Today we will take about :

 Intracoronal restorative materials .

 Choice of material in pediatric restorations .

 Anterior restorations .

 Posterior restorations .

 Intracoronal restorative materials :

Amalgam

so will start with amalgam : amalgam is a restorative option

in pediatric dentistry , you might notice that we don’t use it
very frequently or very often , there are some debates about
amalgam , the final recommendation regarding amalgam is
to use it sparingly or if you have other choice to use , don’t
use amalgam , use it when it’s the only option , so if we have
other option like composite restorative we might don’t need
to use amalgam very often .

• The advantages of the amalgam :

 Simple – ease of manipulation : it’s very easy to use ,

you don’t have the isolation problem , the tooth has to be
isolated but not like with composite .

 Quick : very quick to place it and carve it .

 Cheap : compared to composite .

  Technique insensitive .

 Durable : it is very durable restoration , but recent

researches show that PRR has the same durability .

• The disadvantages of the amalgam :

 Not adhesive : that’s mean you have to extend your

cavity in order to retain the amalgam inside and obtain
the resistance features for the amalgam .

 Not esthetic .

 Requires mechanical retention in cavity.

 Environmental and occupational hazards : some

countries bond using amalgam for this issue like Denmark
and Poland .

 Public concerns : some population aware from the

amalgam hazards .

So the last recommendation about amalgam that is still used

but it’s better to use it sparingly .

• The clinical uses of amalgam :

 Class I restorations in primary and permanent teeth .

 2- surfaces class II restorations in primary molars where

the preparation does not extend beyond the proximal line
angles : so make a very small box , if the box its too wide
so we can’t put amalgam because the primary tooth can’t
obtain large amalgam in it , so in this case we use
stainless steal crown (S.S.C) .
  Class II restorations in permanent molars and premolars
.

 Class V restorations in primary and permanent teeth :

we can use it but doctor prefers other choices .

• Indications :

 Patient at moderate risk for caries : so patient with

moderate or high risk for caries we use amalgam because
the recurrent caries issue is less.

 Patient uncooperative (poor moisture control) .

• Amalgam – success :

The success of amalgam according to a 5 – year study by

papathanasiou , he compared all types of the Intracoronal
restoration on patients he found that :

 Class I amalgam will last in 93% of the cases in 5

years .

 Class II is 71% survive of the amalgam primary teeth .

 All primary molar amalgams is 79% .

 S.S.C is 92% so we prefer specially in primary molar to

use S.S.C because their size and inability to maintain the
amalgam inside and that’s why we don’t use it very often .

• Method for interproximal class II amalgam

restoration in primary molars:

 We inject local anaesthesia , and we put rubber dam .

 You can use small round or pear – shaped diamond bur

in high speed handpiece , you include small isthmus and
dovetail for retention , and you break the contact points .
  Slow speed round bur can be used to remove deep
caries .

 Place glass inomer liner , we usually use vetrabond , we

put matrix band and wedge and then amalgam , you
condense it , carve it and burnish it .

 Check the contact points with floss .

 Remove rubber dam and check occlusion : the rubber

dam could be for single tooth isolation or to a quadrant
isolation , bi slit to isolate all the teeth together in the
quadrant .

• Class II amalgam – modified outline for primary

molars :

This is done by making a very small box not extend it very

much , so the occlusal outline shouldn’t extend into all
fissures but needs to incorporate a small isthmus and
dovetail for retention .

Composite resins

• The advantages of the composite resin :

 Adhesive .

 Aesthetics .

 They have reasonable wear properties : they are very

strong .

 Command set : you can place it and shape it the way

you want and then you set it when you want .
• The disadvantages of the composite resin :

 Technique sensitive : you need very good moisture

control .

 Rubber dam is required .

 Expensive .

 Polymerization shrinkage : which is the biggest issue in

placing composite , it means that the whole filling will
shrink and it will move away from the cavity margins
which mean the bacteria can go in and recurrent caries
can occur underneath it so most of the companies try to
work in this issue on the future generation of composite .

