Selection of Restorative Materials and Techniques

Dr.
Nesrine Elsahn 2/21/2018
Objectives
I-Requirements of an ideal restoration
II-Available restorative materials
III-Requirements of an ideal restorative material
Dr. Dr. Nesrine Elsahn

IV-Factors influencing selection of the suitable
Assistant Professor of Operative Dentistry Restorative materials
Ajman University
Dr.Nesrine Elsahn
I-Requirements of an ideal restoration I-Requirements of an ideal restoration
Biological Biological
 Stop further progress of the
present lesion.
 Protect and maintain pulp vitality.
 Restore and maintain the

arch integrity and periodontium.
Dr.Nesrine Elsahn Dr.Nesrine Elsahn
Dr. Nesrine Elsahn 2/21/2018
Biological Biological
Mechanical Esthetic
 Protect the remaining tooth structure.
 Should restore
 Sustain normal physiologic occlusal normal esthetic.
load without fracture
 Maintain constant relationship with the
surrounding tooth structure.
 Restore normal function of the affected
tooth i.e. cutting, tearing and mastication.
I-Requirements of an ideal restoration II-Available permanent restorative materials
Direct Indirect
Esthetic Gold foil Amalgam Cast gold Cast metal
Composite GI Ceramic

Direct Restorations Indirect Restorations

II-Available permanent restorative materials As plastic (soft) material Hard piece
Built in increments, bulk or injected Cemented as one ready-made piece
Direct Indirect Adapted directly to cavity walls and margins Cemented to cavity walls (poor adaptation).
 Cavity Size Need one visit Conventional types need more than one visit
Machinable chair-side needs one visit ( more
chair side time)
 Strength, Hardness and wear resistance
Lower wear resistance, less hard Higher wear resistance, Stronger and harder
 Ability to reproduce contact and contour

Restoration of contact, contour and Perfect and more controllable restoration of
occlusion is more difficult in large size contact, contour and occlusion
 Number of visits cavities
Indicated in small and medium size cavities Indicated in large size cavities
 Expense Dr.Nesrine Elsahn Dr.Nesrine Elsahn
Less expensive More expensive
Direct Restorations Indirect Restorations

II-Available permanent restorative materials
Direct Indirect
 Wall direction
 Retention Buccal and lingual walls converge occlusally Buccal and lingual axial walls diverge occlusally
Mesial, distal, buccal and lingual axial walls at any step converge
occlusally
 C.S.A Retention gained from: Retention gained from:
• Macro-mechanical interlocking • Frictional and gripping action of dentin ( parallel walls)
• Micro- mechanical interlocking (bonding) • Micro- mechanical interlocking (for bonded restorations)
 Cavity depth (brittleness) • Chemical adhesion • Chemical adhesion ( depending on cement type)
For posterior restorations, 90° C.S.A For cast gold posterior restorations C.S.A should be beveled
 Internal line angles
1) Convenient and easy in its manipulation and

Rounded More definite Sharp application
2) Reasonable cost
3) Harmonious color simulating the affected tooth
4) Biologically compatible with the pulp and the adjacent
soft tissues
5) Anti-cariogenic property
Direct Gold
6) Insoluble in oral fluids
7) Withstand the functional forces without fracture and
protect the remaining amount of hard tooth structure
8) Bond to or maintain constant adaptation with the
cavity walls under oral conditions
1-Convenient and easy in its manipulation and application 1-Convenient and easy in its manipulation and application
Without detailed procedures or

expensive special equipment.
More convenient Less convenient Technique dependent

Direct gold restorations Direct gold restorations
A, Pellet of gold foil is degassed in pure ethanol flame. B, Mica tray mounted over alcohol lamp for degassing
several increments of gold simultaneously. C, Gold foil degassed on an electric annealer. (Courtesy of Terkla
and Cantwell.)
Conventional impression Digital impression
Indirect restorations

Stone and virtual models
Wax pattern and casting
asting Man-made ceramic inlays:
1. Ceramic inlays produced on refractory die material.
2. Castable and ceramic inlays.
3. Pressed ceramic inlays.

Machined restorations:
1. CAD/CAM (Computer Aided Designed / Computer Aided Manufacturing).
2. Celay type inlays.
3. Prefabricated size-matching restorations (Sonicsys).

Fired Porcelain (Feldspathic) Castable ceramics Pressable ceramics

on refractory die (Dicor) (IPS Impress)  Packing then firing the porcelain on
a refractory die
 Technique sensitivity
 Low fracture resistance
 Poor fitting
 Technique sensitivity  Stronger  High strength

 Excellent marginal fit
 Low fracture resistance  Increased fit  Surface hardness, occlusal wear and Coefficient of
 Poor fitting thermal Expansion are similar to enamel
 Stronger  IPS Impress, Finesse All-Ceramic

 Increased fit  Same like castable Ceramics but pneumatically pressed into a
 lost wax technique: mold.
 Wax burn out

 Material heated  Excellent marginal fit
 Centrifugal casting ( to produce an accurate  High strength
casting)  Surface hardness and occlusal wear similar to enamel.
 Ceraming process (Heat treatment) in which  Coefficient of thermal Expansion similar to enamel.
nucleation and growth of the crystals occur
(mica crystals) which are responsible for strength
of the inlay (about 6 hours).
Copy-milling (Celay) CAD-CAM (Cerec) Prefabricated Ceramic inlays

(SonicSys)
Device for pressing heated ceramic

(Programat EP 5000). Selection of ceramic ingots used for forming
A shaded ceramic ingot is placed the restoration.
into the special furnace
1- Copy-milling e.g. Celay 1- Copy-milling e.g. Celay

