Composite placement the challenge of placing resin composite restoration

in a posterior cavity lies between ease of placement and not

comprosmising the seal , adaptation , resistance and the mechanical
properties of the tooth / restoration

Introduction

For decades, we used old restoration like amalgam for durability,

longevity but amalgam have some defects as thermal conductivity ( this
need base), mercury poisoning, cannot do polishing to the restoration
immediately and the patient cannot eat on the tooth which put restoration
on it he should wait for 24hours before eating. Also we use amalgam
manly in posterior teeth for its mechanical properties and if the patient
has bad oral hygiene, amalgam will be suitable to him. But if the patient
has good oral hygiene or low caries index I will use composite or glass
ionomer ( if I will do sandwich technic). So I want a restoration that I
will use in the posterior teeth should be good esthetic requirements and at
the same time give function. In the past we had to make an initial cavity
(extension for prevention), make dufften, have to make depth 2mml so I
can put amalgam to give me retention because the retention of this
restoration depends on the walls so in the past I depend on mechanical
but now I will depend on a chemical not mechanical (bonding from the
walls ), so now I don’t have to open wide cavity or make the cavity
deeper. Now the new era of the restoration (composite restoration )in
posterior teeth become suitable, better because as a restoration I can make
polishing immediately but composite need good isolation by rubber dam
in the other hand mercury doesn’t have to do isolation, also in composite,
the technic of the etching very important, the most important success
factor in composite restoration is technic of etching and bonding should
doing it right so I have 3 types of etching ( total-etch – self etch –self-
adhesive) . In esthetic posterior restoration, we have two types (direct-
indirect ) each one has specific properties, and I don't have to make a big
cavity, I can make a small cavity (small box ) like the buccal pit, I don’t
have to make it deeper because mainly I depend on bonding with walls (c
factor). So the main causes of the transition from metallic to tooth colored
restoration materials ( resin composite) are 1- the growing demand for
esthetic restorations 2- the great improvement of the materials and their
. properties 3- the change of the treatment to more conservation approach
 Review

Types of resin composite restoration

direct composite-1
indirect composite -2

THE choice between the utilization of direct and indirect

techniques for resin composites in posterior teeth relies on the
width  of the cavity to be restored. Small and medium cavities
.are usually restored with direct composite resin restorations

On the opposite hand, in large cavities, where the width of the

isthmus exceeds two-thirds of the space between facial and
lingual cusp tips, indirect restorations become indicated
However, due to the evidence that direct resin composite
restorations have properties suitable to be used in posterior teeth
, don't require invasive preparation
cost, many dentists are using them in large cavities, making the
clinical decision challenging

Bond strength evaluation of direct and indirect resion composite

:restoration
direct composite :greater bond strength-1
different types of cement and different thickness of cement -2
:different bond strength for indirect composite to tooth structure

Direct composite → polymerization shrinkage→ leakage,

discoloration , sensitivity→failure

Indirect composite →Minimize polymerization shrinkage,

insignificant difference of properties in comparison to
composite to direct materials ( affected by type and thickness of
the cement)
Direct composite that is fabricated carefully, respecting the *
correct indications for this technique , willprovide properties
. higher or equal to indirect one
INDICATIONS OF RESIN COMPOSITE
class-I,II,III,IV,V,VI RESTORATION-1
core buildups -2
Sealant and preventive resin restorations-3
high esthetic demand to the patient-4
non stress bearing area of the tooth-5
luting-6
temporary restoration-7
periodontal splinting-8
non carious lesion-9
enaml hypoplasia-10
composite inlay-11
repair old composite restoration-12
patient allergic to metals-13
conservation restoration in nature-14

CONTRAINDICATION OF RESION COMPOSITE

high caries incidence and poor oral hygiene-1
teeth with heavy or abnormal occlusal stress like para--2
functional hapits
if access and isolation difficulties-3
subgingival difficulties-4
patient allergic or sensitive to resin composite-5

ADVANTAGR OR RESIN COMPOSITE

RESTORATION
Good ethetics-1
conservation of tooth struvture-2
easy to manipulate-3
good compressive strength-4
rapid polymerization-5
can be repaired -6

DISADVANTAGE OR RESIN COMPOSITE

polymerization shrinkage(can result in postoperative -1
sensitivity, recurrent caries, failure or interfacial
bonding , fracture or the restoration and the tooth)
expensive-2
technique sensitive-3
increased occlusal wear-4
low modulus of elasticity-5
staining-6
lack of anticariogenic-7
difficult,time consuming-8