• Basic chemistry :

 There a monomer/resin which is Bis – GMA or UDMA :

the same as in fissure sealant .

 There is a filler : quartz or glass .

 Silane coupling agent : which bind all the material

together .

 And there a photo – initiator : a material which

enhances the initiation inside the material as it exposed to
light .

 Stabilizer .

 Pigments : to give it a proper shade .

 Radio opaque agent : like yttrium tri – f .

• Bonding agent :
The bonding agent bonds to the primer and the composite
resin , why do we use bonding agent after we acid etched
the tooth ? we place the bonding agent which will act as a
material that will help the composite to bind to the tooth
surface . why do we need bonding agent ? most modern
bonding systems use an intermediary priming agent which
allows a hydrophobic bonding agent to bond to the wet
surface of dentin below and create a superficial bond to the
hydrophobic composite resin , in the past we have to use
after the acid etch , the primer then the bonding agent and
then the composite , now the primer is combined within the
bonding agent , all in one product .

The primer used to act in order to clean the micro porosities

which might be there which acid etch made , and then the
bonding agent will hold onto that , then it bond the
composite in top , now the bonding agent has a hydrophilic
property it’s attached to the wet surface of the tooth
structure but composite is hydrophobic , so we put the
primer to hold the composite later on .

A mechanical interlocking is achieved by flowing the water –

tolerant primer into the surface of the dentin where it
permeates the spaces in the networked structure of the
collagen that was created by the acid etch . in so-called fifth
– generation systems , the chemically active agents making
up the primer and bonding agent are delivered from the
same bottle . even in cases a priming procedure followed by
a bonding procedure must be accomplished prior to
placement of composite resin . so as I said we acid etch ,
then the primer will go into these porosity , the bonding
agent will hold into that primer and the composite will
chemically binding on top .
• Composite resin – filler content :

Composite resin can be categorized according to their filler

content , the filler content may range from (0%-85%) , so
according to how much filler you place ,you get different
properties which will affect specially the wear resistance ,
the more filler you place the harder composite you will get
but it’s harder to polish it .

Category Filler content

Unfilled resin 0%
Unfilled bonding agent 0%
Unfilled sealant 0%
Filled sealant 15 – 50 %
Filled bonding agent 15 – 50 %
Flowable composite 50 – 70 %
Composite resin 70 – 85 %

• Composite resin – filler size :

The other classification of composite resin is according to the

filler size , particles which placed in composite in different
sizes .

Category Particle size

Microfilled 0.01 – 1
Hybrid ( both micro 0.05 – 5.0
and macro)
Macrofilled >5.0 - 50
• Composite resin – clinical use :

In primary molars , composite is a satisfactory restorative

material , providing that the child is cooperative , because
you want a cooperative child in order to place it .

It includes :

 Small pit and fissure caries – PRR in both primary and

permanent dentition .

 Occlusal surface caries extending into dentin .

 Class II restorations in primary teeth that do not extend

beyond the proximal line angles , as I said , otherwise we
use S.S.C .

 Class II restoration in permanent teeth that extend

approximately one – third to one – half of the buccolingual
intercuspal width of the tooth . it’s the same idea of not
having very wide box , so it will not stand the occlusal
forces .

 Class V restoration in primary and permanent teeth .

 Class IV restoration in primary and permanent teeth .

 Class III restoration in primary and permanent teeth .

 Strip crowns in the primary and permanent dentition .

• Composite resin – contraindication :

 Where a tooth cannot be isolated to obtain good

moisture control .

 Individuals needing large multiple surface restorations

in the posterior primary dentition . in this case we place
 S.S.C , if we have many cavities in the tooth we don’t
place composite .

 High risk patients that have multiple caries and/or tooth

demineralization , exhibit poor oral hygiene and
compliance with daily oral hygiene and when maintenance
is considered unlikely .