Technique:
 Manufacturing the master model. Advantages of Celay system:
 Modeling the pro-framework 1. A precisely fit ceramic
(blue composite inlay fabricated on a die). restoration can be done in one
 Attaching to machine holder. visit.
 Copy-milling the framework (Tracing 2. No need for laboratory
with a stylus – milling with technician.
diamond stones. 3. The processing time is very
 Trimming the framework. short, complete inlay in 12-13
minutes.
2-Computer generated ceramics

(CAD/CAM) e.g CEREC  CAD-CAM = Computer Aided Design
-Computer Assisted Manufacturing
 CEREC = CERamic REConstruction
 A small handheld scanner is

used to make an optical
impression of the tooth
preparation
 Coating the tooth with a thin
layer of titanium oxide to
eliminate light reflection.
• It is essential to position the camera over
the long axis so that the computer can read
all internal walls and cavo-surface equally.

 Once the restoration has been designed,

the computer develops a three-
dimensional image of the inlay, onlay, or
veneer.
 The milling is accomplished by a three-
axis of rotation cutting machine which
mills the restoration from prefabricated
ceramic blocks with different shades.
 Final finishing, staining and color
enhancement
Computer-driven software controls small, diamond-
 Final occlusal adjustment in pt mouth coated milling devices that mill the restoration out of a
 Cementation block of high-quality ceramic (as shown in B).
1. Single appointment.
2. No impression
Facial view Occlusal view
3. Wear hardness is similar to enamel.
4. Excellent polishing characteristics.
5. Less fracture because it is milled from homogeneous blocks.
6. The whole procedure is accomplished in 1- 1 ½ hours

SonicSys Inlays
SonicSys Inlays
It is a recently introduced ceramic inlay system to
provide easier and less costly prefabricated ceramic
restorations for proximal cavities of posterior teeth.
The system is composed of:
1. Varying sizes of ultrasonic abrasives with the
abrasive particles are bounded to all surfaces
except the surface facing the adjacent tooth to
avoid injury during cavity drilling.
2. Standardized ceramic restorations to match the
corresponding abrasive tips.
Indirect composite restorations In clinic (one visit) In clinic (one visit) In lab ( more than one visit)
No temporary restoration No temporary restoration Temporary restoration is

needed
No impression Impression is taken Impression is taken

• Lowest cost • Medium cost • Highest cost
• Least control • Intermediate control • Best control
• Opposing reference is not • Opposing reference might be • Opposing reference is

available available available
• Technique sensitive • Technique sensitive • Least technique

sensitivity
Fabricated directly on the tooth (tooth as a die)

The rationale of the semi direct approach is to provide the
1) Matrix and Wedge Placement:
patient with the benefits of luted restorations without the
cost of indirect lab-made inlays or onlays.
Clear matrix is placed and clear reflecting wedges are used.
3) Composite Resin Inlay material Placement

2) Lubrication of the Inlay Preparation
A. The proximal box is filled, and gently condensed with a ball burnisher.
This lubricant must be compatible with B. The occlusal portion of the
the composite resin inlay restorative preparation is completely filled
and gently condensed.
material and will allow inlay removal
after intraoral light curing. C. The interproximal area is cured
for 40 seconds through the end of
the reflecting wedge.
D. The interproximal surfaces are cured from the facial and lingual aspects;
then the occlusal surface is cured for 40 seconds also.
4) Inlay Removal:  Try-in

Should be done carefully to avoid breaking of
the margins.
 Adjusted
 Separator lubricant is painted
on all the inlay surfaces.
 Bonded into preparation
 This will act to exclude air ( no air-inhibited
layer). (cementation).
 The inlay is then light cured for an additional 60
seconds.
5) Oven Tempering: • Finishing and polishing
The composite resin inlay must now be
tempered in a special tempering
Dr.Nesrine Elsahn oven. Dr.Nesrine Elsahn
 Impression is made after Preparation

 Cast is poured
 Master die made from silicon material ( flexible model)
 Master cast made from Fast-setting die stone.
 Restoration fabricated on the die
 Primary Light cure
 Secondary Curing
Advantages:
- Single visit (no provisional)
- Improved contacts, contours & esthetics
- lower cost than the indirect technique
Disadvantage:
 Long chairside time.
 Expensive.
 The opposing reference is not available
Direct composite Indirect composite Indirect ceramic

High polymerization shrinkage stress Low polymerization shrinkage stress 2-Reasonable cost
Lower Degree of conversion Higher Degree of conversion
Lowest mechanical properties and In between Best mechanical properties and surface
surface hardness hardness ( More opposing tooth
abrasion)
Conventional ceramic restorations are
brittle ( weak under tensile forces)
Lowest color stability and poorest In between Highest color stability and best
esthetics esthetics
Least biocompatibility In between Best biocompatibility
Easiest repair In between Most difficult repair
Poor contact, contour and occlusion Better contact, contour and occlusion Better contact, contour and occlusion
in large cavities in large cavities
Lowest cost Highest cost

Lowest cost Dr.Nesrine Elsahn
In between Highest cost Dr.Nesrine Elsahn
3-Harmonious color simulating the affected tooth 3-Harmonious color simulating the affected tooth
Tooth colored Esthetic
Poorest color Best color

reproducibility reproducibility
and stability and stability
3-Harmonious color simulating the affected tooth 3-Harmonious color simulating the affected tooth
Multi-shaded Polychromatic
4-Insoluble in oral fluids 5-Anticariogenic property (Fluoride release and recharge)

