Direct Posterior Composite Restoration

Indications:
1. Small and moderate restorations, preferably with enamel margins 2. Most premolar or first molar restorations, particularly when esthetics is considered 3. A restoration that does not provide all of the occlusal contacts 4. A restoration that does not have heavy occlusal contacts 5. A restoration that can be appropriately isolated during the procedure

6. Some restorations that may serve as foundations for crowns 7. Some large restorations that are used to strengthen remaining weakened tooth structure ( for economic or interim use reasons).

Contraindications:
1. When the operating site cannot be appropriately isolated 2. When heavy occlusal stresses are present 3. When all the occlusal contacts are on composite only 4. In restorations that extend onto the root surface.

Advantages
1. Esthetics 2. Conservative tooth structure removal 3. Easier, less complex tooth preparation 4. Economics ( compared with crowns and indirect tooth- colored restorations)

5. Insulation 6. Bonding benefits

Decreased micro leakage. Decreased recurrent caries. Decreased postoperative sensitivity. Increased retention. Increased strength of remaining tooth structure.

Disadvantages 1. Material related Possible greater localized wear. Polymerization shrinkage effects. Linear coefficient of thermal expansion. Biocompatibility of some components unknown . 2. Require more time to place.

3. More techniques sensitive Etching, priming, adhesive placement. Inserting composite. Curing composite. Developing proximal contacts. Finishing and polishing. 4. More expensive than amalgam restorations.

Pit and fissure sealants

Pit and fissures result from incomplete coalescence of enamel and are prone to caries. Clinical Technique 1. Isolation with Rubber dam. 2. Cleaning with slurry of pumice on bristle brush (brush better than a rubber cup.) 3. Rinsing well and dry.

4. Applying of Acid Etchant (35% phosphoric Acid by Applicator tip for 30 secs. 5. Rinsing for 20 secs. and dry . 6. Self- cured sealants is mixed and applied with a small applicator.

Preventive Resin and Conservative Composite Restorations

When restoring small pits and fissures on an unrestored tooth, an ultraconservative, modified preparation design is recommended. This design allows for restoration of the lesion or defect with minimal removal of tooth structure and often may be combined with the use of composite or sealant to seal radiating noncarious fissures or pits that are high risk for subsequent caries activity.

Direct Class I Composite Restoration

Clinical Technique - Shade selection should be done beginning preparation. - An assessment of the preoperative occlusal Relationship of the tooth to be restored should be done. - Isolation of the preparation (before or after).

Tooth Preparation
Typical Composite preparation is divided into 3 forms. Conventional Beveled Conventional Modified - When resistance form needs to be provided, conventional preparation form may be indicated.

-Small to moderate restorations may use modified tooth preparations, which usually do no need more resistance form.

Conventional Class I Tooth Preparation

For the large class I composite tooth preparation, one enters the tooth in the distal pit area of the faulty occlusal surface with the inverted cone diamond or carbide bur then transverse mesially parallel to the long axis of the crown. The pulpal floor is prepared to an initial depth of 1.5 mm, as measured from the central groove. This initial depth is approximately 0.2 mm inside DEJ.

 Extensions toward cusp tips should be as minimal as possible. Extensions into marginal ridges should result in approximately a 1.6 mm thickness of remaining of tooth structure( measured from the internal extension to the proximal height of contour) for premolars and approximately 2 mm for molars.

After extending the out line form to sound tooth structure, any caries or old restorative material should be removed. No attempt is made to place beveling On the occlusal margins, Retention is gained by Convergence of the walls, and the ends of enamel rods are exposed by preparation.

Beveled Conventional Class I Tooth Preparation - Large class I Composite tooth preparation is primarily a conventional design. If a facial or lingual groove is included, usually it is beveled, and the resulting preparation design would be a combination of conventional and beveled conventional.

Modified class I Tooth Preparation

Small class I Composite tooth preparation may be restored with this form. These preparations are less specific inform, having a scooped out appearance. They are prepared with small round or inverted burs. The pulpal depth is 1.5 mm from the central occlusal groove or 0.2 mm in DEJ.

Restoration Technique
Etching, priming and placing Adhesive.

As Manufacturer instructions ( According to Generation )

Inserting and Curing of the Composite

Inserting of composite should be done incrementally to Maximize the polymerization depth of cure and reduce the negative effects of polymerization shrinkage or high Cfactor.

- Contouring can be started immediately after a light cured composite material has been polymerized or 3 minutes after hardening of self cured. - Twelve (12) flutes finishing burs can be used to obtain excellent contouring and finishing results. - Polishing the contoured composite restoration is done with very fine polishing discs, fine rubber points or cups, diamond polishers, and composite polishing pastes.

Occlusal Box The occlusal portion of class II preparation is prepared similarly as described for class I preparation. Proximal Box The extent of the caries lesion and amount of old restorative material are two factors that dictate the facial, lingual, and gingival extension of the of the proximal Box preparation.

- It is Not required to extend the proximal box beyond contact with the adjacent tooth (clearance ). If all of the faults can be removed without extending the proximal preparations beyond the contact, the restoration of proximal contact is simplified. - The depth of preparation should be 0.2 inside DEJ. - The facial and lingual margins are extended as necessary and should result in at least a 900 degree cavo surface margin.

- The gingival floor is prepared flat with an approximately 90 degree Cavo surface and the axial wall should be 0.2 mm inside DEJ and have slight convexity. - Usually no secondary preparation retention features are necessary. - No bevels are placed on the occlusal Cavo surface margin. - Usually, bevels are not placed on facial and lingual walls of proximal box. - Bevels can be placed in proximal facial and lingual margins if it is wide and additional retention form may necessary.

- The preparation portion on the root should have: 1. 900 degrees Cavosurface margin. 2. Axial depth 0.75 -l mm 3. No secondary retention forms. - When the gingival floor is on the root surface ( No Enamel) the use of RMGI liner may decrease micro leakage, gap formation and recurrent Caries.

- In contrast to amalgam, posterior composites are almost totally dependant on the contour and position of the matrix for establishing appropriate proximal contacts. - Early wedging and retightening of the wedge during tooth preparation aid in achieving sufficient separation of the teeth to compensate for the thickness of the matrix band. - Generally, the matrix is applied before the etching, priming, and adhesive.

Inserting & curing

- The bonding adhesive is placed over the entire etched and primed enamel and dentin. - The adhesive is lightly air-dried and polymerized with a light-cure, usually for 20 seconds. - Small layers of composite are added and cured. It is important to place and cure composite incrementally to maximize the curing potentially and reduce the negative effects of polymerization shrinkage, C-factor, or gap formation.

- The first small increment should be placed along the gingival floor and extend slightly up the facial and lingual walls. - This layer should be only 1-2mm in thickness. - Subsequent additions are made and cured (not exceeding 2mm) until the preparation is filled to slight excess. - The matrix is removed, and the restoration is cured from facial and lingual directions.

- Contouring can be initiated immediately after a light cured composite material has been polymerized or 3 minutes after initial hardening of self cured. - Twelve (12) flutes finishing burs can be used to obtain excellent contouring and finishing results. - Any overhangs at the gingival area can be removed with a No. 12 surgical blade with light shaving strokes. - Polishing the contoured composite restoration is done with very fine polishing discs, fine rubber points or cups, diamond impregnated polishers, and composite polishing pastes.

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