• Composite resin – success :

The success rate of class II composite resin in primary

molars is 40 % after 6 years .

• Method of cavity design :

Cavity design needs to be modified from that for amalgam

, because you don’t need a resistance form , we need a
slight retentive form but mostly we relay on enamel ,
when we do a composite restoration always think of
enamel , you want it to be retained well so the bevel
should be prepared around the occlusal margins for
additional adhesion to enamel. Because the more enamel
we achieved , the more retention we get so that’s why
some of your composite will fail or fall off because we
don’t have enough enamel to bind to , so in cases of
amelogenesis imperfecta the enamel is defective , the
composite doesn’t bind to the tooth structure , or in cases
of MIH so you have to remove all the defective part and
place on the healthy one , and that’s why we do a bevel
because it’s increase the surface area of enamel and
increase the bond .

 Put local anaesthesia and rubber dam .

 Outline of cavity should follow extent of caries , no

extension for prevention , you need an occlusal dovetail
not usually necessary ,some books said that we don’t
 need that because its relay on the adhesive properties to
enamel but doctor think that it’s very important , may
place grooves into dentin using ½ round bur for extra
retention . (doctor don’t like that) .

 Remove soft caries with round bur or hand

instruments .

 Place matrix band if needed .

 Place composite resin incrementally , no more than 2

ml for increment and we do that to reduce microshrinkage
. place bonding agent to protect from post – operative
sensitivity .

 Check occlusion .

• Problems with composite resin restorations :

 Integrity of bond at depth of the box , next to gingiva

because it’s hard to get moisture control , we always
place dentin liner , to ensure a good bond because the
dentin liner will bind very well to a composite , remember
the sandwich technique and it will reduce microleakage
and release fluoride .

 Placement of composite is difficult and moisture

sensitive , if that happened place rubber dam and place
composite resin incrementally .

Glass inomer

• The advantages of the glass inomer :

 They are adhesive .

  Aesthetic : but not like composite .

 And the important thing is Fluoride leaching .

• The disadvantages of the glass inomer :

 Brittle : the cohesive bond is very weak , they can

break easily .

 Susceptible to erosion and wear .

• Glass inomer basic chemistry :

 A conventional glass inomer cement comprises a

powder and liquid component . when mixed together , an
acid – base reaction occurs .

 The liquid is polyalkenoic acid such as polyacrylic acid

+ glass component that is usually a F-AL silicate (the
powder) .

 As the metallic polyalkenoic salt begins and proceeds

until the cement sets hard . so what happened is that the
glass inomer is liquid then it will become like a jelly then it
becomes hard .

• Glass inomer – characteristics :

 Ability to chemically bond to enamel and dentin with

insignificant heat formation or shrinkage : it’s a very good
property of glass inomer but what is very important a bout
it that its can be bond to dentin and can be a good
replacement to it .

 Biocompatibility with the pulp and periodontal tissues .

 Fluoride release producing a cariostatic and

antimicrobial action .

 Less volumetric setting contraction .

  A similar coefficient of thermal expansion to tooth
structure : it has the same rate of expansion and that’s
very important because if it’s different it could make
cracks or gaps .

• Glass inomer – disadvantages :

 Physical strength .

 Water sensitivity : it’s not purely insensitive to moisture

contamination , so when we put it , we make sure that the
tooth is dry and after place it we put an isolation material
like Vaseline , the doctor like to put bonding agent on the
top of glass inomer to protect it . and when we place glass
inomer put some bonding agent on the plastic instrument
to avoid making a mess on the patient , but don’t use
alcohol because it’s dissolute the glass inomer .

• Glass inomer – success :

 The failure rate of glass inomer cement is higher than

amalgam : 33% VS 20% .

 Average survival time for glass inomer cement is 33

months , it’s ok if patient is uncooperative , no local
anaesthesia , we use the ART technique .

 You got less recurrent caries , f release .