Topical application of fluorides through fluoride gel, rinse or
toothpaste can recharge the GIC and the fluoride cycle is thus continued.
Only GI or GI containing Restorative Material
Solubility decreases:
• Properly manipulated GI Degradation (water sorption or
• Resin modified GI enzymatic) decreases:
• Reinforced GI Increase
• High M.W monomers %
All • Filler content
types
Insoluble of Soluble • Degree of conversion
cements.
• PH
5-Anticariogenic property (Fluoride release and recharge) 6-Biologically compatible with the pulp and the adjacent soft tissues.
Topical application of fluorides through fluoride gel, rinse or
toothpaste can recharge the GIC and the fluoride cycle is thus continued.
Only GI or GI containing Restorative Material

Restorative material
must be free from
noxious effects on
the pulp and the
gingival tissues
6-Biologically compatible with the pulp and the adjacent soft tissues.
Sealing potential of GI :
 This ion-enriched layer is firmly attached to tooth structure.
 Even if GIC is de-bonded, it remains sealing the dentinal
tubules.
More compatible Less compatible

1-Chemical 2- Thermal
Thermally conductive metallic 3- Electrical 4- Mechanical
 Metallic ions restorations such as amalgam Galvanism which could result Forces of condensation of
 Corrosion products and cast gold. amalgam, cementation of inlays
from the use of dissimilar
 Acids and chemicals from and stress result from force of
metals
restorative materials mastication
 Bacterial toxins
(Improper cavity preparation
Or restorative Technique)
6-Biologically compatible with the pulp and the adjacent soft tissues. 6-Biologically compatible with the pulp and the adjacent soft tissues.
The cavity depth is considered to be the most The judgment for the need of specific liner or base depend on:
important influencing factor in pulp reaction to 1. Remaining dentin thickness:
when it is decrease the need for more intermediary material
irritation by cavity preparation, or restorative will increase.
technique and materials. 2. Adhesive properties of liner and base:
Deep cavities, therefore, must be considered to be like pulp Adhesive materials should be applied directly except for pulpal
exposures and be lined with a non-irritant material such as medication .
calcium hydroxide applied to the floor of the cavity with least 3. Type of restorative material:
pressure. metallic or non metalic.
•At the pulpal floor (and or) axial wall

• In the closest relation to the pulp
1-When a base is required under esthetic or non esthetic indirect  Sealer is always recommended with amalgam restorations
restoration, the base material is selected to be similar to the only at any cavity depth.
cement material will be used to cement the final indirect
restoration.  CH liner is highly soluble, but its use is mandatory in pulp
capping procedures, limited to the deepest areas, to be
2- When calcium hydroxide is placed in very deep cavities under followed by a reinforced or resin modified GI material as a
composite or indirect esthetic restoration, a layer of GIC or base in case of metallic final restorations or a sealing
RMGIC has to be placed over the calcium hydroxide liner to seal it protective layer of RMGI liner in case of non metallic
in order to decrease its solubility. restorations.
 In Cavities with moderate depth,  In case of moderate or deep cavities for direct composite
restorations:
In case of metallic final restorations only a reinforced or resin
 A layer of flowable composite might be used under packable
modified GI material is required as a base, or a base which is
or highly filled composites
compatible with the cement selected for indirect metallic 1. To increase the adaptation and sealing of the first increment.
restorations. 2. To act as an elastic layer to absorb stresses.
 In moderately deep cavities, the sandwich technique may be

used.
Closed sandwich technique Open sandwich technique
 Adding GI will:
1. Provide chemical adhesion and fluoride release
2. Decrease the volume of composite used ( polymerization shrinkage)
3. Decrease C-Factor ( polymerization stress)
 Resin modified glass ionomer is preferred
 The open technique can be used for marginal elevation in cases with deep subgingival
margins (Difficult isolationDr.Nesrine
and uncontrollable
Elsahn polymerization). Dr.Nesrine Elsahn
7-Withstand the functional forces without fracture and

The restorative material must have

adequate strength against all the
types of functional stresses including
tensile, compressive, shear and
impact, whether these be static or
dynamic.
Better Mechanical properties
STRENGTH PROPERTIES
• Because of the improved strength properties of HYBIRD

• gold is superior to all restoratives. and Nano-COMPOSITES, they are suggested for
applications in stress-bearing areas such as class IV and
• Non strengthened ceramic restorations are brittle class II restorations.
• amalgam lacks only adequate tensile strength • The restorative formulations of GLASS IONOMER CEMENT
(Type II) fail the strength properties and, therefore, are
selected for use as an anterior restoration, particularly in
non-stress-bearing situations (class III & V).


Strength increases: Strength increase with increasing Brittleness counteracted by

• Properly manipulated GI • Filler size adjusting cavity depth
• Resin modified GI • Filler content
• Reinforced GI • Degree of conversion

Ability to reinforce the remaining tooth structure
Unbonded restorations Bonded restorations Indirect onlays and overlays

Doesn’t reinforce the reinforce the reinforce the
remaining tooth structure remaining tooth structure remaining tooth structure
The ability of the restorative material to maintain the physical

property of the tooth
• Acid-etch union between enamel & resin provide protection

• Gold is the material of choice because it can be used in thin to weakened cusps.
section to protect and reinforce remaining tooth structure,
reestablish ideal contour and anatomy, rebuild occlusion with high
accuracy. • Amalgam restorations are confined to intra coronal
restorations. They will not restore strength to remaining tooth
• Ceramic is the second choice. However, it is too brittle to be structure
designed in thin section and more of the remaining tooth
structure must be removed to allow sufficient room for adequate - Glass ionomer has low tensile strength & will not offer
thickness of ceramic. significant reinforcement to remaining tooth structure.
8-Bond to or maintain constant adaptation

