by saline.
4) Disinfection of cavity by chlorohexidine or sodium hypochlorite 2.5% on
cotton for 30 seconds.
5) Immediate seal by capping material (MTA: mineral trioxide aggregate,
Theracal: calcium disilicate, calcium hydroxide).
 No need for base placement in deep cavities.
 We should depend on normal sound probing of dentin and bitewing x-ray
to ensure complete caries removal.

Cavity Design
Class I cavity design guidelines:
1) Check marginal thickness.
2) Exposure of enamel rods by flaring with flame stone 45° on all the margins
to increase bonding strength.
3) Roundation of internal walls by finishing stone 45°.
4) Marginal ridge 1.6 mm in width at least.
5) Width of cavity buccolingually should not exceed 1/3 or 1/2 the width of
occlusal surface.
6) Tooth Restoration Interface (TRI) should be away from centric occlusion,
checked by using articulator paper.
7) If the remaining cusp is weakened (thickness less than 2 mm), go for cuspal
coverage with composite restoration after reduction of the cusp 2mm.
Class II cavity design guidelines:
1) Extension of cavity margins in self cleansable area.
2) Gingival step should be below the contact area by 0.5 mm.
3) Cuspal coverage if cusp less than 2 mm.
4) Roundation to line angles especially axio-pulpal line angle.
5) Undermined enamel should be removed.

General cavity design guidelines:

 Cavity floor: it is not necessary to make flat floor with composite, so you
will not cut more in tooth structure and leave suitable amount of dentin,
internal walls should be rounded to avoid stress concentration, also
cause pulling of the bond at this area creating space, and stresses fall
resulting in compression forces and pressure on dentinal tubules,
roundation is done by rounded end stone (TR).
 Cavo-surface margin (tooth restoration interface): must be well finished
for better adaptation to avoid white line of demarcation, walls must be
flared to increase amount of opened enamel rods for better bonding
also ends appearance of white lines. It is important to check stresses
that falls on this area as direct occlusion will affect bond and cause
fracture, so finish and flare the cavo-surface margin using finishing stone
45°.
 Cusp thickness: any undermined enamel in posterior teeth under direct
force as cusp, buccal and lingual walls of the proximal box, even if
supported by composite will fracture, should be removed by finishing
stone.
But cervical enamel should not be removed, you should preserve it as it
is the most site for recurrent caries, also bonding to dentin or
cementum is not strong as with enamel.
So before making the cavity do pre-wedging to preserve the cervical
enamel, also build up cervical area immediately for support.
In case of class I, measure the thickness of mesial and distal marginal
ridges, in premolars minimum 1.6 mm, and in molars 2 mm, if less open
it class II.
 Cusp thickness must be 2 mm to withstand occlusal forces, if less
fracture will occur, so do cuspal coverage, reduction to cusp 2 mm using
straight fissure bur or rounded bur, to convert forces from wedging
action to be directed towards long axis of the tooth.

 When to do cuspal coverage?

1. If cusp thickness less than 2 mm.
2. Depth of the cavity more than 4 mm and width more than half
occlusal surface.
3. Functional cusps of opposing occlude at cavo-surface margin.

Etching & Bonding

 Etch use phosphoric acid 37% (36% to 40%), enamel for 30 secs and dentin for
15 secs.
 Nowadays we make selective etching to enamel for 30 secs to avoid
denaturation of protein in dentin that release MMP enzyme that cause bond
degradation.
 Etch may be polymer or silica it is better to use polymer as it is easier during
washing.
 Also after etch application you must observe air bubbles due to reaction
between etch and tooth structure this indicate a good etch, also observe
chalky white appearance.
 Bond from fourth generation to universal bond, mostly used either self-etch
bond or universal bond (used with all techniques, but if you use it without
etching, bonding with enamel will be very weak) they have acidic monomer
that cause etching.
 If you will use single bond, don’t etch dentin more than 15 secs, do selective
etching on enamel for 15 secs then fill all the cavity for another 10 to 15 secs
then wash.
Steps:
1) Selective etching to enamel from 15 to 30 secs.
2) Washing
 3) Drying: by sponge or use microtip of high suction with flowable tips, as
over-dryness will cause dentinal fluids to go out and tubules will collapse,
also will cause postoperative hypersensitivity.
4) Bonding: use appropriate size of brush, make active brushing, then get chip
syringe slowly to remove excess, do this until there is no bond moving in
the cavity.
When the cavity become glowy, it is ready for curing.
5) Cure as near as possible, but some light cures generate heat which results
in postoperative hypersensitivity, to avoid this cure in intervals (cure for 10
secs then wait 2 secs then cure another 10 secs and so on).

