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Resin composite restorations 1

We will go through dental materials a little bit as an introduction to resin composite restorations.

Resin composite has four components:

1- Polymer matrix based on bis-GMA or UDMA or a combination of the two materials. 2-filler particles (type of glass) which give the physical properties of composite. 3- silane coupling agent connects the Matrix and the filler. 4-an initiator, either chemical (chemical cure) or photoinitiator(light cure).

Classification of resin composite

Resin composite may be classified in different ways, but the most common one is according to the filler particles inside the composite, because it determines the physicals properties of composite and the indication where to use it as we will see later. It may be classified according to: 1- Filler content. 2- Size of filler particles 3- Method of filler addition, which is a manufacturer's consideration. 4- Matrix composition (bis-GMA or UDMA). 5- Polymerization method (light or chemical cure). Classification according to filler particle size: *Microfilled *Hybrid *Nanofilled (the newest)

# Microfilled resin composite:

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-Contains small particles (in micrometers), about 0.04 m. -Can be polished to a higher luster and smoother than other composites, and this is the advantage of microfilled (very esthetic). -indicated in class V restorations. -although it's esthetic, it's not indicated in class IV because its not strong.

# Hybrid resin composite:

-hybrid means a mixture or a blend of submicron (0.04 m) and small particles (1-4 m) fillers. -higher level of filler loading, they can add a lot of filler inside the matrix to improve the physical properties. -can be polished to high luster, but not to the extent of microfilled, so they are stronger than microfilled but not as esthetic as microfilled. - So they can be used in class IV and III restorations where strength is important because it may be a result of fracture, so composite fracture is highly considered, but here we also need esthetics since it's located anteriorly, and microfilled are highly esthetic but not strong, we need something strong and esthetic, so what can we do? We use hybrid composite for strength, and then we apply a surface layer of microfilled for luster and polishing (we do layering). Manufacturers solved the problem by nanofilleds.

# Nanofilled resin composite:

-Filler size range from 0.005 to 0.01 m, and basically manufacturing depends on a cluster of nanofilled particles of a certain weight. -very high filler loading and thus improving physical properties. -can be polished to a high luster and has superior physical properties, so it has the advantage of both the hybrid and microfilled (can be polished to a high luster so it's esthetic, and has high physical properties so its strong).

Methods of activation (polymerization)

Through the development of composite a lot of methods have developed to improve the activation of resin composite. -1963: chemical-cured polymers (two pastes are mixed together to start the polymerization process), still in use but has a lot of drawbacks which are changing in shade and physical properties, and incorporation of voids so it will be weak. -1970: UV photopolymerization, using ultra-violet light, but still has drawbacks. -1980: visible light curing (VLC), which we use nowadays, it's blue light(which we use in the lab), and again it's photopolymerized resin composite.

Light-cured resin composite

-camphoroquinon(CQ) is the photoinitiator: we apply light on composite and light is absorbed by CQ. -CQ absorbs light in the visible blue light portion of the electromagnetic spectrum. -In the polymerization process: carbon-carbon double bonds break into carbon-carbon single bonds and the reaction starts, so CQ breaks the double bonds and converts them to single bonds. Polymerization shrinkage Also called volumetric shrinkage, it occurs when the C=C break down which leads to shrinkage of composite, it's one of the drawbacks and clinical problems of composite that will be reflected in the patient's mouth, because it will lead to microleakage, this gab will cause recurrent caries and sensitivity. And the opposite, which is strong adhesion on the cavity walls, will cause pressure and thus enamel cracks and fracture.

Factors affecting photocuring (very important)

Composite is very sensitive, if you don't cure it well it will cause problems. Because it will affect physical properties of composite, wear susceptibility will increase, and multi fracture will occur, also toxicity will increase(it will release toxins to the gingiva and periodontium. These factors are: 1-exposure: it's recommended that the minimum exposure according to the standards worldwide is 40 sec. for each layer. 2-intinsity of light: should be proper if it's less than required composite will not be cured completely for well cured restoration power density should not be less than 300 mW/cm. 3-temperature: composite should not be cold, it should be hold at room temperature, so you should take it from refrigerator about one hour prior to use. 4-distance: when you bring the tip of the light curing unit away from composite the intensity of light will be reduced. The light intensity should not be less than 300 mW/cm, so if for example the distance between the tip of the curing unit and the tooth surface is X and the light intensity is 500 mW/cm, the light that is absorbed is 400, so if we double the distance the absorbed light will be reduced to 200 mW/cm, which is below the recommended light intensity. This is visible light so it's not harmful to the eyes, but long exposure may have effect, we always say don't look directly to the light, use a shield or don't look at it, but make sure that it's as close as possible and well located(not on the adjacent tooth).

Light-curing units
#Quarts Tungsten Halogen Curing Lights (QTH): -the commonly used one, light source is a pulp of blue light.

-inexpensive. -good power density (600-1000) mW/cm. -broad spectrum (don't worry about it). -fiber optic probes (it's advanced to you, just know it). Drawbacks: -main output is infrared energy (means a lot of heat). Which is the same energy used in microwave devices, When heat is produced we should get rid of heat. So the QTH has a fan for cooling. -Pulp and filter reliability: the fan may be susceptible to damage or failure so the fan or filter have to be changed if they are damaged, and if you don't change it the IR will increase, which will increase the heat, decreasing the efficiency of curing, so these light curing units need periodic check up (the pulp and the fan). -Limit effective lifetime of the halogen pulp is about 50 hours.