Restoration and maintenance of occlusion:
with the cavity walls under oral conditions
* Gold is the material of choice
- Wear factor is almost identical to enamel Cyclic forces, Thermal fluctuation, PH fluctuation , Saliva
* Ceramic are useful for restoring anatomy and occlusion, however:
- Abrading opposing enamel
- It is desirable to occlude porcelain to porcelain
As a result of shrinkage
and cuspal deflection
- Amalgam then composite are next
* Glass ionomer is not suitable, because their wear is too great

Adaptability to cavity walls and margins
Perfect marginal adaptation and cavity seal

by the restoration is essential to prevent …
This refers to the degree of proximity to
• The ingress of fluids, bacteria and other
cavity walls and margins that the
irritants from the mouth.
• Post restorative hypersensitivity. restorative material will be able to attain
• Recurrent caries. and maintain under oral conditions.
• Pulp irritation.
• Discoloration of the restoration and the
tooth structure.

with the cavity walls under oral conditions Maintenance of satisfactory adaptation
Coefficient of thermal expansion requires also:
that the restorative material have a Coefficient
of Thermal Expansion similar to or very close to
that of the tooth. Otherwise, the tooth and the
restoration will expand and contract differently
when subjected to temperature changes leading
to Marginal Percolation.

 Whether during setting or due to thermal changes or forces in EXPANSION causes

the mouth.
1. Marginal overhangs.
2. Pressure on dentin and discomfort to
the patient.
3. The margins may also protrude and
fracture with increased chances for
Amalgam Creep recurrence of caries..
CONTRACTION leads to:

Dimensional stability
- Marginal leakage. • Gold and ceramic are the

- Irritation of dentin. best.
- Marginal discoloration. • Amalgam is next.

- Recurrent caries.
• Composite and GIC contract on
- Looseness of the restoration. setting.

Amalgam
Incremental ,
Forceful,
Multidirectional condensation.
Direct gold
Incremental ,
Forceful,
Multidirectional compaction.
Composite
Elastic bonding concept

Conditioning of tooth substrate
10-25% polyacrylic acid applied
for 10-15 seconds
Incremental packing technique
The material is syringed into the
deepest areas of the cavity first
and is continued to be expelled
while withdrawing the syringe. Guided polymerization technique
Indirect restorations Indirect restorations

Moisture control Proper pretreatment of the
Tissue displacement tooth and fitting surface of
the restoration
Accurate impression
Moisture control
Undistorted wax pattern Tissue displacement
Accurate casting and firing Cementation under pressure
Advanced ceramic techniques Sufficient light curing

8-Bond
2-Bond to or maintain
chemically or maintain constant adaptation
constant adaptation
chemical diffusion-based Micro-mechanical Chemical interaction with Self Adhesives
adhesion adhesion
 GIC undergoes chemical diffusion-based adhesion
(4-MET, 10MDP and Phenyl-P)
to tooth structure.
 Adhesion is initiated by polyalkenoic acid when
freshly mixed material contacts the tooth surface.
 Phosphate and calcium ions are
displaced from apatite by carboxyl
groups (COO).
 These ions will combine with the
surface layer of cement and
develop an ion-enriched layer or
Inter-diffusion zone adhered to
tooth structure.
Dr.Nesrine Elsahn self-assembled nanolayered Dr.Nesrine Elsahn
 chemical interaction is achieved through specific functional Each layer of this self-
monomers, such as 10-MDP, assembled nanolayered
 The ionic bond formation of the carboxylic/phosphate structure consists of two 10-
groups of these functional monomers to Ca of HAp was MDP with their methacrylate
groups directed toward each
proven
other and their functional
hydrogen phosphate groups
directed away from each
other. In between the layers,
Example: Clearfil SE (Kuraray, Japan) calcium salts are deposited.
Etched dentin
Van Meerbeek (2001)
Total- etch
4th generation 5th generation 5th generation 6th generation

7th generation
Dr.Nesrine Elsahn
( All in one- single bottle) Dr.Nesrine Elsahn
Etched dentin Ideal hybridization

Courtesy of Dr. Michael Cochran
Total- etch Total- etch Courtesy of Dr. Michael Cochran
Incomplete hybridization Incomplete penetration

Total- etch Total- etch
Over drying
Over etching

Applying self etch adhesive – smear layer Complete infiltration of SEA - smear layer
Incomplete penetration Complete penetration

and minerals detached from dentin
surface.
and minerals incorporated in the hybrid
layer
Total- etch Self- etch
Over wetness Remnants of

Smear layer

•De-minerlization aggressiveness
•Depth of de-mineralization
 Van Merbeek et al, 2006 •Remaining HA crystals
•Remaining smear plugs
Dr.Nesrine Elsahn Dr.Nesrine Elsahn •Thickness of the hybrid layer
 Smear layer removing agent ( etch and rinse) IV-Factors influencing

 Smear layer dissolving agent ( strong self etch) selection of the
 Smear layer modifying agent ( mild self etch) suitable
restorative materials

Factors concerning the available restorative materials.
I-Factors concerning the available restorative materials. 1. The physical properties of the presently available
restorative materilas
II-Factors related to the operator.
These physical properties must be
III-Factors related to the patient.
thoroughly understood and the
1-Factors related to the general condition of the patient. influence of the functional
2-Factors related to the condition of the oral cavity. performance of the restoration highly
3-Factors related to the tooth to be restored.
appreciated.
4-Factors related to the cavity to be restored.
Contraindications of direct gold restorations:
• Small to moderate size cavities l