Principles of posterior composite restoration

PROTOCOL PROPOSED FORPOSTERIOR .
: RECONSTRUCTION IS
Diagnostic and initial occlusal check-1
cavity preparation and cavity finshing-2
the main aim of preparation 1- acess should be (
limited to that required to visualize and remove
carious tooth tissue or any previous restoration 2-
)permit access for instruments
proximal reconstruction and occlusal layering-3
isolation and pre-wedging-4
straining and-5
finishing
polishing and final occlusal check-6

HOW TO REDUCE POLYMERIZATIONS

SHRINKAGE
c.factor-1
incremental layering technique-2
light curing procedure-3
altering layering formulations-4
stress absorbing layers with low elastic moduls-5
incorporation of macro-fillers to reduce the overall -6
volume of composite
preheating composite -7

C-FACTOR)1
Is the ratio of the bonded surfaces of the restoration to the
unbonded surfaces
C-FACTORE is internal surfaces area versus external
surfaces area
We are trying to reduce the c- factor which provide more
free surface for flow so we can reduce polymerization
shrinkage
THE HIGHER THE VALUE OF C-FACTOR , THE *
GREATER IS THE POLYMERIZATION SHRINKARE

INCREMENTAL LAYERING TECHNIQUE-2

this step is so important for the success of the -
.restoration
THE bonded \unbonded ratio would be reduced and
consequently , the stress level within the cavity might
be reduced
reduced volume being cured-
to facilitate proper light-activation-
development of correct anatomy-

CONVENTIONAL INCREMENTAL
TECHNICQE

1-Horizontal layering technique

The horizontal positioning technique uses composite resin
layers, each < 2.0 mm thick. This technique has been
documented to raise the C-factor, thereby raising the shrinking
tension between the opposing cavity walls.
2-Oblique layering technique
By positioning a series of wedge-shaped composite scales,
the oblique technique is accomplished. Every increment is
photocured twice, first from the cavity walls and then from
the occlusal side, to guide the polymerization vectors towards
the adhesive surface This technique decreases the C factor
and avoids cavity wall distortion.
THREE VARIATIONS OF THE BASIC OBIQUE-*
LAERING TECHNIQUE ARE DISCRIBED
SUCCESSIVE CUSP BUILD UP -1
SEPARATE DENTINE AND ENAMEL BUILD -2
UP
SEPARATE DENTINE AND -3
ENAMEL BUILD UP USING AN
INDEX

4-Vertical layering technique

Place small increments in vertical pattern starting from one
wall likebuccal or lingual, and carry to another wall. Start
polymerisation from behind the wall, i.e. if buccal
increment is put on the lingual wall, it is healed from
outside the lingual wall. This reduces the gap at the gingival
wall that is created by shrinking polymerisation, thus postoperative
vulnerability and secondary caries
5-Centripetal buildup technique
The technique of centripetal buildup provides a
range of advantages when posterior restorations
of composite resins are suggested. This
technique employs thin metal matrix bands and
wooden wedges removing the need for
transparent matrix bands that do not provide
strong contact areas and proximal anatomical
contours, and are difficult for many practitioners
to use. Moreover, recent studies are not
indication any detriment to metal matrix bands created by cervical gaps.
The centripetal buildup steps provide an important benefit of the
procedure first by creating a very thin proximal layer which affects the
internal healing of this layer which can strengthen the composite and
minimize the cervical distance that may form. However, even if this gap
develops, the next consecutive layer condensed toward the gingival floor
is likely to fill the gap as the created space continuity is not obscured.
Comparative microleakage tests have yet to be performed but the author's
more than 6-year experience with this technique has shown excellent
marginal radiographic adaptation.. Occlusal surface ring formation is yet
another important addition to the proposed technique. An occlusal
reference surface is created by constructing a continuous layer to cusp
slopes, preventing overfilling and minimizing the subsequent need for
rotary burs. These finishing procedures are known to be detrimental to the
composite external surface. Finally, with the protection of sound tooth
structure, the centripetal buildup technique is very conservative; it is not
time-consuming, and easy to implement. Upon completion of the second
step of the procedure and creation of a peripheral composite envelope, the
cavity is managed as a simple Class I cavity. The systematic use of
shades of enamel and dentin achieves consistent and satisfying esthetic
result . The technique of centripetal buildup was profitably exercised
where small to medium posterior restauration is indicated. However, if
extensive stress-bearing occlusal surfaces are directly restored,
particularly in molars, silver amalgam is still the material of choice when
carefully manipulated to achieve a long-lasting dental restauration.