Build Up Techniques
 In class I cases, we use “Successive Cuspal Build Up Technique”:
o Each cusp is built separately.
o If depth doesn’t exceed 2 mm add flowable composite on the floor (0.5
mm), it will act as shock absorbent and make excellent adaptation.
o Build each cusp using probe, plastic instrument and brush.
o Adapt composite on cavo-surface margin, use a clean brush to blend the
composite with the margin to avoid white line which appears due to
improper adaptation or traumatic finishing.
o Restore anatomy of the tooth, by drawing grooves using probe.
o Cure from 10 to 20 secs.
o Build marginal (mesial and distal) fossae if included then make an overall
curing from 20 to 40 secs from occlusal surface.
Benefits of successive cusp build up:
1) Give perfect anatomy to each cusp.
2) Decrease polymerization shrinkage.
3) Decrease C-factor.
4) No cuspal deflection as 2 wall maximum are cured at a time.
5) Decrease postoperative hypersensitivity.
Composite is a sticky material as it sticks to the instruments resulting in microgaps
that appear after finishing as white lines.
To avoid this:
1) Clean the instruments from any particles or remnants.
 2) Alcohol drops on the instrument, will act as separating medium.
3) Make excellent adaptation of composite and confirm it with brush.
Sometimes after building cusps and making excellent anatomy you destroy that
during checking occlusion.
To avoid this:
1) Make sure that restoration end at same level of cavo-surface margin.
2) Composite should have 45° with cusp.
You can check that by probe tip at central groove 45° at cusp tip and see
it from in front of the patient.
If the cavity is more than 2 mm in depth: use bulk flow from Ivolclar or SDR (Smart
Dentin Replacement) from Dentsply. They have advantage of excellent
adaptation, also curing depth from 4 to 5 mm, so can be built and cured at one
shot. However, they can’t build the whole cavity up to the occlusal surface due to
low wear resistance, so fill the last 1.5 mm by composite paste as done in class I.
 In unbounded class I cases (with buccal or palatal extension):
it can be built either: free hand, by using a band, or by double band technique.
 In class 2 cases, “Centripetal Technique” is used:
o Build the missing wall first to convert it to class I
o Build the gingival layer by “Snow Plow Technique”, by putting flowable
composite for 0.5 mm without curing, then put composite paste 1.5
mm, then make excellent adaption using instrument or brush, until
flowable composite escapes occlusally, then start curing.
The benefit of excellent adaptation of flowable composite with low
polymerization shrinkage and better mechanical properties of composite
paste are gained using Snow Plow technique.
o Build every 2 mm incrementally until cavo-surface margin.
o Remove ring and band but leave wedge in place to avoid bleeding and
leakage into the cavity.
o Cure from buccal, occlusal and lingual for 20 secs.
o During making marginal ridge use tip of probe at 45° with the band to
make roundation to this area.
o Continue as class I.
Bands Selection
You deal with bands, wedges, and rings
1) Rings: there are different types, as Palodent (2000), Garrison (twin more
than 2000), TorVM v or delta (120).
a. Help adaptation from buccal and lingual.
b. Separate teeth.
2) Wedges: there are wood or plastic, transparent.
Adapt the band on gingival step, also must enter with friction (wedge is
bigger than space), this friction helps in separation and overcome band
thickness.
In cases of deep caries using wooden wedges, we find that cervical profile
change from convex to concave as it is very deep and wedge can’t make
deep adaptation to the band so in these cases we use diamond wedges of
Bioclear Green wedge (has gingival extension, convex in shape to enter
concave part of the tooth), also can use teflon to increase adaptation,
teflon is hydrophobic material that can make seal but stick to the
instrument, so make the field dry but the instrument wet.
Position of wedge: always enter from wide embrasure to narrow one, then
it may be at same level of gingival step or slightly at higher level or at a very
high level, the last 2 positions are very wrong as the highest point of the
wedge must be at the same level with gingival step to avoid matrix
deformation and will result in a gap and food accumulation.
3) Bands:
There are different types; metal, clear, plastic, self-locked, circular,
sectional, and saddle.
Different heights; small, medium, large, or numbered as Bioclear and
Palodent.
Different thickness; either 35 microns, 50 microns, or 70 microns.
Also there are soft (HD bands of Bioclear band) or hard (transitional band of
Bioclear).
a. Bioclear system: bands HD (blue, soft) or transitional (clear, hard) 70
microns with 4.5, 5.5, 6.5 heights, with twin rings and diamond
wedges.
 b. Palodent: their bands are soft 35 microns with 4.5, 5.5, 6.5 heights
but easily deformed, wedges, forceps, and rings.
c. TorVM: saddle (larger contour, hard, 50 microns) it can be either
contoured with heights start from 1311 for lower premolars, 1312 for
upper premolars or small molars, and 1313 for upper and lower
molars, and non-contoured as tofflemire, start from 301, 302, 303 or
sectional bands (soft or hard, 35 or 50 microns, with heights small,
medium and large), also shape number 1 is without gingival
extension, 2 with small gingival extension, and 3 with large gingival
extension in deep caries.
Spring clip with saddle bands to adapt band on the tooth, so it is very useful
in case of restoring last tooth, also in double band technique.
o Features of the matrix:
1. Contoured
2. Thickness from 35 to 50 microns
3. Hard
4. Should adapt to gingival step and be 1mm below
5. Doesn’t exceed margin ridge of the adjacent tooth (max 0.5 to 1mm)
to make contact at the middle third, otherwise contact will be at
marginal ridge
6. No deformation
7. Well locked
8. Centralized buccolingually
9. No inner scratches
It is measured from gingival step to the nearest point of adjacent tooth,
thin if it is from 0.5 to 1 mm, medium if 1 to 2 mm, and wide if more than 2
mm.
Also thin can use saddle 1301, 1302, 1303 non contoured.
Medium I still have cervical enamel, while in wide there is none.
In very wide cases, you can either use one build up technique by using
saddle or Bioclear matrix or 2 build up technique using sectional, in this
technique you put flowable 0.5mm the paste 1mm to convert cavity from
wide to medium, trim your composite to have a flat gingival seat, use a
wooden wedge and ring, then etch and bond (sometimes sandblasting),
then complete your steps.
Thin Medium Wide
 1. TorVM small 50 1. TorVM small 35-50 1. Saddle contoured
microns hard microns H&S matrix no. 1313
2. Tofflemire matrix sectional matrix shape 2-3
3. Saddle metal 2. Palodent 5.5-6.5 2. Bioclear biofit HD
matrix no. (1301- 3. Saddle contoured 3. Bioclear Curved
1302) 50 microns small- 4. 2 step build up
medium technique by
4. Bioclear biofit sectional
5. Bioclear Average contoured matrix
large one
5. TorVM Mmedium
& large