Contraindications
1.Young patients –
It is time consuming
2.Limited Accessibility -
It makes the manipulation of gold difficult so defies its use.
3.Size of the Lesion -

If large amount of tooth is destroyed, it is not indicated to use direct filling gold.
4.Esthetics –
If esthetics is of prime importance, direct filling gold is not indicated.
Amalgam restorations Contraindications of amalgam restorations

☻ Small and medium size cavities of
Class I, Class II and V in bicuspids and molars.
☻As a restorative for cavities in the
☻It is also used to restore the distal cavities of anterior part of the mouth
cuspids where there is a concentration of
anterior component of forces ( replaced now
with direct composite).
☻ It is also not recommended as a
☻It is indicated for build up cusps or restorative in mouths containing
cores under full crown restoration of another dissimilar metal.
mutilated teeth.
1-Selection of amalgam type
 Spherical particles require much less mercury.

 Spherical particles also increase the fluidity of the mixture by
presenting less resistance to particle sliding (soft
consistency)→ can adapt well around pins and posts
Low copper Zinc free  Spherical particles needs less pressure so used with very
deep cavities and pulp capped teeth.
BUT
High copper Zinc containing  This soft amalgam can’t be forcefully condensed →
establishing proper contact and contour will be difficult
with expected marginal overhangs.
Admixed
 It is not recommended in case of extensive restorations
which involve the external line angles of the tooth.
Unicompositional
 Spheroidal (blended or admixed) alloy shape is indicated in High cu alloys provide amalgam with
extensive restorations especially those requiring cusp building lower Hg content and superior physical and chemical properties
and extensive restoration of contact and contouring. :
1-increasing the strength
2-More resistance to tarnish and corrosion
3- Decreasing creep
 Zinc was eliminated from most high Cu alloys Amalgam alloy could be supplied
in the form of:
 Zn free alloys are recommended in lesions where moisture
A. Powder (needs accurate proportioning with Hg)
control is difficult B. Pressed tablets (has to be crushed first to powder before
 This could result in pain, marginal fracture or detching of the trituration).
C. Pre-weighed capsules.
restoration
Powder Forms other than Capsules, used to be triturated
manually and squeezed in a piece of gauze to drive the
excess Hg out of the mix.

Capsule (pre-weight) 1- Can be used in all Classes of cavity

The most convenient as it is: preparations whether originating from
a) Properly dispensed and
proportioned. carious or non carious lesions.
b) More hygienic as it is well sealed 2- Used in esthetic enhancement
and the operator will not subjected
to Hg vapors. procedures.
c) Lesser manipulation procedures → 3- Used as pit and fissure sealant and in
i.e. no need for proportioning and
squeezing conservative restorations, e.g. Preventive
Resin Restorations (PRR).
4- Used as foundation or core build-up
material under crowns and bridges.
5- Used for cementation of posts and

indirect esthetic restorations (resin
1. Patients with bad oral hygiene and high caries index.
cement).
2. Improper isolation of the operating site from oral fluids,
e.g. deep subgingival areas that are difficult to isolate from
the sulcular fluid. This will lead to failure in bonding.
6- Used in repair of restorations, 3. Patients with heavy occlusal stresses due to unfavorable
periodontal splinting and bonding of occlusion or bruxism, or if all the occlusal contacts will be on
orthodontic brackets. the composite material.
The heavily filled hybrids, because of high strength properties,

are best for mechanical support.
Composition in terms of filler size and loading
determines the composite’s ability to provide three
functions:
1) mechanical support,
2) form and contour
3) Surface finish while various types of microfilled are best in providing a lasting
Hybrid light-activated composites are suitable for
almost all indications of anterior and posterior smooth finish
composite restorations.
 Hybrid , Nano hybrid and Nano composite are considered as
universal restorations.
The filler loading also affects the modulus of elasticity of the

material;
 composites with high filler loading have high modulus of
elasticity and are thus stiff and can withstand direct
occlusal forces in posterior restorations.
 composites with low filler loading, e.g. homogenous
microfill and flowable composites, have low modulus of
elasticity and are flexible enough to withstand flexure of
the tooth in the cervical part under stresses.
 Flowable composite is used as an elastic liner and for repair
of restorations.
EQUIA™
GC Fuji II®
GC Fuji II LC®
1.For restoration of class III and
class V carious cavities, especially if
GC Fuji II LC® CAPSULE
cervical wall is sub-gingival.
GC Fuji II LC® CORE Material
GC Fuji IX GP®
GC Fuji IX GP® EXTRA
GC Fuji IX GP® FAST
GC Fuji Filling™ LC
GC Fuji LINING™ LC Paste Pak
GC Fuji LINING™ LC Powder-Liquid

GC Fuji TRIAGE®
LINING CEMENT
Miracle Mix®
2-Also used in cervical non-carious 3-It is also indicated in restoration

lesions (abfraction, abrasion and of root caries.
erosion), after proper control of
the cause..
4- Used as pit and fissure sealant

material.
5- Used as a luting
cement for crowns, inlays 7- Used as core buildup for crowns
and veneers and bridges in non-stress bearing
areas.
6- Used as liner/base
(dentin substitute) under 8- Used in minor repair of
restorations and crowns.
any restorative material
9-In Caries Control restorations:

(poor oral hygiene and high caries  Treatment of such patients requires
index) a comprehensive treatment plan
rather than to "drill and fill" each
 Patients with multiple acute tooth individually.
carious lesions, that have
progressed at least half the  Caries Control is an intermediate
distance from the DEJ to the pulp. step in the treatment plan of such
conditions, until the reason behind
this acute condition is dealt with..
eg:For patient with xerostomia as a result of radiotherapy:

The GIC is an excellent Caries Control restoration owing to its
fluoride release as well as its adhesion potential which precludes
the need for extensive cavity preparation.
1. gingival inflammation is treated
2. proper isolation is maintained by a rubber dam The patient is also given proper oral hygiene measures and
3. The lesions are excavated salivary substitute until the acute condition is alleviated, and
4. pulpal medication with calcium hydroxide is applied where indicated
then a permanent restoration is placed.
intermediary
temporary restoration is placed.
9. In Atraumatic Restorative Treatment ( ART restorations):
In poor locations routine dental treatment is not accessible or

possible.
In Field dentistry in schools and villages

ART using GIC restorations could be used to relief pain and stop
the progression of frank carious lesions until the patient could
access dental facilities.