BONDED –BASE TECHANIQE -4

BY placing RMGI below composite restoration →
reducing the bulk of composite materials →reducethe
polymerization shrinkage
BASES ANS LININGS (CLOSED SANDEITCH – *
OPEN SANDWICH)

AN ALTERNATIVE *
TECHNIQE IN
INCREMENTATION

Split-increment horizontal layering technique

By using traditional horizontal technique, each
composite increment connecting the cavity floor to
the four surrounding walls creates the maximum
and most unfavorable C-factor ratio of 5 by photocured Concern has been
expressed about placing individual increments against opposing walls
simultaneously before photocuring, as the resulting polymerization
shrinkage stress can cause the cusps to bend towards each other and
deform as a result This stress can cause postoperative sensitivity and can
be detrimental to the tooth and marginal integrity over time . For the
proposed procedure, each horizontal increment was divided into four
triangle-shaped parts before healing, each portion being positioned
against only one cavity wall and part of the floor being filled with
composite dentin shade and photocured. The other diagonal cut was filled
up and photocured at this point, one half at a time. The same technique is
followed until the dentin-enamel junction and later the enamel shade
composite are placed and shaped to establish occlusal morphology
followed by translucent shade. This sequence would prevent composite
resin from simultaneously connecting two opposing cavity walls,
minimizing the adverse effects of polymerization shrinkage on the cavity
walls and adhesive interfaces. This will also low the C-factor ratio to the
second most desirable C-factor ratio of 0.5 from 5, which is the highest
and most unfavorable. Certain limited parts in increment with low C-
factor ratio would ease the shrinking stress due to the free composite
surface flowing at the diagonal cuts and not at the bonded interfaces, thus
minimizing the adverse effects of polymerization shrinkage stresses.

AVAILABLE FOLF OF BULK FILLED *

COMPOSITE
Light-curing composites are
generally used in a layering
technique with individual
increments of no more than 2.0
mm in thickness, due to their
polymerization properties and
limited cure depth. -- individual
increment is separately formed
polymer, with exposure times between 10 and 40 seconds
depending on the strength of the curing light and the color /
translucency of the composite material Until recently, with
the materials available, thicker composite layers resulted in
inadequate polymerisation of the composite resin and thus
provided inferior mechanical and biological properties
Applying the composite in 2.0-mm increments, especially in
large posterior cavities, can be a very time-consuming
procedure. Consequently, there is considerable demand on
the market for composite-based materials for this range of
indications that are simpler, faster to use, and thus more
economical. Bulk-filled composites have been developed to
recent years, which can be positioned faster in the cavity by
means of a streamlined application technique in layers 4.0 to
5.0 mm thick and with quick curing times of 10 to 20
secondsTaken literally, "bulk-fill" means that they can be
used to fill the cavity in a single-step procedure without the
need for layering. This is actually only possible for cements
and chemically activated or dual-curing core composites of
plastic restorative materials .However, the former may not
possess sufficient mechanical properties for clinically stable
restorations in the long-term posterior region of permanent
dentition. They are thus only suitable for use as interim
restorations or as long-term temporaries The latter are
neither approved as restoratives nor suited from a handling
perspective for such indications (– for example, shaping of
occlusal surfaces). The bulk-filled composites currently
available for the simplified filling technique in the posterior
region are not "bulk" materials in the true sense. when
analyzed more precisely in that, in particular, the
approximale extensions of clinical cavities are usually
deeper than the maximum cure depth defined for such
materials (4.0 to 5.0 mm). Having said that, if a appropriate
material is chosen, it is possible to fill cavities with depths
up to 8.0 mm in 2 increments, and this covers the majority of
.defect measurements found in normal clinical practice
THE FOLLOWING FEATURES USUALLY LEAD *
TO FALIURE IN RESIN COMPOSITE
Incomplete excavation of caries-1
incomplete etching or failure to remove residual acid -2
from the enamel
non-uniform coat of bonding agent-3
lack of isolation-4
touch of composite with fingers-5
bulk placement of composite-6
inadequate curing (time or coverage)-7
poor finishing and polishing (especially at the beveled -8
areas)
high spots-9

CONCLUSION
Resin-based composite materials continue to gain popularity
among dentists and the demand for such esthetic restoration is
growing. Manufacturers are working aggressively to improve
resin composite materials by modifying components to decrease
polymerization shrinkage, to improve mechanical and physical
properties, and to enhance handling characteristics Secondary
caries and facture (restoration or tooth) are the two main causes
of post-composite restoration failure. A review and update of
the posterior resin composite in terms of preparation design,
matrix selection, and resin systems show the limited extent to
which these factors affect the overall clinical life of resin placed
in the posterior teeth. Dentists and patient factors m including
caries risk, cavity size, type of cavity, number or restored
surfaces, and mouth position of the tooth must be carefully
.selected for any restored material, including composite resin
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