Laser curing units #argon laser (drawbacks):

-expensive -cannot be made cordless. -require active cooling (because laser releases heat). -strict safety procedure for the patient, the assistant, and you.

#Light Emitting Diodes (LED) (which we use in the lab):

-narrow wavelength (470 nm), no UV or IR), so no heat build up and no need for cooling. -no filter, minimal heat generation.

-can be cordless (rechargeable), it has a lot of types like the "blue base" which is a gun connected to the electricity and this has a buttery and can be recharged. - Expected lifetime of several thousand hours of operation, this is an advantage over the QTH, which has a limited working time and should be checked.

Now we move to composite restorations

-originate on the proximal surfaces of anterior teeth without involving the incisal edge. -can be detected with explorer: in early stages (as we assumed in the lab) it's very minimum so can be detected with explorer, radiographically or with transillumination. Transillumination: using light source to see through the marginal ridge so if you see something opaque that means a carious lesion. -starts below the contact. #Preparation Approach and Instrumentation of Class III Restoration -Outline is determined by access and by the extension of caries. -Outline should be as conservative as possible. when we use composite (although its esthetic) keep as much tooth structure as possible because the most esthetic is enamel. - Lingual approach unless the location indicated otherwise. to maintain the facial enamel so esthetics will be better, unless teeth are crowded or overlapping so I can't access the caries from the lingual side, or if the caries are already extended to the facial surface so we can do facial approach, otherwise we always use lingual approach. -High speed handpiece can be used for initial access through the marginal ridge.

Class III Composite Restorations

-A large round bur on slow speed to excavate caries the guidelines for caries excavation we did in class I are applied in all classes.
Access enamel with high speed fissure bur, and when dentin is exposed excavation of caries with slow speed round bur. -narrow bevel (functional bevel), 0.5 mm on accessible margins with

tapered diamond bur.

Class IV Composite Restorations

-Involve the proximal surfaces of anterior teeth, and include the loss or removal of the incisal angle. -The main cause is traumatic fracture, but may be class III caries extended to involve the incisal edge causing fracture to become class IV. -For fracture, wide bevel (esthetic bevel) of all enamel margins (1.0 to 1.5) -For carious lesion carious tooth structure and weak incisal enamel are removed then a wide bevel is placed.

Shade or Color Selection

-always select shade before cavity preparation, apply the anesthetic until it works, then select the shade, and then do the cavity preparation. Because of dehydration which might change the shade of the tooth. #Factors influencing shade selection:

-proper lighting: natural light is recommended not the over-head light. -color acuity and eye fatigue: if you look at something for a long time you will not be able to decide the exact shade because of eye fatigue, if this happened look at a natural/constant color like blue (they say it's the best) and then go back and pick the shade. - Achieving optimal color match, ask the assistant for example, and for proper shade selection choose 2-3 shades and pick one of them.

Matrices

*For Class III Restorations: -Clear plastic matrix (celluloid strip). -Wedge can prevent gingival overhangs. *For Class IV Restorations: - clear plastic matrix (celluloid strip) with wedge. -clear plastic crowns: similar to celluloid strip, but they are crowns, they come in different sizes, and we can cut them to fit the fractured tooth, (of course we cut gingivaly). Can we make class IV by etching, Appling the bonding agent, placing the whole composite in the plastic crown and then cure? Yes, we can. But there will be a bulk of composite, and we said composite has to be applied in layers, so it's better to place the first layer of composite without the plastic crown and cure it, and then put the second layer in the crown to make the anatomy and get the shape of the crown, then cure it.

Wedges

-Seal the gingival margin, and prevent overhang: excess composite gingivaly can cause trauma to the gingiva or periodontal pocket and accumulation of debris and subsequent recurrent caries. -Separate the teeth, to allow me to put the celluloid strip. -Protect interproximal gingiva, if the cavity is very close to the gingiva we use it to protect the gingiva from trauma. -Push the gingiva to open the embrasure, for proper contour and rebuild the contact. -Ensure proximal contact. Clinical Steps for Class III or Class IV Composite Restorations

-Select shade before initiation of dehydration. -Place a rubber dam or proper isolation (cotton rolls and suction) -Prewedge if difficulty in achieving proximal contact.
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Prewedge: place the wedge before cavity preparation. -Make the cavity preparation with bevel. -Apply acid etching (30% phosphoric acid for 15 seconds), protect adjacent tooth from etching and bonding agent because there will be difficulty in finishing the restoration in the proximal surface. - Place the adhesive and light cure for 20 seconds. -Place a clear matrix strip and wedge. -Place the resin composite into the deepest area (gingivaly) first to make sure there is no voids and then the second increment and so on (light cure for 40 seconds for each increment). -Add composite and contour to proper shape and light cure again for 40 seconds. -Remove the matrix and strip. Inspect for voids. Add composite if necessary (this is very important). Before you remove the isolation you have to check for any deficiency, because if there is deficiency place composite while there is isolation, but if you remove the isolation, later on a deficiency may be detected so you have to acid etch and bond again. -Remove gross excess composite with finishing diamond burs. -Finishing disks and strips can be used for finishing and polishing. -Impregnated rubber points and cups, for extra gloss and shiny surface, and it's done after polishing. -Check occlusion, if there is extra material. THE END

Done by: Lana Zedan

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