 The procedure does not need electricity or expensive In general, GIC restorations are highly
equipments. recommended in patients with:
• High caries index and poor oral hygiene
 With the patient lying in supine position on a table, the • Low salivary flow
dental personnel can deal with cavitated carious lesions with • Non cooperative patient with limited chair
hand cutting instruments. time
 Chisels are used for cleaving undermined enamel and • Medically compromised patients
excavators are used for excavating soft carious dentin. In addition, GICs are widely used as long-term
 Powder/Liquid GIC is then hand-mixed and packed into the intermediary restorations in geriatrics (old age)
cavity. and pediatrics (children).
1. GICs are contraindicated in stress-

• The correct type of GIC required for luting, liner/base or
bearing areas. e.g. in Class II and IV owing
restoration should be chosen.
to its brittleness and low
• Conventional GIC is indicated when high initial fluoride release is
fracture toughness which causes its
needed.
fracture under stresses.
• Highly-filled viscous GIC can be used in situations where GIC with
increased physical properties is desired but exact color match is
not important.
• Resin-modified glass ionomer can be used in situations with high
esthetic demands.
2. It has poor optical properties, thus if esthetics is of prime • Silver cermet can be used as core-biuld ups in non-stress bearing
importance, it is better to laminate GICs with resin composite. areas and for repair of amalgam restorations.

1• Extensive tooth involvement, including: 2• Correction of occlusion or when

teeth suffer from wear, attrition
or erosion ( rehabilitation cases).
o Cracked or crazed teeth
3• Adjunct to perio-therapy.
o To restore cavities extending deep 4• Fixed ( fixed supported) or

removable prostheses abutments.
sub-gingivally ( biological compatibility)
1 • High Plaque and Caries Indices

(need full coverage).
2• Where other permanent direct restorations are indicated for

tooth conservation (small cavities).

Indirect esthetic restorations:

1- Replacement of Large inadequate
amalgam or composite restoration.
3 • Deciduous Teeth. (expensive) 2- Where Esthetics are primary
consideration.
4 • Compromised Patient. ( long procedure)
3- Large carious lesion and heavy
5• Esthetically sensitive areas. occlusal forces but occlusal load must
not exceed the flexural strength of
6. Patient with other metallic restorations. the restoration/tooth complex.
Indirect esthetic restorations: II. Factors related to the operator
Knowledge:
4. Good oral hygiene.
Knowledge of the dentist about all available restorative materials.
5. Deep subgingival preparations and when
obtaining a dry operating field is difficult to Skill:
achieve for the time needed to place a direct Skillful dentist can master any technique required for manipulation of
composite restoration. any restoration.
Experience:
6. Sufficient tooth structure available for bonding.
Ideally, the cavity margins must be placed in The long experience of the dentist helps so much in the selection
enamel. of the restoration.
Objectives
I-Requirements of an ideal restoration
II-Available restorative materials
Dr. Dr. Nesrine Elsahn

Assistant Professor of Operative Dentistry Restorative materials
Ajman University
Dr.Nesrine Elsahn
IV-Factors influencing selection of the suitable III. Factors related to the patient
1-Factors related to the general condition of the patient.
I-Factors concerning the available restorative materials. a-Age:

Young ages
II-Factors related to the operator.
III-Factors related to the patient. • Can not withstand long

chair side time.
1-Factors related to the general condition of the patient.
• Can not follow
2-Factors related to the condition of the oral cavity.
postoperative instructions.
3-Factors related to the tooth to be restored. • Prefer esthetic materials.

III. Factors related to the patient III. Factors related to the patient
1-Factors related to the general condition of the patient. 1-Factors related to the general condition of the patient.
a-Age: a-Age:
Middle age Old ages
prefer ideal restorations. • Can not withstand long chair

side time
• Prefer Permanent restorations.
b-Gender c-Occupation. Regular patients
Ask for reasonable

restorations with
reasonable cost.
Prefer esthetic restorations Prefer strong durable restorations

Public personalities Technicians, butchers,
c-Occupation. c-Occupation.
fruit sellers and shoemakers
prefer golden
Prefer esthetic. metallic
color.
e-Educational and social conditions:
d-physical condition:
Well-educated patients
Well-educated patients prefer the ideal and

Patients with normal physical fitness are indicated to any type of most suitable restoration.
restorations.
Handicapped patients prefer short term restorations. Uneducated patients

Uneducated patients agree with the operator
Dr.Nesrine Elsahn
selection. Dr.Nesrine Elsahn
f-Mental condition:
g-Habits:
Normal persons
Smokers
Satisfied with the suitable restorations. Suffer from staining on rough surface and acidic saliva.
Alcoholics
Psychic patients
Suffer from increased solubility of dental cements.
Can not withstand treatment for long time. Bruxers