Finishing and Polishing

Improper finishing and polishing will lead to staining.
Oxygen inhibiting layer (uncured layer), should be removed using glycerin or by
finishing and polishing, also any present roughness can accumulate biofilm and
plaque.
Finishing is proper contouring and removing excess and roughness.
Polishing is to increase light reflection, having highly smooth surface to give
surface glaze.
90% of finishing and polishing should be done before curing of last composite
layer, by making excellent adaptation by brush, drawing grooves by probe and
smoothening of restoration as much as possible. This will help to decrease steps
and time of finishing and polishing.
During finishing class II, start with buccal and lingual using discs, remove
roughness then remove high points.
In case of restoring 2 adjacent teeth, use double band technique to divide space
between 2 teeth, and to preserve profile for each tooth, start with the more
difficult (deep gingival step), but if they are the same start with small cavity.
 Steps:
o After removing rubber dam, start removing any excess composite and
give proper contour.
o Remove high spots (Bull’s eye marks only) using flame shape bur
(yellow/ red coded) on low speed or high speed burs with adaptor on
low speed.
o Pre-polishing:
Using silicone rubber cups as Kedna, MicroDont, or OptiCare.
Used to remove roughness due to high spot removal, and to smoothen
the surface.
o Polishing:
Using brushes impregnated with silicone carbide abrasive particles, as
Soflex spiral (3M), Astrobrush (Ivoclar), OptiShine (Kerr).
Used on low speed with drops of water.
o Extra-polishing (Gloss):
Using goat hair brush with diamond paste or felt wheel with aluminum
oxide paste.
With nanohybrid composite: use diamond paste (1 micron) with goat
hair brush.
With microhybrid composite: use diamond paste (3 microns followed by
1 micron).
Always on low speed with few drops of water, then accelerate speed
with continuous water from chip syringe.