• Glass inomer indications :

 Shouldn’t be used in large restorations subject to

occlusal load in teeth retained for more than 3 years
because of the previous study that show that is will last
for 33 months and if you use it in big cavity , make sure to
cover it with other material like composite .
  It can be used in small occlusal and interproximal caries
.

 You can use stronger , packable , chemically cured

glass inomer cement and avoid use RMGIS for posterior
restorations .

• Glass inomer – clinical uses :

 Luting cement :

- Stainless steel crowns .

- Orthodontic bands .

- Orthodontic brackets .

 Cavity / base liner .

 Class I restorations in primary teeth .

 Class II restorations in primary teeth .

 Class III restorations in primary teeth .

 Class III restorations in permanent teeth in high- risk

patients when you want to arrest caries to some time , or
teeth that cannot be isolated .

 Class V restorations in primary teeth .

 Class V restorations in permanent teeth in high- risk

patients or teeth that cannot be isolated .
  Caries control : when the patient doesn’t have the
cavity done and you want to asses and monitor his case
for sometime then you place glass inomer restoration to :

- High risk patients .

- Restoration repair .

- Atraumatic restorative treatment : technique employs

the use of hand instruments to remove tooth structure
affected by caries . then glass inomer placed into the
cavity .

• Method for glass inomer restorations :

 Local anesthesia may not always be necessary ,

specially in the ART technique , rubber dam where
possible .

 Outline of cavity should follow extent of caries not like

amalgam , no extension for prevention , small occlusal
dovetail not usually necessary , may place grooves into
dentin using ½ round bur for extra retention .

 Remove soft caries with round bur or hand instrument .

 Precondition dentin with 10% polyacrylic acid , 10

seconds , wash , dry: the conditioner is a very light acid
it’s 10% poly acrylic acid , very weak but very good to
remove debris from the dentin and to clean the tooth , it
will increase the retention for the tooth .

 Place glass inomer , compress with burnisher , place

bonding agent to prevent from sticking .

 Prevent final restoration from moisture contamination

by placement of unfilled resin which is bonding agent .

 check occlusion on removal of rubber dam .

 RMGIs

Resin modified glass inomer consist of glass inomer

cement + composite or resin .

Two setting reactions occur in this case :

 1st – light activated polymerization of resin .

 2nd – acid base reaction between glass and poly acid .

 3rd – dark cure continuous polymerization of resin ( tri –

cure RMGI) after light cure the material it goes on and on
for awhile and it called the dark cure process .

Adhesion enhanced by use of enamel and dentin

conditioner , their also a primer , the material that we use
called vitremer , there is liquid , powder and there is a
primer (the conditioner we apply before the vitremer) and a
gloss . the liquid and powder are mixed together and placed
in the cavity , the gloss placed finally which has the same
idea of bonding agent to protect the material from saliva .

• The advantages of the glass inomer : it’s combined

between composite and glass inomer but it’s more toward
glass inomer , the compomer which we will talk about later
it’s toward composite more than glass inomer .

 Adhesive .

 Aesthetic .

 Command set .

 Simple to handle .
  There is a low percentage of F release .

• The disadvantages of the glass inomer :

 Water absorption .

 Significant wear .

• RMGI success :

 Over 3 years , primary teeth .

 Overall is 93.0% .

 Class I is 92.3% success rate .

 Class II is 93.3% success rate .

 Class III is 100% success rate .

 Class V is 98.0% success rate .

It’s pretty high , it has a good retention .

• RMGI examples :

 vetrabond (3M , liner) .

 vitremer (3M , restorative material) .

3M : it’s just the company that manufacture these

materials in the names of vitremer .

• RMGI properties :

 Adhesion (chemical bond to dentin) .

 Margin adaptation and leakage .

 Mechanical strength .

 Fluoride release .
  Esthetics .

 Biocompatibility .

• RMGI disadvantages :

 Physical strength .

 Water sensitivity .

• They are superior to glass inomer by :

 Providing a longer working time with a command set

upon light curing , we have a longer time .