Patients with bruxism need high strength materials.
1-Factors related to the general condition of the patient. 2-Factors related to the condition of the oral cavity.
h-Economic condition of the patient:

a-Oral hygiene:
Wealthy patients
Select the best restoration whatever the cost.
Ordinary patients
Should be informed about the expenses before treatment.
Poor patients
Prefer amalgam in posterior teeth and composite for anterior teeth. Good oral hygiene Bad oral hygiene
All restorations are preferable. Increased acidity and solubility of cements
III. Factors related to the patient
2-Factors related to the condition of the oral cavity.
b-Caries incidence  placing dental restorations does little or nothing to manage

the caries disease process.
Teeth with rampant
caries are better to be  In addition to a comprehensive restorative treatment plan,
restored with temporary each patient should have a comprehensive caries
restorations until the management treatment plan.
condition subsides.
 It treats dental caries as an infectious

disease that is curable and preventable.
 By evaluating the caries balance of a patient

(the dynamic interaction of the pathological
factors compared to the protective factors),
clinician can assess the likelihood that the
patient will develop dental caries.

 It means categorization of individuals according to their

liability to caries occurrence, either of high or low risk.
 Risk factors predisposing for dental caries
are either: →  This is done by :
 Non-oral factors including: → Age. Sex,
medical condition and general health, fluoride 1. DMFT &DMFS Systems
and genetic role. 2. Cariogram.
 Oral factors including: → Tooth anatomy, oral 3. Traffic light system.
flora, oral hygiene, previous restorations and 4. Caries risk assessment forms
reduced salivation.
Susceptibility :
Previous caries experience
Related general diseases
Diet:
Diet content
Diet frequency
Bacteria:
Amount of plaque
Streptococcus mutans
Circumstances:
Fluoride program
Saliva secretion rate
Saliva buffering capacity
Clinical judgment
1. Saliva
2. Diet
3. Fluoride
4. Oral biofilm
Modifying factors
. past and current dental status
. past and current medical status
.lifestyle
. socioeconomic status

Classify the Patient as 
 High Risk
 Moderate Risk
 Low Risk
The borderline between low, moderate or high risk is not

precise.
The International Caries Detection and

Assessment System  0 Un-restored or unsealed
 1 Sealant, partial
An integrated system for measuring dental  2 Sealant, full
caries  3 Tooth colored restoration
 4 Amalgam restoration
 5 Stainless steel crown
conducted by the Detroit Center for Research on  6 Porcelain or gold or PFM crown or veneer
Oral Health.  7 Lost or broken restoration
 8 Temporary restoration
 9 Tooth does not exist or other special cases.

The examiners visually examine and classify the carious status

of each tooth surface using a seven-point ordinal scale
1: First visual change in
ranging from sound to extensive cavitation. 0: Sound tooth surface enamel ( dry tooth )
The Scale correspond to radiographic and histological findings
of extensive researches
2: Distinct
3: Microcavitation.
Dr.Nesrine Elsahn visual changeDr.Nesrine
in enamel Elsahn (moist tooth).
ICDAS score
1,2 ( brown lesion): 1 point
5: Distinct cavity with
4: Underlying dark shadow from dentin 1,2 ( white lesion): 3 point
visible dentin.
with or without cavitation in enamel. 3,4,5 or 6: 4 points
Plaque stagnation
Yes: 3 points
No: 1point
Surface texture
Rough or soft: 3 points
Smooth or hard: 1 point
6: Extensive distinct cavity with visible dentin.

 It is based on the infiltration of an initial enamel caries lesion with low-viscosity

light-curing resins called infiltrants.
 The surface layer is eroded and desiccated, followed by resin infiltrant application.
The resin penetrates into the lesion microporosities driven by capillary force and is
hardened by light curing.
 Infiltrated lesions lose their whitish appearance and look similar to sound enamel.
Additionally, the treatment prevents lesion progression. This technique might be
an alternative to microabrasion and restorative treatment in treating of white spot
lesions of esthetically relevant teeth.
 Icon-Etch (15% hydrochloric acid gel) applied for 2 minutes erosion

 Icon-Dry (Ethanol) applied for 30 seconds desiccation
 Icon-Infiltrant (low viscosity resin)applied for 5 minutes infiltration
 Approximal-Tips
 Dental wedges
http://www.dmg-dental.com/products/icon-caries-infiltration/
 (a) Preoperative picture showing incipient caries in the lower

central incisors.
 b) Preoperative picture.
 (c) Application of Icon Etch for 2 min. ( remove it with cotton roll)
 (d) Rinsing of Icon Etch after 30 s.
 (e) Application of Icon Dry for 30 s
 (f) Air drying.
 (g) Application of Icon resin and allowing penetration for 5 min.
Add glycerin to prevent polymerization inhibition
 (h) Light curing the resin.
 Rinse the glycerin and plolish
 (i)Postoperative picture
2-Factors related to the condition of the oral cavity. 2-Factors related to the condition of the oral cavity.
C-Condition of the occlusion: d-Presence of metallic restoration:

Normal occlusion Mal-occlusion
The material should

be the same as the present
metallic restoration to avoid
galvanism.
has no troubles in selection needs high strength

of restorative material. properties.

