Composite, Amalgam, Varnishes, Lining and Bases ,with special emphasis on material used in clinic(part 1)

The cavitated lesion and non cavitated lesion;

A non cavitated caries is the first clinically notable sign of the disease. Demineralization of hard dental tissues has reached the level when it can be seen with the naked eye but without a visible breakdown of dental enamel.

the cavitated lesion is broken because of caries, not like the non cavitated lesion. The big question you will face in your clinic when you remove caries is should I stop or continue removing?! To get the answer of this question you need to follow certain steps, you dont need to remove all fissures, just the carious one. Some fissures are stained we leave them. Areas to cut away: 1. Infected areas, theyre soft, orange-brown in color. 2. Decalcified lowed bearing areas (undermined enamel). Its important to remove any undermined enamel because itll cause fracture and failure of your restoration after all, especially in amalgam restoration. 3. Decalcified cavosurface margins, we need to remove them
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because these are the marginal of the tooth and the restoration. If these are decalcified they are force, they will affect the marginal seal and theyre undermined so I need to remove them. choky enamel is decalcified, we need to remove it.

The Dr gave an example of an upper 6, there were two cavities one on the mesial and the other on distal side without interfere with the important and vital part of the tooth structure(preserving), which is the oblique ridge in this example. So we follow the caries and then after removing them I have to stop and make sure that the cavity is dry. We do isolation using the suction, dry cotton rolls and we also use the gauze to wipe the mirror and retract the tissues when giving anesthesia. Then I use the excavator to assess what I have and the suspicious areas that I have within the cavity. I check the color and the texture, the texture if its soft and flaky then I have to remove it, if its hard Ill leave it. The color if its dark, hard and close to the pulp(deep) I leave it because this is affected dentine not infected dentine its hard, the dentinal tubules are already plugged. Otherwise if I remove it Im opening more dentinal tubules increasing the risk of post operative sensitivity and most important I might
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cause pulp exposure. After that I think do I need a lining material or not? if I want to use it I have to think what lining material and where do I need to apply it. The lining material that we are using in our clinic: 1. Vetra bond(RMGI) 2. Calcium hydroxide(we use it in direct pulp capping). *please refer to dental materials and read about them* And before you bring the lining material make sure you have the light cure in your clinic by your side. The next step is to think of the restorative material (Amalgam vs. composite), if its amalgam I need to modify the cavity, amalgam bonds mechanically to tooth structure, so I need to create the resistance and retention forms. For the isolation of the upper centrals we put 2 cotton rolls in the labial sulcus on both sides because of the frenum. For the lower arch we also use two cotton rolls one in the labial and one in the lingual. Isolation is important during the access of the cavity, application of the lining and during cavity restoration, whether its amalgam, composite or GIC. Amalgam is less sensitive than composite because it takes less time but this doesnt mean not to isolate the tooth.

~The cavity preparation now is done.

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Lining (Pulp protection)

Include: 1.the varnish is placed over the floor and walls of the cavity, the organic solvent evaporates and the resin stays there sealing the dentinal tubules, so its temporarily seals the dentinal tubules, decreasing the chance of post operative sensitivity and sealing the dentinal tubules protecting them from the corrosion byproduct not to discolor them.(the varnish in microns). 2.Lining material: thicker than varnish, we apply it only on certain walls apposing to the pulp( pulp protection), it also provides a therapeutic effect like calcium hydroxide and provides some thermal insulation. 3. Base: its the thickest one, we use it to block some certain areas and also to compensate for the loss of a ___ amount of the tooth structure. The varnish dries very fast within 10 sec and because its thin and we apply it in tow layers after making sure that the first layer is dry we apply the other layer, we dont use it under the composite because it will leak the composite, we use it with amalgam. Calcium hydroxide is self cured, not like RMGI also applied in thickness of 0.5mm, it composed of suspension of
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calcium hydroxide as a main indicates in organic liquid. what we have in the clinic comes in tow pastes( base and catalyst) . We use ZOE as a temporary filling material, The powder is zinc oxide and the liquid contains Eugenol among other things. Its the least irritating material use in dentistry (ph=7). It has a sedative effect but we dont put it directly over exposed pulpal tissues. The only materials we use directly over exposed pulpal tissues are calcium hydroxide and MTA(mineral trioxide aggregate). We dont use ZOE under composite because itll interfere with the free radicals in the composite resin. Glass Ionomer(GI): came as powder and liquid(what we use in clinic), the powder contains calcium fluoroaluminosilicate and the liquid is polyacrylic acid, we mix them together to get the glass ionomer in an acid-base reaction. Or it may come capsulated and we dont use it in our clinic. # Advantages of GI: (1) It bonds to the tooth structure. (2) coefficient of thermal expansion, it compatible with tooth, if its not compatible it means itll contract more than the tooth structure or itll expand more than the tooth structure. If it contracts more itll affect the marginal seal between the restoration and the tooth.
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(3) It has anti bacterial properties. (4) Fluoride release.