 Easier clinical procedure and manipulation .

 Improved mechanical strength towards that of

composite resin , so it’s strength higher than glass inomer
but it’s less than composite .

 Improved esthetics towards that of resin composite ,

better esthetics than glass inomer but less than composite
.

 When we go toward the composite we get better

esthetics , adhesiveness , better wear strength but more
polymerization shrinkage , when we go toward glass
inomer we will get the opposite .

• RMGI VS CR : compares to composite resin , RMGI

are :

 Generally more difficult to handle because they require

skilful mixing techniques in order to give the correct
consistency , otherwise the paste may be too sticky
during placement or harden too quickly before contouring
can be finished .
  Their overall strength and esthetics properties are still
inferior to that of composite resins .

PMCR

Now with the compomer they have the same idea of RMGI ,
they may contain the glass inomer and the resin but the
ratios are different from RMGI so you have contain Ca – Al –
Si glass filler + poly acid . it contains either or both
components of glass inomer cement but not water based ,
there is no acid – base reaction , they remove water.

Two setting reaction :

- 1st – resin photo polymerization .

- 2nd – acid – base reaction intra orally with F release from

material .

Adhesion requires use of dentin bonding primer . They stop

using compomers because it was claimed by the
manufacturers that it doesn’t releases fluoride as it should
be , so they not do their job , so they are not available in the
market and they use something else which is the giomers .

• PMCR chemistry :

 All of them have in common the following

characteristics :

 single paste light curing materials with glass particles

as fillers : The compomer come in small capsule and in
few shades
  at least two different resins for the matrix including a
light –curable monomer like urethane dimethacrylate
(UDMA) or Bis-GMA .

• The advantages of the PMCR :

 Adhesive .

 Aesthetic .

 Command set .

 Simple to handle .

 Radio-opacity .

• The disadvantages of the PMCR :

 Technique sensitive .

 less F release than GIC .

 polymerization shrinkage: because it resembles

composite in someway .

• Example :

 Dyract (one component with an adhesive system ) ,

restorative .

 Compoglass F (hardened through light cure) ,

restorative .

• Success rate –compomers :

 Class II restorations ,perform well in primary teeth with

a failure rate of 10.3% over a 24 month evaluation
period .

 Main reasons for failure :

 - Bulk fracture at the isthmus .

- Recurrent caries at the gingival margin .

 The low failure rate suggests that compomers are

suitable alternatives to amalgam or other tooth colored
materials when used as class II restorations in primary
molars .

• Clinical properties :

 Adhesion (self-adhesive property and adhesion to the

tooth surface through the primer/adhesive system) .

 Strength and wear performance (more than GI) .

 Fluoride release (Dyract F releases was significantly

less than resin-modified glass inomer cement .

 Ease of handling and manipulation .

 Choice of material in pediatric restorations .

• Choice of material : So how to choose the material in

the clinic

 First look at the Age : Cooperation (RD,LA) durability

required e.g. restore D in a 6yo Vs a 9yo , so the
composite for 3 years or the GI for sometime .

 Caries risk :

- GIC for initial caries control .

- moderate risk-amalgam .
 - high risk –SSC

- low risk – composite .

 Cooperation of the child .

- Poor cooperation and no general anaesthesia facility .

- Amalgam tolerates moisture contamination .

- RMGIs and GICs used for anterior primary teeth

temporarily , replaced later with composite .

 Anterior restorations .

• Anterior restorations in primary teeth :

 Composite ,RMGIs ,Compomers .

 Excellent for one – surface restorations in primary

anterior teeth .

 And we can use Composite resin –strip crowns : it will

be discussed in next lecture (extracoronal restorations).

 posterior restorations .

• Posterior restorations in primary : Options include :

 Amalgam .

 Composite .

 RMGIs .

 PMCR .

 SSC .
I received the lecture this Tuesday (17/2) , and it’s finish
now 11:00 pm of (18/2) .