3-Factors related to the tooth to be restored. 3-Factors related to the tooth to be restored.
a-Position of the tooth: b-Size and condition of the remaining coronal portion:
Anterior tooth Posterior tooth
Esthetic restorations Strong restorations

A. The location of cavity

- When primary retention features (axial
walls Convergence, Axial grooves, dove
margins in relation
tails) are not adequate → auxiliary to central fissure and cusp tip 
retention are used to enhance retention
form:
- Pins. - Coves (A).
- Slots (B). - Locks (C).
- Amalgapins - Amalgam bonding.
- Capping of undermined or week cusps,
providing 90° Cavo-surface angle, smooth
walls, flat floor and rounded internal line
angles.
C-Size of the cavity

< 1/2 Distance between central fissure and cusp tip 
.
1/2 - 2/3 Distance between central fissure and cusp tip  Large cavities should be restored with cast gold, ceramics or full
based on coverage.
1-Thickness / height ratio (depth of the cavity)
2-Stresses (functional or non functional cusp) Medium cavities → Amalgam or composite.
> 2/3 Distance between central fissure and cusp tip  Small cavities → Gold foil, glass ionomer, amalgam or composite.
.
3-Factors related to the cavity to be restored. 3-Factors related to the cavity to be restored.
d-Location of the cavity
e-Accessibility to the cavity:
Wide mouth opening provides sufficient accessibility, however small

mouth opening creates difficulty in cavity preparation and
1- Occlusal cavities should be restored with strong material to withstand occlusal force restoration.
2- Mesial cavities in anterior teeth and premolars should be restored with esthetic
materials. Anterior teeth, premolars and first molar are more accessible than second
3- Distal cavities of canine should be restored with metallic or strong restoration. and third molars.
4- Labial cavities should be restored with esthetic materials.
5- Cervical cavities of anterior teeth should be restored with esthetic materials.
6- Cervical cavities of posterior teeth may be restored with metallic or composite or Labial, palatal and occlusal cavities are more accessible than lingual,
glass ionomer restorations. cervical and proximal cavities.
7- Subgingival cavities are better to be restored with cast gold or ceramic restoration or
an open sandwich Dr.Nesrine
technique.
Elsahn Dr.Nesrine Elsahn

Summary
f-Depth of the cavity: 1. Selection of suitable material may determine the success or failure of the final
restoration.
2. The ideal restorative material is yet to be found.

Cavities with conventional depth can be easily restored 3. Intelligent selection of restorative material depends upon meticulous evaluation of
without precautions. the available materials in the light of all factors presented by each individual case.
4. Some of these factors may modify the selection of the restorative material but
Cavities with moderate depth need base before restoration. should never justify using material of inferior qualities.
Deep cavities need liner and base before restoration. 5. In the absence of the ideal restorative material, combination of two or more
materials may be used to obtain the required qualities.
Dr.Nesrine Elsahn

Selection of Restorative Materials and Techniques

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Selection of Restorative Materials and Techniques

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Dr.

Nesrine Elsahn 2/21/2018

II-Available restorative materials

III-Requirements of an ideal restorative material

Dr. Dr. Nesrine Elsahn

I-Requirements of an ideal restoration I-Requirements of an ideal restoration

 Protect and maintain pulp vitality.

 Restore and maintain the

I-Requirements of an ideal restoration I-Requirements of an ideal restoration

Dr.Nesrine Elsahn Dr.Nesrine Elsahn

I-Requirements of an ideal restoration I-Requirements of an ideal restoration

I-Requirements of an ideal restoration II-Available permanent restorative materials

Dr.Nesrine Elsahn Dr.Nesrine Elsahn

Dr.Nesrine Elsahn Dr.Nesrine Elsahn

Direct Restorations Indirect Restorations

 Ability to reproduce contact and contour

Less expensive More expensive

Direct Restorations Indirect Restorations

III-Requirements of an ideal restorative material

1) Convenient and easy in its manipulation and

Without detailed procedures or

More convenient Less convenient Technique dependent

Direct gold restorations Direct gold restorations

Conventional impression Digital impression

Dr.Nesrine Elsahn Dr.Nesrine Elsahn

Stone and virtual models

Dr.Nesrine Elsahn Dr.Nesrine Elsahn

Wax pattern and casting

asting Man-made ceramic inlays:

1. Ceramic inlays produced on refractory die material.

2. Castable and ceramic inlays.

3. Pressed ceramic inlays.

1. CAD/CAM (Computer Aided Designed / Computer Aided Manufacturing).

2. Celay type inlays.

3. Prefabricated size-matching restorations (Sonicsys).

Dr.Nesrine Elsahn Dr.Nesrine Elsahn

Fired Porcelain (Feldspathic) Castable ceramics Pressable ceramics

 Technique sensitivity  Stronger  High strength

 Stronger  IPS Impress, Finesse All-Ceramic

Copy-milling (Celay) CAD-CAM (Cerec) Prefabricated Ceramic inlays

Device for pressing heated ceramic

1- Copy-milling e.g. Celay 1- Copy-milling e.g. Celay

2-Computer generated ceramics

 CEREC = CERamic REConstruction

Dr.Nesrine Elsahn Dr.Nesrine Elsahn

 A small handheld scanner is

Dr.Nesrine Elsahn Dr.Nesrine Elsahn

 Once the restoration has been designed,

Dr.Nesrine Elsahn Dr.Nesrine Elsahn

No temporary restoration No temporary restoration Temporary restoration is

No impression Impression is taken Impression is taken

• Least control • Intermediate control • Best control

• Opposing reference is not • Opposing reference might be • Opposing reference is

• Technique sensitive • Technique sensitive • Least technique

Fabricated directly on the tooth (tooth as a die)

Dr.Nesrine Elsahn Dr.Nesrine Elsahn

3) Composite Resin Inlay material Placement

4) Inlay Removal:  Try-in

 Impression is made after Preparation

Direct composite Indirect composite Indirect ceramic

Least biocompatibility In between Best biocompatibility

Easiest repair In between Most difficult repair

Lowest cost Highest cost