Resin Modified Glass Ionomer (RMGI): we use it in the clinic, basically its glass ionomer with few composite resin(mix of chemical reaction and light cure), So you cure it and itll continue the setting reaction. # Advantages of RMGI: 1. It bonds to the tooth structure. 2. Has anti bacterial properties and F release. 3. Strong material. Where to apply lining material? If we have class II cavity, we apply the lining material on the axial wall and pulpal floor if needed but not on the gingival floor. We apply it with the applicator not the condenser or a spatula, not anything else. Make sure not to apply it on the walls just the pulpal floor(axial floor in class II). ~the cavity lining is done.

The Matrix
Benefits of the matrix:
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1. Provide walls to condense against(compensate for the missing walls). 2. Create a proper contact area. 3. Provide isolation. Types of matrix: 1. The universal(tofflemire); we use it in the clinic, it comes in different shapes. The occlusal part is upward and the gingival part downward, when you apply it make sure it covers the tooth structure not the gingival tissues, Then put the wedge below the contact point we use the larger embrasure but if we have any difficult we can put it from the buccal side. We use the wedges to prevent the overhang, We have wooden wedges and plastic wedges come in different sizes. The wedge has an apex and base(pyramidal in shape), we put the base toward the gingiva and the apex toward the contact point, you should be able to see the shape of the pyramid from above, if you place it the other way around youll open the contact. 2.The auto matrix, we dont need a tofflemire just the matrix and we use a certain device to help adapting the matrix to the tooth. 3.i couldnt hear it, we use it for deep subgingival areas. 4.Sectional matrix, use with composite restoration, we put the matrix and then the rings or vice versa, the ring is to stabilize the matrix.
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5.The celluloid strip, use in class III and IV, we put it before applying the acid etch and the bonding agent, dont use long celluloid strip because itll interfere with placement of the composite so use the short one.

The Restoration
1. Amalgam: mercury + metal alloy. Advantages: - Low cost. - Longevity. - Less sensitive to clinical techniques because it takes less time. - More resistant to wear than composite. Disadvantages: - Absence of adhesion. - We need to remove more from tooth structure to create resistance and retention form because it bonds mechanically to the tooth structure. -not esthetic. - The mercury hazard. 2. Composite: Components: Fillers, matrix, coupling agent and the

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initiator(initiate the reaction between the previous 3 components). Advantages: - Adhesion to tooth structure, which means less removal of tooth tissues. - More conservative because I dont need to create a retention and resistant form. -More esthetic. Disadvantages: - Polymineralization shrinkage. - Stress build up because of polymineralization shrinkage. - Micro leakage and consequences like staining, recurrent caries and sensitivity. - Its difficult to make proper contact because of the polymineralization shrinkage. - Technique sensitive, very sensitive to the moisture. - More time is needed because you have more steps to do. - Less resistance to wear.

Microleakage:
The penetration of the oral fluids and bacteria in the interface between the preparation wall and the restorative material, This interface should be as smooth
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as close as possible. The influx of these bacteria and fluids can cause problems including post operative sensitivity, marginal discoloration or staining, secondary caries, pulpal inflammation and irritation leading for the need of RCT. To prevent the micro-leakage we need proper isolation and restoration technique as well, if you applying a composite dont apply it as a bulk we have a layering technique, margins should be as seal and smooth as possible. How can I improve the margins of the restoration? As you know when you choose the restorative material you have certain criteria to choose on: 1- The difference of the coefficient of thermal expansion. 2- Polymineralization shrinkage and how to decrease it. 3- Finishing and polishing, you dont leave rough surfaces and in the same time you dont over finish or over polish your works because you might create some cracks and open margins between the restorative material and the tooth. 4-Orientation of the enamel prisms, especially when youre doing composite restoration thats one important reason why we do the bevel. 5-Application methods, as we said when you apply it you have to maintain good isolation control. 6-Cavity configuration.

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Composite versus Amalgam This will guide you to which material you are going to apply . - In the school they focus on composite, teaching the students more skills about how to place a good composite restoration. - We still dont have a very solid evidence about banning amalgam restoration, The more concern is about the environmental hazard not about our health. - Patients concern about esthetic and dentists concern about being conservative.

Biocompatibility is defined as the materials ability to perform a proper biological response when contact with a body or the body tissues. The composite is not safe, we have cytotoxicity, allergenicity and the effect of the UV light on retina. The amalgam is the fifth source of mercury; the inorganic one not organic mercury, organic mercury is more hazard to our body. The source of inorganic mercury is dental amalgam, electrical switches lamps and batteries as well. Amalgam is there for more than 150 years but composite is there for more than 50 years.. this gives advantage to amalgam.

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The common mode of fracture for composite is the fracture of the restoration in secondary caries because of the polymineralization shrinkage. While for amalgam its tooth fracture and __ syndrome.
Sorry for any mistake, wish you all the best.. Eman Idkaidek

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